Medication

Relapse

• Short course of corticosteroids (Methylprednisolone 500 mg-1g, IV or oral for 3-5 days) accelerate recovery from relapse and should be considered for any attacks resulting in significant disability. Steroids do not appear to influence long-term outcome from relapse and there is no role for long-term oral steroids.

Disease management

• In ambulant patients with active relapsing remitting MS (2 significant relapses in the last 2 years) referral to secondary or tertiary care should be discussed for consideration of disease modifying agents (ref 172). Interferon Beta-1a/b and Glatiramer Acetate are licenced for the treatment of relapsing remitting MS, in most patients treatment will reduce relapse rate and may delay development of fixed disability. All treatments are given by injection, varying from weekly I/M to daily s/c dependent upon particular product. Initiation of treatment will normally be supervised by MS Nurse specialists, good education on the role and likely side-effects of treatment and good patient support in the early stages are imperative to ensure compliance.
• In secondary progressive MS there is much more limited evidence for a role of disease modifying agents. Current guidelines http://www.theabn.org) suggest that treatment should be considered in ambulant secondary progressive patients with frequent disabling relapses, though such patients are rare as relapses tend to be less frequent in more advanced disease, again assessment by local Neurology services is appropriate.
• No treatment to date has been found to alter the natural history of primary progressive MS
• In very active MS there may be a role for more potent immunosuppressive treatment, under the guidance of specialist neurology services.

Symptom management

• Careful consideration should be given to the use of symptomatic treatments, particularly in patients on multiple drug treatments. Both drug interactions and impact on other symptoms need to be considered (eg worsening of fatigue or impaired balance with carbamazepine given for neuropathic pain) (ref 173).
• Symptomatic treatment should be regularly reviewed in the light of fluctuations or progression of disease, occasional careful withdrawal of individual drugs may be appropriate to confirm the continued need for treatment
• Symptomatic spasticity (painful spasms, disturbed sleep by spasm) should be treated with anti-spasmodics (Baclofen, Tizanidine). Side-effects can include exacerbation of weakness or impairment of function by alleviation of ‘useful’ spasticity (eg in the patient who uses the lower limb spasticity to allow them to briefly stand and transfer).
• Neurogenic bladder symptoms of detrusor instability (usually urgency or frequency) can be suppressed with anticholinergics. A significant post-micturition residual (usually >100mls), suggesting detrusor/sphincter dysnergia, should be excluded as this will tend to be worsened by treatment. Incomplete bladder emptying is best managed by clean intermittent self-catheterisation by patients or carers, usually once or twice daily.
• Mood disturbance, particularly depression, is common (up to 50% at some point in the illness) and both under-recognized and treated. Standard treatment with a tricyclic (which may also improve neurogenic bladder instability) or SSRI should be considered.
• Persistent pain occurs in around 30% of patients and may be neuropathic or musculoskeletal, secondary to abnormal gait or limited mobility. Neuropathic pain (generally described with terms such as ‘burning, sharp, stabbing’) can be treated with low-dose Amitryptiline or anticonvulsants.
• Erectile dysfunction occurs in up to 50% of male patients and should be actively identified, it is particularly likely to occur in conjunction with other symptoms of spinal disease (lower limb weakness and spasticity, bladder dysfunction). Treatment with sildenafil (Viagra) or tadalafil is generally effective, if not consideration should be given to referral to secondary care for assessment.

References

172. Rice GA, Incorvara B, Munan L et al. Interferon in relapsing-remitting Multiple Sclerosis. In: The Cochrane Library, Issue 2, 2002.

173. Burgess M. MS symptoms and their treatment. In: Multiple Sclerosis: Theory & Practice for Nurses. London: Whurr 2002, pp. 72-100.

Last edited: 26/1/2004

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