This document discusses multiple sclerosis (MS), including its diagnostic criteria, classification, clinical courses, and current and emerging treatments. It begins by defining radiologically isolated syndrome, clinically isolated syndrome, relapsing-remitting MS, secondary progressive MS, and primary progressive MS. It then discusses the McDonald criteria for diagnosing MS and provides a case study example. Current MS therapies discussed include interferon-β, glatiramer acetate, natalizumab, mitoxantrone, and teriflunomide. The document concludes by discussing considerations for deciding which MS medication to use based on whether therapeutic goals are being met or not.
Here is very good and amazing presentation on Multiple sclerosis ..its about brain
read this carefully and work on this because the work on brain is very good for future research...
Multiple sclerosis (MS) is a nervous system disease that affects your brain and spinal cord. It damages the myelin sheath, the material that surrounds and protects your nerve cells. This damage slows down or blocks messages between your brain and your body.
No one knows what causes MS. It may be an autoimmune disease, which happens when your body attacks itself. Multiple sclerosis affects women more than men. It often begins between the ages of 20 and 40. Usually, the disease is mild, but some people lose the ability to write, speak or walk. There is no cure for MS, but medicines may slow it down and help control symptoms. Physical and occupational therapy may also help.
Multiple sclerosis is generally referred to as an autoimmune disease or disorder in which the nerve cells of brain and spinal cord are attacked by patients own immune system.
The patient's bodys immune system perceives myelin sheet as an intruder and attack it resulting in damage due to which this sheet no longer carry the messages properly causing the message transmission process to be slowed, distorted or stopped altogether.
At present there is no cure available for multiple sclerosis, however, using certain drugs such as interferon’s, exercise and physiotherapy it is possible to manage the attacks and symptoms.
Researchers hope that stem cell therapies may provide new approaches that can both prevent damage and enable us to repair it.
A wonderful and interesting presentation on Multiple Sclerosis! It includes videos, pictures and great insight into the possible cure for MS. I truly hope whoever downloads it enjoys it as much as I do. Blessings!
Here is very good and amazing presentation on Multiple sclerosis ..its about brain
read this carefully and work on this because the work on brain is very good for future research...
Multiple sclerosis (MS) is a nervous system disease that affects your brain and spinal cord. It damages the myelin sheath, the material that surrounds and protects your nerve cells. This damage slows down or blocks messages between your brain and your body.
No one knows what causes MS. It may be an autoimmune disease, which happens when your body attacks itself. Multiple sclerosis affects women more than men. It often begins between the ages of 20 and 40. Usually, the disease is mild, but some people lose the ability to write, speak or walk. There is no cure for MS, but medicines may slow it down and help control symptoms. Physical and occupational therapy may also help.
Multiple sclerosis is generally referred to as an autoimmune disease or disorder in which the nerve cells of brain and spinal cord are attacked by patients own immune system.
The patient's bodys immune system perceives myelin sheet as an intruder and attack it resulting in damage due to which this sheet no longer carry the messages properly causing the message transmission process to be slowed, distorted or stopped altogether.
At present there is no cure available for multiple sclerosis, however, using certain drugs such as interferon’s, exercise and physiotherapy it is possible to manage the attacks and symptoms.
Researchers hope that stem cell therapies may provide new approaches that can both prevent damage and enable us to repair it.
A wonderful and interesting presentation on Multiple Sclerosis! It includes videos, pictures and great insight into the possible cure for MS. I truly hope whoever downloads it enjoys it as much as I do. Blessings!
Multiple sclerosis: Introduction, Risk Factors, Diagnosis and TreatmentEnriqueAlvarez93
Introduction about Multiple Sclerosis.
Risk factors affect to Multiple Sclerosis.
When to Suspect Multiple Sclerosis.
Evaluation and Diagnosis of Multiple Sclerosis.
How to treatment of Multiple Sclerosis.
Treatment of Multiple Sclerosis with Monoclonal Antibody.
