Need at least 2 neurological events separated in time and place
Clinical
CSF Mononuclear cell pleocytosis (usually <20)
Increase total IgG
Oligocloncal IgG (found in 75-90%, but may be absent at onset)
Evoked Responses Visual (suaully remain abnormal)
Auditory
MRI Abnormal hyperintense areas on T2
New lesions are gadolinium enhancing
Education
Support
Physio
OT inc home modifications
(notice the nice mnemonic)
Spasticity
Constipation
Lethargy
Erections
uRgency
Ouch-Pain
Shaking-Tremor
Immunisations
Suicide/Depression
Spasticity – Use drug treatment only in conjunction with physio. Beware that some people rely on spasticity to overcome leg weaknes and walk. If there is an acute worsening rule out underlying infecion. Other drug treatment modalities include Baclofen (GABA analogue) 40-80mg in 3-4 divided doses (initially can lead to weakness and sedation so give the dose at night) and be careful not to stop this abruptly as it can resulting tachycardia, psychosis and seizures. Baclofen can also be given in an intrathecal pump. Valium 2-10mg po tds, Gabpentin 900-1200mg in divided doses are also an option. Finally, Dantrolene, only if the patient is bed bound can be used but beware the side effects of hepatitis, seizures, pleural effusions, pericarditis, slurred speech and enuresis.
Constipation- Initially recommend a high fibre diet, hydration, exercise. The a bowel program consisting of aperients such as docusate, suppositories and manual stimulation. If the constipation affects the patients quality of life, rarely colostomies are formed.
Lethargy- First of all rule out depression, get occupational counselling and consider recommending a sleep in the middle of the day. Amantadine 100-200mg po daily and fluoxetine can be trailed. These may be able to be withdrawn after a number of months because of spontaneous improvement.
Erections- Differentiate the pathological and psychological causes of sexual dysfunction. In women, vaginismus may be a problem, consider baclofen. Dryness may also require lubrication. In men, erectile dysfunction may be treated with Viagra or prostaglandin injections. Referral to a sexual counsellor may also be important.
Urgency – In simple cases there is no need to do urodynamics, but its always important o exclude infection and constipation. The main three problems include detrusor instability – leading to urgency which usually responds to frequent bladder emptying and the use of an anticholinergic agent sucha as prpantheline/ amitriptyline/ imipramine or oxybutynin. If the manifestation is not just simply urgency then formal urological assessment is needed Detrusor-sphincter dyserngia usually responds to an anti-cholinergic and intermittent catherisation. Bladder hypotonicity (retention) may need a cholinergic agent such as bethanacol 10-50mg tds.
Ouch-Pain (relates to paroxysmal symptoms) – this can include trigeminal neuralgia, dystonic posturing and pseudosciatica. Trial carbamazepine, clonazepam, phenytoin, tricyclics, valproate (2nd line agent) or acetazolamide which seems ot be good for paroxysmal paraesthesiae.
Shaking-Tremor – Trial clonazepam (1mg po initially increasing to 6mg) then carbamazepine (100 to 300mg po bd). Rarely use isoniazid.
Immunisations – Essential ones only
Suicide/ Depression – Psychiatric complications approach 50%, may tend to use tricyclics because of the beneficial side effects. Beware that depression can be exacerbated by steroids, beta-interferon and baclofen.
Acute relapse – Exclude pseudorelapses due to infections. Then treat with IV methylpred e.g. 500mg IV for 3-5 days. Remember to ask about acute (and chronic) side effects e.g. mood, increased BSLs
Chronic –
Relapsing-Remitting
IFN-1B SC 8 million units q2nd daily Flu-like symptoms, BM depression, Inc LFTs, Depression
Contriindicated in pregnant women
Prevents relapse, decrease progression to disability
IFN-1B IM 6 million units 1* week As above
SC 6-12 million units 3 times week
Glatimer Acetate SC 20mg daily Transient flushing, chest tightness, SOB, Palpitations
Prevents relapses/ possible disability
Decreased efficacy with increased entry diability
Secondary Progressive
IFN-1B
Rarely Methotrexate
Primary Progressive
?Mitoxantrone