Multiple sclerosis resident survival guide
Synonyms and Keywords: Multiple sclerosis management, Multiple sclerosis workup, Multiple sclerosis approaches, approach to Multiple sclerosis, Multiple sclerosis treatment
Multiple sclerosis is an autoimmune demyelinating disease of the central nervous system and it’s known to be multi-factorial. The onset of symptoms are mostly between the age of fifteen to forty years (rarely before age fifteen or after age sixty), and include fatigue, mood problems, spasticity, bowel and bladder dysfunction, cognitive impairment, eye movement problems, heat sensitivity, incoordination, pain, sexual dysfunction, sleep disorder, vertigo and visual loss. There is no single diagnostic study of choice for Multiple sclerosis. Diagnosis is currently made by the fulfilment of the McDonald criteria, which include clinical presentation, cerebral plaques on MRI , and oligoclonal bands in CSF analysis. Treatment for multiple sclerosis includes disease-modifying medications (DMTs) and immunosuppressors to prevent relapses and Glucocorticoid therapy in acute exacerbations.
Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.
- There are no life-threatening or permanent disabiling causes for Multiple sclerosis if left untreated within 24 hours.
|Clinical presentation||Additional Data Needed|
||New criteria: Dissemination in space, demonstrated by:|
||Dissemination in time (DIT), demonstrated by:
and non-enhancing lesions at any time; or A new T2 and/or gadolinium-enhancing lesion(s) on follow-up MRI, irrespective of its timing with reference to a baseline scan; or await a second clinical attack. [This allows for quicker diagnosis without sacrificing specificity, while improving sensitivity]
||New criteria: Dissemination in space and time, demonstrated by:
||New criteria: One year of disease progression (retrospectively or prospectively determined) and two or three of the following:
|Single clinical episode suggestive of MS|
|Without MRI abnormalities||With MRI abnormalities and fulfilling the McDonald criteria|
|Do not treat||Fulfills the definition of Clinically Isolated Syndrome (CIS)||Patient with relapsing-remitting MS||Radiological markers indicative of a poor prognosis for rapidly developing permanent disability|
|Do not treat||Interferon beta 1a or glatiramer acetate||Alemtuzumab or Ocrelizumab|
|Relapse||2 significant relapses in last 2 years|
|Plasmapheresis||Alemtuzumab or Ocrelizumab|
|Steroids||Severe relapse or contraindications to high dose-steroids|
|Positive John Cunningham (JC) virus|
|Close MRI follow-up or change to Cladribine|
- If patient presents with clinical isolated sindrome (CIS), recommend serial imaging at least annually for the first 5 years and close follow-up rather than initiating DMT.
- Counsel patients with newly diagnosed MS about specific treatment options with DMT, side effects, and reproductive plans at a dedicated treatment visit.
- In the presence of a relapse, do not waste time to give steroids; plasma exchange may be necessary in case of an acute-severe setting or when there is contraindications to high-dose corticosteroids.
- Cladribine and the monoclonal antibody therapies should be discussed by a multi-disciplinary team (MDT) meeting, defined as a minimum of at least two specialist consultant neurologists plus at least one specialist MS nurse, with access to neuro-radiology expertise.
- Perform follow-up MRIs in patients with anti-JCV antibody positive status using Natalizumab. Natalizumab may be changed to Cladribine or Fingolimod if treatment duration exceeds 2 years or the patient is in a immunosuppressant state.
- Indicate six weeks of comprehensive multidisciplinary outpatient rehabilitation, since it has shown to be effective for improving disability/function.
- Do not continue disease modifying therapy if adverse effects of the drug are observed, the patient becomes pregnant or they develop progressive disease or fixed disability above EDSS 6.5.
- Do not prescribe mitoxantrone to people with MS unless the potential therapeutic benefits greatly outweigh the risks, due to high frequency of severe adverse effects.
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