Multiple sclerosis (MS) is a demyelinating disease in which the insulating covers of nerve cells in the brain and spinal cord are damaged.This damage disrupts the ability of parts of the nervous system to communicate, resulting in a range of signs and symptoms, including physical, mental, and sometimes psychiatric problems
Risk factors in Multiple Sclerosis: Detection and Treatment in Daily Life
Caroline Pot and Patrice Lalive
Unit of Neuroimmunology and Multi Sclerosis Geneva University Hospital
Understanding, Diagnosing, and Classifying MS Symptom Managementericss1234_msvn
Understanding, Diagnosing, and Classifying MS Symptom Management. Presented by Tricia Pagnotta, MSN, ARNP, CNRN, MSCN at the MS Views and News Education Seminar Maitland, Fl on April 2013
Multiple sclerosis: Introduction, Risk Factors, Diagnosis and TreatmentEnriqueAlvarez93
Introduction about Multiple Sclerosis.
Risk factors affect to Multiple Sclerosis.
When to Suspect Multiple Sclerosis.
Evaluation and Diagnosis of Multiple Sclerosis.
How to treatment of Multiple Sclerosis.
Treatment of Multiple Sclerosis with Monoclonal Antibody.
Multiple sclerosis (MS) is a demyelinating disease in which the insulating covers of nerve cells in the brain and spinal cord are damaged.This damage disrupts the ability of parts of the nervous system to communicate, resulting in a range of signs and symptoms, including physical, mental, and sometimes psychiatric problems
Risk factors in Multiple Sclerosis: Detection and Treatment in Daily Life
Caroline Pot and Patrice Lalive
Unit of Neuroimmunology and Multi Sclerosis Geneva University Hospital
Understanding, Diagnosing, and Classifying MS Symptom Managementericss1234_msvn
Understanding, Diagnosing, and Classifying MS Symptom Management. Presented by Tricia Pagnotta, MSN, ARNP, CNRN, MSCN at the MS Views and News Education Seminar Maitland, Fl on April 2013
Switching DMDs and new pipeline therapies - Dr Eli SilberMS Trust
Outline:
Where are we now
Therapies
Uncertainties
Induction v.s escalation v.s. rescue
Modelling outcomes
What is progressive disease, SP &PP
Risk reduction
Why is there a need for new therapies?
When is there a need to switch?
This presentation by Gavin Giovannoni looks at the new treatment paradigm for MS. It includes: arguments for early treatment in multiple sclerosis, the effect of MS on quality of life and whether highly-effective treatments stabilise MS.
It was presented at the MS Trust Annual Conference in November 2013.
A brief description about Demyelination topics by Dr Sabu Augustine for MBBS Students in Medical school.
References from textbooks and other presentations.
references:
Phases and Phenotypes of Multiple Sclerosis By Orhun H. Kantarci, MD.
Diagnosis of Multiple Sclerosis By Jiwon Oh, MD, PhD, FRCPC
Nature Reviews | Disease Primers
Multiple sclerosis Massimo Filippi1,2*, Amit Bar- Or3, Fredrik Piehl4,5,6, Paolo Preziosa1,2, Alessandra Solari7, Sandra Vukusic8 and Maria A. Rocca1,2
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
2. Overview
• The diagnostic criteria of multiple sclerosis(
MS)
• Classification of idiopathic inflammatory
demyelinating disorders
• Clinical course of MS
• Current and emerging MS therapies
5. Radiologically Isolated Syndrome
(RIS)
– No typical symptoms of CNS demyelination
– No formally accepted diagnostic criteria
– MRI : Typical MS lesions
– CSF abnormalities
– Clinical MS Attack:
– 35% over 5 years
– MRI progression:
• 59-83% in 2 years
– DMT is initiated only in case
of clinical/MRI progression
Okuda DT et al, Neurology2011:76()8, 686-692
6. Diagnostic Criteria for MS
• An effort to make the diagnostic process more
objective
• Formal criteria were devised to codify the typical MS
features into indisputable diagnostic criteria
• The primary driving force is identification of patients
for research trials. ”a consensus on which patient has
MS”
• Criteria are designed to be specific
• There are patients with MS who do not meet those
criteria
• “A patient has MS when an an experienced neurologist
says he or she has MS”
7. Schumacher Criteria- 1965
• Onset of symptoms between 10 and 50 years
• Objective abnormalities on neurologic
examination
• The signs and symptoms indicate CNS white
matter damage
• The lesions are disseminated in space ( 2 or more
separate lesions)
• The lesions are disseminated in time (2 attacks at
least 1 month apart)
• No better explanation
8.
