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Symptom Management

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  1. Symptom Management

  2. ARS Polling Which of the following strategies is recommended in the management of MS-related bladder dysfunction? • Restrict fluid intake to a maximum of 3 glasses daily • Increase intake of citrus juices to help prevent urinary tract infections • Prophylactic antibiotic use • Anticholinergic agents as first-line treatments for urgency • All of the above

  3. MS Symptoms vs Relapses MS symptoms • Chronic or ongoing indicators of MS lesion damage to certain areas of the brain or spinal cord MS relapses • Flare-ups or attacks of new or previously resolved symptoms that typically evolve over at least 48 hours and last several days to weeks

  4. Common MS Symptoms Fatigue Bladder dysfunction Spasticity Pain Cognitive impairment Mood instability Sexual dysfunction

  5. MS Fatigue One of the most common (80%) symptoms One of the most disabling symptoms Primary reason to stop working More likely than other types of fatigue to interfere with daily responsibilities Occurs daily, starts suddenly Can start early in the morning, even after restful sleep Worsens as day progresses, with heat and humidity Cause unknown National Multiple Sclerosis Society. http://www.nationalmssociety.org/about-multiple-sclerosis/what-we-know-about-ms/symptoms/fatigue/index.aspx

  6. Managing MS FatigueLifestyle Changes Physical therapy/exercise Good nutrition Enough sleep Going to bed on time Management of other symptoms that interfere with sleep Rest breaks Weight management Prioritization of tasks; maintaining realistic expectations Letting others help Avoidance of excessive caffeine, multitasking, overheating

  7. Managing MS FatiguePharmacologic Strategies (Off-Label Uses) Amantadine hydrochloride 100-200 mg/d early in day May need additional 100 mg around noon Modafanil 100-200 mg/d early in day Amphetamine-type therapies Methylphenidate, can start at 5 mg PO in AM and titrate to effect; 10 mg in AM and around noon or early afternoon is common Can use long-acting formulations

  8. Bladder Dysfunction Affects 80% of MS patients Frequency and/or urgency Hesitancy in starting urination Nocturia Incontinence and/or dribbling Urinary retention, which can lead to UTIs May interfere with normal activities and cause social embarrassment National Multiple Sclerosis Society. http://www.nationalmssociety.org/about-multiple-sclerosis/what-we-know-about-ms/symptoms/bladder-dysfunction/index.aspx and http://www.nationalmssociety.org/about-multiple-sclerosis/what-we-know-about-ms/symptoms/bladder-dysfunction/download.aspx?id=64

  9. Managing Bladder DysfunctionManagement Assessment Urinalysis/dipstick, culture (UTI) Postvoid residual urine Urodynamic studies Dietary and fluid management Do not restrict fluids! 6-8 glasses daily, spread over course of day, but fewer before bed Exception: restrict intake ~ 2 hours before activities where no bathroom will be available Limit caffeine, alcohol, citrus juice Intermittent self-catheterization Absorbent pads National Multiple Sclerosis Society. http://www.nationalmssociety.org/about-multiple-sclerosis/what-we-know-about-ms/symptoms/bladder-dysfunction/index.aspx and http://www.nationalmssociety.org/about-multiple-sclerosis/what-we-know-about-ms/symptoms/bladder-dysfunction/download.aspx?id=64

  10. Managing Bladder DysfunctionPharmacologic Strategies Antibiotics if positive for UTI Anticholinergic agents Oxybutynin, propantheline, imipramine, tolterodine, solifenacin succinate, darefenacin, trospium chloride Desmopressin acetate nasal spray or tablets (for nocturia) Need to monitor serum sodium Antispasticity agents (to relax sphincter muscle) Baclofen, tizanidine hydrochloride Alpha-adrenergic blockers Prazosin, terazosin, tamsulosin National Multiple Sclerosis Society. http://www.nationalmssociety.org/about-multiple-sclerosis/what-we-know-about-ms/symptoms/bladder-dysfunction/download.aspx?id=64

