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KEY CONCEPTS

KEY CONCEPTS

  • image The etiology of multiple sclerosis (MS) is unknown, but it appears to be autoimmune in nature. Currently there is no cure.

  • image Multiple sclerosis is characterized by central nervous system (CNS) demyelination and axonal damage.

  • image Multiple sclerosis is classified by the nature of progression over time into several categories, which have different clinical presentations and responses to therapy.

  • image Studies only support one FDA-approved disease-modifying therapy (DMT), ocrelizumab (Ocrevus), in patients with progressive forms of the illness. Information derived from multiple studies suggests younger patients with progressive illness and those with either superimposed acute relapses or enhancing lesions on magnetic resonance imaging (MRI) scans may benefit from some of the presently used DMTs.

  • image The diagnosis of MS is made primarily on the basis of clinical symptoms and examination, but does require evidence of dissemination of lesions over time in multiple parts of the CNS and/or optic nerve. Additional diagnostic criteria include use of MRI, spinal fluid evaluation, and evoked potentials to aid in the diagnosis.

  • image Exacerbations or relapses of MS can be disabling. When this is the case, exacerbations and relapses are treated with high-dose glucocorticoids, such as intravenous (IV) methylprednisolone, with onset of clinical response typically within 3 to 5 days.

  • image Treatment of relapsing-remitting multiple sclerosis (RRMS) with the DMTs interferon-β (IFN-β) (Avonex, Betaseron, Rebif, Extavia), glatiramer acetate (Copaxone), natalizumab (Tysabri), ocrelizumab (Ocrevus), mitoxantrone (Novantrone), fingolimod (Gilenya), teriflunomide (Aubagio), dimethyl fumarate (Tecfidera), and alemtuzumab (Lemtrada) can reduce annual relapse rate, lessen relapse severity, slow progression of MRI changes, and slow progression of disability and cognitive decline. In addition, DMTs have been shown to reduce the likelihood of developing a second attack after a first clinically isolated syndrome (CIS) consistent with MS.

  • image In most cases, treatment with DMTs should begin promptly after the diagnosis of RRMS, or after a CIS, if the brain MRI is suggestive of high risk of further attacks. Natalizumab, and other choices that have been associated with problematic adverse events, should be reserved for those patients who have failed one or more standard therapies and those with poor prognostic signs.

  • image The definition of “treatment inadequacy” for RRMS remains unclear, and therapy changes after “treatment failure” should be individualized.

  • image Patients suffering with MS frequently have symptoms such as spasticity, bladder dysfunction, fatigue, neuropathic pain, cognitive dysfunction, and depression that may require treatment. Patients must be counseled that DMTs will not relieve these symptoms. Depression is common in MS and can pose the risk of suicide.

PATIENT CARE PROCESS

Patient Care Process for Multiple Sclerosis

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Collect

  • Patient specific demographics such as age, race, gender, geographical places of residence before or after the age of 15, current smoking level and history, family history of MS, and previous infection with certain viruses

  • Laboratory values such as vitamin D, liver function tests, complete metabolic panel, and complete blood count

  • Magnetic resonance imaging (MRI) of brain and spinal cord with and without contrast

  • Lumbar puncture for ...

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