9. The Mc Donald Criteria
• ‘the world consists of three types of person: those who
have multiple sclerosis; those who do not; and those
who might’. Polman CH et al,Ann Neurology, 2001
Episodes
from history
Objective clinical signs Additional data needed
from MRI or clinical
follow up
2 attacks
2 attacks
1 attack
1 attack
Progressive
course over 1
year
2 lesions
1 lesion
2 lesions
1 lesion
None
DIS
DIT
Both DIS&DIT
DIS demonstrated by 2 :
1- MRI brain
2. MRI cord
3. CSF oligoclonal bands
16. CASE
• On 18/3/08 patient complained of ocular pain on
moving the left eye with blurred vision.
• 2 days later she developed left frontal headache.
• Seen by the ophthalmologist who diagnosed her as
optic neuritis and advised to be on neurobion.
• She had several attacks of Rt. Upper limb heaviness
in the last 2 years, each was lasting for a week.
• Her cousin has MS .
17. CASE : Examination
• Her vision was 20/200 in the left eye and 20/40 in the
right eye. There was a central scotoma, and red and
blue colors were less intense in the left eye.
• RAPD on the left
• Left fundus: disc is congested and swollen.
• Central Scotoma
• Treated with pulse IV methylprednisolone for 3 days
and improved followed by short prednisolone taper
23. Clinically Isolated Syndrome (CIS)
• MRI:
– Low risk: 1 or no other asymptomatic brain lesion
– High risk: 2 or > asymptomatic lesions
• Treatment approved for high risk patients
– IFN-B, GA reduces second attack: ARR 15%
24. Baseline MRI and Risk of CDMS for
Monofocal onset CIS (BENEFIT
Placebo N=93)
26. TOPIC
Primary end point:
Conversion to CDMS (as defined by the occurrence of a relapse)
Key inclusion criteria:
• Patients 18 to 55 years of age with a first acute/subacute neurologic event
consistent with demyelination.
• MS symptom onset within 90 days of randomization.
• Screening MRI scan with 2 T2 lesions 3 mM diameter that are characteristic
of MS.
Screened
(N=846)
Placebo
(n=197)
Teriflunomide 7 mg
(n=205)
R Long-Term Extension
Teriflunomide 14 mg
(n=216)
108-Week Treatment Phase
Randomized
n=618
Miller A. Plattform presentation ECTRIMS 2013
27. Primary / Key Secondary Endpoint
Primary Endpoint:
Time to Clinically Definite MS
(CDMS)
43%
Safety / Tolerability:
Adverse events observed in the trial were consistent with previous clinical trials
with Aubagio.
Miller A. Plattform presentation ECTRIMS 2013
21%
p=0.43
66
59%
p=0.00
08
Gd-enhancing T1 Lesions)
28. CIS: When To Initiate Therapy?
• Patients with normal MRI or with fewer than 2
– Low risk of developing early clinical attacks
– Clinical and MRI monitoring
– Without immediately commencing immunotherapy
(DMT)
• Those with abnormal MRI with2or> lesions
consistent with MS or with evidence of
intrathecal synthesis of antibodies should be
considered for DMT,
• Patients with atypical clinical or MRI presentation
require further diagnostic evaluation.