  11. Spasticity Velocity-dependent increase in muscle tone, with hyperactive deep tendon reflexes Clonus: repetitive rhythmic beating of foot or wrist Difficulty initiating movement Impaired voluntary muscle control Difficulty relaxing muscles after movement cessation Sensation of muscle tightness or pain Decreased range of motion Potential triggers: sudden movements or position changes, fatigue, stress, cold, humidity, tight clothes, tight shoes, constipation, poor posture, infection Can be worsened by interferons Can add to MS fatigue National Multiple Sclerosis Society. http://www.nationalmssociety.org/about-multiple-sclerosis/what-we-know-about-ms/symptoms/spasticity/index.aspx. Kushner S, et al. Spasticity. NMSS Clinical Bulletin. http://www.nationalmssociety.org/download.aspx?id=147

  12. Managing SpasticityNonpharmacologic Strategies Daily stretching and exercise (cool environment) Balance and coordination, strengthening, timing, range of motion, posture Transcutaneous electrical nerve stimulation (TENS) Thermal (hot and cold) Biofeedback Relaxation (yoga, Tai Chi) Bracing/splinting Kushner S, et al. Spasticity. NMSS Clinical Bulletin. http://www.nationalmssociety.org/download.aspx?id=147

  13. Managing SpasticityPharmacologic Strategies Baclofen - oral or intrathecal; start low and titrate Tizanidine Dantrolene sodium Diazepam Other off-label agents sometimes used Clonazepam, gabapentin Botulinum injections for focal spasticity Phenol nerve blocks Kushner S, et al. Spasticity. NMSS Clinical Bulletin. http://www.nationalmssociety.org/download.aspx?id=147.

  14. Managing SpasticitySurgery for Intractable Symptoms Tenotomy Neurectomy Rhizotomy Kushner S, et al. Spasticity. NMSS Clinical Bulletin. http://www.nationalmssociety.org/download.aspx?id=147

  15. Managing Gait Difficulties Dalfampridine—previously known as fampridine SR or 4-aminopyridine SR FDA approved January 2010 Indication: improve walking speed in patients with MS This is not a disease-modifying therapy Mechanism: K+ channel blockade Enhances axonal conduction Dose-dependent side effect: seizures Ampyra [package insert]. Hawthorne, NY: Acorda Therapeutics; 2010.

  16. P <.001 Responders (%) Dalfampridine Phase III Studies • Dalfampridine 10 mg BID (n = 229) or placebo (n = 72) x 14 weeks • Response = consistent improvement on timed 25-foot walk • Walking speed improved by 25% among fampridine responders vs 5% with placebo (Trial 1) Ampyra [package insert]. Hawthorne, NY: Acorda Therapeutics; 2010. Goodman AD, et al. Lancet. 2009;373:732-738.

  17. Managing Other MS Symptoms National Multiple Sclerosis Society. http://www.nationalmssociety.org/about-multiple-sclerosis/what-we-know-about-ms/symptoms/pain/index.aspx, http://www.nationalmssociety.org/download.aspx?id=127, http://www.nationalmssociety.org/about-multiple-sclerosis/what-we-know-about-ms/treatments/medications/antidepressants/index.aspx, http://www.nationalmssociety.org/about-multiple-sclerosis/what-we-know-about-ms/symptoms/sexual-dysfunction/index.aspx

  18. ARS Polling Which of the following strategies is recommended in the management of MS-related bladder dysfunction? • Restrict fluid intake to a maximum of 3 glasses daily • Increase intake of citrus juices to help prevent urinary tract infections • Prophylactic antibiotic use • Anticholinergic agents as first-line treatments for urgency • All of the above

  19. Conclusions Managing MS means thinking about more than just preventing relapse and new lesions It is important to address other symptoms that interfere with QOL Symptoms need to be recognized in order to treat Address 1 or 2 symptoms per visit—prioritize Through counseling and treatment, most symptoms can at least be reduced Refer to specialists as needed for optimized symptom control Expect that many symptoms will never be fully controlled