Patient Encounter Part 2

CN begins to improve after 2 days of methylprednisolone 1 g IV daily. The treatment team wants to begin a disease-modifying treatment.

Do you agree that she should be on a disease-modifying treatment? Why?

If so, which treatment would you choose? Recommend a dosing regimen.

How should the patient be counseled on the chosen treatment?

MS patients usually have upper motor neuron spasticity; this type of spasticity cannot be treated with muscle relaxants (i.e., carisoprodol). MS patients must be treated with agents specific for upper motor neuron spasticity (Table 29-8).10 MS spasticity is classified as focal or generalized. If the spasticity involves on1l0y one muscle group, it is focal and may benefit from botulinum toxin administration.1 Systemic medications are used for generalized spasticity. No clear conclusion can be reached regarding the superiority in efficacy of one agent; medication selection is usually based on adverse effects (see Table 29-8).10

Other Symptoms

Two types of urinary tract symptoms are commonly seen in MS: Incomplete bladder emptying and incontinence. Incomplete bladder emptying is due to dyscoordination of the external urethral sphincter and detrusor activity.1 Most patients who develop this

condition require intermittent or permanent urinary catheterization. Incontinence in most MS patients is caused by neurogenic detrusor overactivity. First-line treatments are anticholinergics such as oxybutynin, tolterodine, flavoxate, or antimuscarinic tricyclic antidepressants.

Bowel symptoms in MS patients can include both fecal incontinence and constipation. Fecal incontinence is difficult to treat; a regular schedule for emptying the bowel with laxative suppositories or enemas may be helpful. Alternatively, antidiarrheal medications such as loperamide can be used.13

Pain may occur in up to 86% of patients with MS. Pain may be neuropathic, related to spasticity, related to treatment, or unrelated to MS. Correct pain type classification is necessary for effective treatment.

Desipramine and sertraline are efficacious for MS-related depression.14 If ^-in-terferon treatment appears to be causing depression, discontinuation could be considered.

Table 29-7 Pharmacologic and Nonpharmacologic Treatments for Fatigue

Honphtf irnt eloq k

Pliarma-tologii

Renal Do il

AppropLHe res! to -activity ratio

Use od «¿nllve devices looonseive energy

Environmental nvidiiicntiorii tomate acidities ■nef c tncigy-i.'ificicnt

Cooling strategies to avoid fatigue caused by elevation» in cme body temperature due ta heit tnrdwftllted l'botiioiv ¿nul fem

Regular afrûhf te. ILHIV*

person's ability, to promote cardiovascular hflllt\ ^tiL'ixjlh. iiTi|>iiivi^ ItWOd, Hid IfAli*'

fjlHjJS

Stress management techniques GQ creatinine clearance From RtHs.il, S3.

Ffrsf'^tetrimipy:

Aiinantadi*ie tÛOingoiallyevery pjn^ri "y jnd «I iy iivi nooft

SenoryiItne ttwapy: Methylphenidate 10-20 mg eve>y ritctn-xj and nocn

C'rCI li-ÎÇmLtnin 100 mg uveryothw day

CrClknttunlS mLAnin 200 nri evoiy 7 (fcyv

Table 29-8 Comparison of Antispasticity Agents

Maceta Therapy

Mcdlullon

Methtnlim of Action

Dois

First Une

Bac bien

Pie and cost synaptfc y aminobutync acid

5 mg orally Î * daily, increase-by 5 mudóse eve«y

jS-fHMMptCl tJüílfíT

ïdày! loa iriMimum oí Sa mg/ldïy

ñoñi dysfunction: Dose reduc ten may be

necessary

"liidnidine

CentiallyacUng u.ieceiUDr acjonitl

A nvg orally daily, irx reaííf by 2- ing 3 4 * daily to a

nBHjniurri of 56 n^diy

(tosí wJvciion may tw

necessary

Sjyiqncl ■ limL

ILmEMlriH1

l mhhil^i ■:il iivu^ l1 [QTilijrlmn

rTK| çijllydLiil^ kKK^Tlfr rni | 1 Í M rEjüy. iN'rk

b^ decreasing the ideate of cafoum

increase by 2i mg every A-7 days (d a maximum of

fiom ilodclal rpuKk' i-irtopljMnk

WQmyföay

«heu hi nn

DiJ2epJrri

vArrtnoburyrk: àtid ¿gomr

2-l(}mçû<dlly 3 J * tidily

ÍMeüfc teduC* Hy SWt

Third-line

lntriliifi.il

Are ■ and poi1-synaplE yaminobutyic acid

Titrated .idividi.-jlly, usual lange iî-749 meg/day

bickjfm

Tocil 5IWÜTÜV

linum toicin

ñr^ipnts hHfúw al icttyfcficftne in chf

Irtdividualired

neuromuscular Junction

Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

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