29. Relapsing-Remitting MS
• Subacute repeated onset of CNS dysfunction with
resolution ( sometimes incomplete , over days to
weeks)
• Revised McDonald criteria
• MRI: Periventricular, brainstem, juxtacortical
prominent T2, often Gad enhancing lesions, T1
hypointense (black holes)
• Treatment: Interferon-B, Glatiramer acetate,
natalizumab, mitoxantrone
30. Features Consistent With MS
• Relapses and remissions
• Age Onset between ages 15 and 50
• Optic neuritis
• Lhermitte's sign
• Internuclear ophthalmoplegia
• Fatigue
• Uhthoff's phenomenon
31. Features Inconsistent With MS
• Steady progression
• Onset before age 10 or after age 50
• Cortical deficits such as aphasia, apraxia, alexia,
neglect
• Rigidity, sustained dystonia
• Convulsions
• Early dementia
• Deficit developing within minutes
32. Secondary Progressive MS
• Majority of RRMS many years following onset
• Progressive impairment (spastic gait
disturbance) between or in absence of attacks
• No clear effect of DMT without ongoing
attacks or inflammation
• Role of DMTs in SPMS patients:
– with ongoing relapses
– Substantial ongoing accrual on new MRI
inflammatory lesions
33. Primary Progressive MS
• Presents with progressive myelopathic gait,
cerebellar ataxia or cognitive impairment without
clear history of any clinical attacks
• Clinical progression must be for at least 1 year
and accompanied by a combinstion of
brain&spinal abnormalities and/or CSF
anormalities consistent with MS
• Lack of clinical attacks/ relative paucity of MRI
lesions
• No approved DMTs
34. Multiple Sclerosis (MS)
• Multiple Sclerosis is the commonest disabling
neurological condition to afflict young adults
• MS is an autoimmune disease triggered by
environmental agents acting in a genetically
susceptible people
• Auto-aggresive autoimmune attack on the
myelin sheath and other components of CNS
• Current&emerging DMTs are based in the above
paradigm
• Is MS a primary neurodegenerative disease
37. Demographic
Characteristics of Multiple
Sclerosis in Kuwait
0
5
10
15
20
25
30
35
Mean Current
age
Mean age at
presentation
Mean duration
of Disease
Years
SD±5.4
SD±9.3
Total recruited patients in study: 195
Gender Distribution N(M/F): 195(76/119)
Cross sectional or retrospectively included
patients:134
Newly diagnosed drug naïve patient:65
SD±10.3
38. Clinical Characteristics of Multiple Sclerosis in Kuwaiti Population
20.50%
11.70%
9.40% 8.60%
7.30%
2.10% 1.50% 1.20% 0.60%
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
Sensory Brain stem
and
cerebeller
Visual Motor Multiple
Symptoms
Sphicter
disturbance
L' Hermitte
sign
Seizures Others
Presenting symptoms
39. PRESENTING SYMPTOMS IN MS Total %
SENSORY LOSS IN LIMBS 30.7
VISUAL LOSS 15.9
MOTOR WEAKNESS 14.2
DIPLOPIA 6.8
GAIT DISTURBANCE 4.8
NCOORDINATION 2.9
SENSORY LOSS-FACE 2.8
LHERMITTE’S 1.8
VERTIGO 1.7
BLADDER SYMPTOMS 1
AUTE TRANSVERSE MYELOPATHY 0.7
PAIN 0.5
OTHERS 2.5
POLYSYMPTOMATIC 13.7
42. MS Therapy: Deciding on which
Medication
• Determine Therapeutic Goals
– To reduce clinical relapse
– To reduce accumulation of new MRI lesions
– new T2 lesions
– Gadolinium-enhancing lesions
– black holes
– Brain and spinal cord atrophy
• Reduce short-term relapse related disability
43. How To Determine of The Goals are
Met?
• Compare with baseline relapse rate
– Recall bias
– Regression to the mean
• Assessment of improvement or stability in
neurological impairment
– Assess functional ambulatory limitation
• May indicate progression
• MRI ongoing/new inflammatory activity
– Serial MRI to assess radiologic stability, worsening or
improvement- q12-24 month except
44. How To Determine of The Goals are
Met?
• If goals of DMT or symptomatic treatment are
being met no change in DMT unless
problems with medication tolerability
• A detailed evaluation of common and
idiopathic side effects will be required
– Switching of medication based on adherence and
tolerability ma be needed
45. What if Goals are not being Met
• If pre-therapy relapse rate is not improved
– A therapeutic switch may be indicated
• Relapse rate is incomplete indicator of ongoing
inflammatory disease activity
– Cranial and spinal MRI
• May show therapy resistant inflammatory disease
• Guide switch to a more potent anti-inflammatory
medication
• Clinical attack or definitive worsening disability is may
lacking
46. Case 2
• Mr. A.M.J is a 33 years old Kuwaiti male, diagnosed to
have MS in 2008.
• In Jan 2008, he developed diplopia, followed by
paresthesia in feet, ascending to abdomen, chest and
forearms.
• These symptoms persisted
• By June 2008, he was ataxic and on a wheel chair,
when he sought medical advice
• MRI was consistent with MS
• Marked imrovement was noted in sensory symptoms
after pulse steroids.
47. Case 2
• His symptoms showed a rapid progression, by
Sept 2008, he had optic neuritis, sphincteric
disturbance, and positive Lhermitte’s sign.
• In Oct 2008, he started to take Rebif.
• His disease remained stable, with no new
relapses and no new lesions on MRI till 2011.
• In April 2011, he went for CCSVI treatment
and discontinued Rebif without our
knowledge or advice.
48. CASE 1
• Lhermitte’s sign was positive
• Cranial nerves were normal
• No motor weakness
• Mild sensory deficit for light touch and vibration
on left side
• Plantars were flexor bilaterally
• Romberg’s sign was mildly positive
• Moderate left sided dysmetria, with tandem
ataxia
• EDSS :2; AI :1.
52. Case 2
• In August 2011 he reported dizziness, ataxia and diplopia
• He was treated with pulse steroids with marked recovery.
• He was clinically stable, and was advised to restart Rebif.
• In Jan 2012, EDSS:1, AI:0.
• MRI in June 2012 showed new cerebellar lesions, with no
enhancement.
• In Oct 2012, he came in with a mild relapse and was
treated with pulse steroids.
• An MRI in Dec 2012 showed worsening lesion load, and he
was advised to start Tysabri after JCV serology.
• He started Tysabri in Dec 2012, and till 5 months post
Tysabri , there were no active lesions.
53. Case 2
• In Sept 2013, patient came with another
severe relapse , with homonymous
hemianopia, sphincteric problems, gait ataxia,
and sensory disturbance.
• Treated with pulse steroids with partial
improvement in urinary symptoms and ataxia,
but not in visual symptoms.
56. Case 2
• MRI showed marked worsening, with
tumefactive enhancing lesions
• A CSF study was done, which was normal,
negative for JCV.
• Considering this as a failure of Tysabri, it is
planned to treat him with Rituximab
57. Is Clinical Worsening due to Attack
related Disease or Progression?
• If it is due to non-inflammatory MS
progressive disease
– Neurodegenerative MS
– ?subclinical ( and sub-radiologic) inflammation
unresponsive to current DMTs
– Switching to alternative MS therapy is futile
• Escalating therapy If clinical impairment is
strongly associated with ongoing relapses or
marked new inflammatory MRI activity
59. IFNβ-1b
SC qod
GA
SC qd
IFNβ-1a
IM qwk
Mitox
IV q 90 d
wks
IFNβ-1a
SC tiw
Natalizumab
IV q 4 wks
Fingolimod
0.5 mg gd
Teriflun
PO qd
Laquin
PO
Daclizumab
SC
BG-12
PO bid
Alemtuz
IV
The Changing Landscape of MS Disease Modifying Treatment
Of Approved and Emerging Therapies
60. How are MS medication is selected?
• Injectable interferon-β and glatiramer acetate
remain the first line DMT for many clinicians
– Their side effects are manageable with minimum
of serious side effects
• First line DMTs are effective in reducing clinical
attacks and new MRI lesions
61. Injectable therapies
Oral therapies
Consider side effects
BG 12
Fingolimod
Terflunomide
Natalizumab
GlatiramerInterferon
β
Relapsing inflammatory MS clinical course
First line
First line?
Severe relapsing
inflammatory MS/JCV
negative
Inadequate
response/inj
intolerance
Inadequate
response/oral
intolerance
Parallel switch
Inadequate
response/JCV
negative
62. Drawback of injectable Medication
• Interferon-β
– “Flue-like illness” often transient
– Liver enzyme monitoring
– Rarely depression
• Glatiramer acetate
– Flushing, eosinophilia, rare allergic reaction,
injection-site reactions (skin liopatrophy)
– Conbination therapy+interferon-β1a IM/weekly
and glatiramer acetate does not appear to be
significantly more efficacious than monotherapy
Lublin FD et al, Ann Neurology 2013
69. BG-12
Integrated analysis
• Compared with PBO, BG-12 240 mg BID and TID
significantly reduced ARR, risk of relapse, adjusted ARR
requiring steroids, disability progression, and MRI
outcomes.
• Demonstrated consistent benefits on clinical efficacy
across prespecified subgroups of RRMS pts with varied
baseline demographics and disease characteristics
• Overall incidence of AEs, SAEs, and discontinuations
due to AES similar across tx groups; flushing and GI
events most common AEs
75. Daclizumab
• Effects similar in patients with highly active MS
compared with pts with less aggressive disease
prior to tx initiation
• Treatment resulted in significant increase in
number of pts who were disease- activity free
following 1 year of tx in SELECT trial
• Patients had reductions in % change in volume of
T1-hypointense and T2-hyperintense lesions over
52 wks of treatment vs increases in PBO group
76.
77. S1P receptor modulators/ agonists
• In phase 2b study, ponesimod significantly reduced inflammatory
MRI activity at all doses tested, with a significant dose response;
lower ARR also observed with ponesimod compared with PBO, and
was generally well tolerated
• Primary endpoint met in phase 2 DreaMS trial: ONO-4641
demonstrated significant efficacy on all key MRI measures of
disease activity at all 3 doses compared with PBO, and was
generally
• well tolerated Compared with PBO, reduction in mean CUAL
observed as early as
• month 1 for siponimod 0.25 mg/day and 2.0 mg/day, and in all
doses at month 2 in phase 2 BOLD trial; effect maintained at each
month up to month 6; similar pattern for new/enlarging T2 lesions
for all siponimod doses at month 2 and maintained at each month
up to month 613
78. Glatiramer acetate
• Compared with PBO, GA 40 mg SC TIW
significantly reduced:
• ARR by 34.4.% (P < .0001) Cumulative # GdE
lesions by 44.8% (P < .0001) Cumulative #
new/enlarging T2 lesions by 34.7%
• (P < .0001) Safety profile consistent with GA 20
mg/day SC
80. Teriflunomide
• Compared with PBO, 7 mg/day and 14 mg/day
teriflunomide significantly reduced ARR by 22.3% and
36.3%, respectively (P = .0183 and P = .0001, respectively)
• Compared with PBO, 14 mg/day teriflunomide significantly
reduced 12-wk CDP (HR = .685; P = .0442)
• Both teriflunomide doses generally well tolerated; safety
profile consistent with prior studies
• Update from TEMSO trial Mean reductions in lymphocyte
and neutrophil observed in TEMSO were small in
magnitude and were reversible after treatment
discontinuation or on treatment in some cases; no other
clinically significant complications to blood cytopenias
reported
81. a)Adjusted for Expanded Disability Status Scale (EDSS) score strata at baseline and takes duration of treatment into
account .ARR, annualised relapse rate; RRR, relative risk reduction
0.369
0.370
0.539
0 0.1 0.2 0.3 0.4 0.5 0.6
14 mg
7 mg
Placebo
Teriflunomide
Adjusteda annualized relapse rate
RRR: 31.2%
p=0.0002
RRR: 31.5%
p=0.0005
TEMSO: Relapse Rate
83. TENERE: Annualized relapse rate
• The ARR in the 14 mg teriflunomide group was
not statistically different from the ARR in the
Rebif® group
• The estimated ARR was higher in the 7mg
treatment group
0 0.1 0.2 0.3 0.4 0.5
Annualized Relapse Rate
Teriflunomide14 mg
N=109
Teriflunomide 7 mg
N=111
0.216Rebif®
N=104
0.259
0.410
Genzyme, Press release, Cambridge, MA – December 20, 2011
85. Fingolimod
• Treatment with fingolimod 0.5 mg:
– Significant benefits on relapse-related outcomes within first 3 months
and on volume loss over 6 months compared with PBO in FREEDOMS
and FREEDOMS II studies; concordant results from 2 large phase 3
trials, along with phase 2 data, allow better definition of expectations
regarding time lag between initiation and effects of fingolimod
treatment
• Fingolimod treatment initiation effects in pooled population from
FREEDOMS, FREEDOMS II (vs PBO), and TRANSFORMS (vs IM IFN à-
1a) a transient, mostly asymptomatic decrease in heart rate;
symptomatic bradycardia and Mobitz I and 2:1 AVBs were dose-
dependent; AVB first occurrences most common <6 h post-dose5
• Analysis of TRANSFORMS trial demonstrated advantage of
switching to fingolimod over remaining on IFN à-1a IM with regard
to time to relapse in RRMS6
86. LN
T-cell FTY720-P
Prevents T-cell invasion
of central nervous
system
S1P receptor
Sphingosine-1-phosphate (S1P) receptor modulator
Internalises S1P1, blocks lymphocyte
egress from lymph node (LN) while
sparing immune surveillance by
peripheral memory T-cells
FTY720 traps circulating
lymphocytes in
peripheral lymph nodes
Multiple sclerosis
FTY720
Fingolimod: Mechanism of Action
87. FREEDOMS (Fingolimod)
Annualized Relapse Rate
0.160.18
0.40
0.0
0.1
0.2
0.3
0.4
Annualisedrelapserate
Placebo
(n = 418)
Fingolimod 0.5 mg
(n = 425)
Fingolimod 1.25 mg
(n = 429)
-54% vs placebo
p < 0.001
-60% vs placebo
p < 0.001
ITT population; negative binomial regression model adjusted for treatment group, country, number of relapses in previous 2 years
and baseline Expanded Disability Status Scale (EDSS) as covariates
88. *Analysis performed using a negative binomial regression model adjusted for treatment group and country
**Analysis performed using rank ANCOVA adjusted for treatment group, country and number of lesions at baseline
Gd+, gadolinium-enhancing; MRI, magnetic resonance imaging
Fingolimod
0.5 mg
(n = 370)
Fingolimod
1.25 mg
(n = 337 )
0
2
4
6
8
10
12
9.8
(13.2)
2.5
(7.2)
2.5
(5.5)
Placebo
(n = 339)
# new/enlarging T2 lesions at month 24
from baseline*
Fingolimod
1.25 mg
(n = 343 )
0
0.2
0.4
0.6
0.8
1
1.2
Mean(SD)lesionnumber
Placebo
(n = 332)
Fingolimod
0.5 mg
(n = 369)
0.2
(1.1)
1.1
(2.4)
0.2
(0.8)
# T1 Gd+ lesions at month 24**
p < 0.001
p < 0.001
p < 0.001
p < 0.001
FREEDOMS (Fingolimod)
MRI Lesion Activity
89. FREEDOMS (Fingolimod)
Disability (Disability) Progression
Placebo
Fingolimod 0.5 mg
Fingolimod 1.25 mg
Patientswith3-monthconfirmedEDSS
progression(%)
Days on study
Fingolimod 1.25 mg vs placebo, HR = 0.68, p = 0.012
Fingolimod 0.5 mg vs placebo, HR = 0.70, p = 0.026
0
5
10
15
20
25
30
0 90 180 270 360 450 540 630 720
HR, hazard ratio
Editor's Notes
70
90
T2- lesions:
% relative reduction vs Placebo is 74% for both fingolimod dose groups
T1-Gd- lesions
% relative reduction vs Placebo is 82% for both fingolimod dose groups
Both oral fingolimod dose groups achieved significant improvements in disability progression over 2 years
Risk reduction for 3-month confirmed EDSS progression was -32% for the oral fingolimod 0.5 mg dose group and -30% for the 1.25 mg dose group