Pharmaceutical Treatments for Multiple Sclerosis

• Learn how multiple sclerosis (MS) affects the nervous system and the physical examinations used in its diagnosis. 
• Understand the different drugs used to treat multiple sclerosis, the typical dosage, and the expected side effects.
• Review information that nurses can share about multiple sclerosis to support their patients. 

Multiple sclerosis, commonly known as MS, is a chronic and progressive degenerative disease of the central nervous system that affects the myelin sheath of the white matter of the brain and spinal cord. It is the most common debilitating disease, especially in adults. Each year, 25,000 people are newly diagnosed with MS. The disease affects the quality of life more than the duration of life.

Generally, nerve impulses are conducted between the brain and the spinal cord along neurons protected by the myelin sheath- a highly conductive fatty material. In multiple sclerosis, inflammation of the myelin sheath occurs, which leads to demyelination, and nerve transmission becomes erratic.

Areas that are commonly involved are:

• Optic nerves
• Cerebrum
• Cervical spinal cord

There are four identified forms of multiple sclerosis, such as:

• Benign MS- causes mild disability; infrequent, mild, early attacks are followed by almost complete recovery.
• Exacerbating-remitting MS- frequent attacks that start in the early phase of illness, followed by a less complete clearing of signs and symptoms, compared to benign MS.
• Chronic relapsing MS- it has fewer complete remissions after an exacerbation than has exacerbating-remitting MS. It has cumulative progression, with more symptoms occurring during each new attack.
• Chronic progressive MS- is somehow similar to chronic relapsing MS except that the onset is more subtle, and the disease progresses slowly without remission.

Multiple sclerosis is an autoimmune disorder. Often the cause for it is unknown. The predisposing factors can be:

• Pregnancy
• Infection
• Trauma

The risk of developing multiple sclerosis increases up to 15 times if the disease is present in the patient’s immediate family.

Physical Examination

The common symptoms of multiple sclerosis include:

• Tingling and muscle cramping
• Tremor
• Ataxia
• Speech disorders
• Visual changes
• Bowel and bladder dysfunction

If you suspect the patient has multiple sclerosis, determine their muscle strength and symmetry, arm and leg movement, and gait. To know about arm strength, ask the patient to use both hands to push against her. Assess both unilateral and bilateral weakness.

Ask the patient to open and close the fist and to move each arm without raising it from the bed. If no purposeful movement occurs, apply light tactile pressure to each arm, gradually increasing the pressure in an attempt to elicit a purposeful response. Assess leg movement in the same way.

Ask the patient to move each leg and, if they cannot, press the Achilles tendon firmly between your thumb and index finger, observing for a purposeful or non-purposeful response.

To observe gait, ask the patient to walk away from you. During that, observe them for ataxia, stumbling, or shuffling. However, stay close to the patient while they perform the task to prevent falls. If the patient performs these tests well, then test their balance by having them walk heel-to-toe in a straight line and observe any leaning to one side.

Drugs Used In Multiple Sclerosis

Here we will discuss the drugs used in multiple sclerosis, their brand names, doses, and side effects.

Alemtuzumab

• Brand name: Lemtrada
• Dose: 12 mg IV once daily for 5 days, followed 1 year later by 12 mg IV once daily for 3 days.
• Side effects: Rigors, tremors, nausea, vomiting, rash, fatigue, hypotension, urticaria, pruritus, skeletal pain, headache, diarrhea, neutropenia, anemia, thrombocytopenia, respiratory toxicity such as dyspnea, cough, pneumonitis, infections

Cladribine

• Brand name: Mavenclad
• Dose: Recommended cumulative dosage is 3.5 mg/kg body weight administered orally and divided into 2 years. The treatment course is 1.75 mg/kg/treatment course.
• Side effects: Upper respiratory tract infection, headache, lymphopenia

Daclizumab

• Brand name: Zinbryta
• Dose: 150 mg SQ once monthly
• Side effects: Autoimmune disorders such as hepatitis, lymphadenopathy, and noninfectious colitis, along with depression, severe hypersensitivity reactions, infections

Dimethyl fumarate

• Brand name: Tecfidera
• Dose: 240 mg PO bid
• Side effects: Flushing, abdominal pain, diarrhea, nausea, vomiting, dyspepsia, lymphopenia, hepatotoxicity, progressive multifocal leukoencephalopathy or PML

Fingolimod

• Brand name: Gilenya
• Dose: 0.5 mg PO once daily
• Side effects: Headache, back pain, cough, infections, hypersensitivity reactions, elevated LFTs, bradycardia, AV block, macular edema, decreased pulmonary function

Glatiramer

• Brand name: Copaxone and Glatopa
• Dose: For Copaxone: 20 mg SQ once daily or 40 mg 3 times per week and Glatopa: 20 mg SQ once daily
• Side effects: Pain, erythema, inflammation, pruritus at the injection site, arthralgia, transient chest pain, post-injection reactions such as chest pain, palpitations, dyspnea

Interferon beta 1a

• Brand name: Avonex and Rebif
• Dose: Avonex: 30 mcg IM weekly and Rebif: 44 mcg 3 times per week
• Side effects: Headache, flu-like symptoms, myalgia, depression with suicidal ideation, generalized pain, asthenia, chills, injection site reaction, hypersensitivity reactions, anemia, hepatotoxicity

Interferon beta 1b

• Brand name: Betaseron and Extavia
• Dose: 250 mcg SQ every other day
• Side effects: Headache, flu-like symptoms, myalgia, upper respiratory tract infection, depression with suicidal ideation, generalized pain, asthenia, chills, fever, injection site reaction, hypersensitivity reactions, anemia, hepatotoxicity, seizures

Mitoxantrone

• Brand name: Novantrone
• Dose: 12 mg/m2 IV every three months
• Side effects: Nausea, vomiting, diarrhea, cough, headache, stomatitis, abdominal discomfort, fever, alopecia, cardiotoxicity, myelosuppression, acute/chronic myeloid leukemia

Natalizumab

• Brand name: Tysabri
• Dose: 300 mg IV every 4 weeks
• Side effects: Headache, fatigue, depression, arthralgia, infections, hypersensitivity reactions, hepatotoxicity, PML

Ocrelizumab

• Brand name: Ocrevus
• Dose: 600 mg IV every six months
• Side effects: Infusion reactions such as pruritus, rash, urticaria, and erythema, along with respiratory tract infections, skin infections, malignancies, PML

Pegylated interferon beta 1a

• Brand name: Plegridy
• Dose: 125 mcg SQ every 2 weeks
• Side effects: Headache, flu-like symptoms, myalgia, depression with suicidal ideation, generalized pain, asthenia, chills, injection site reaction, hypersensitivity reactions, anemia, hepatotoxicity, elevated LFTs, seizures

Siponimod

• Brand name: Mayzent
• Dose: Titration is required for treatment initiation. It can be given as 0.25 mg oral OD on days 1 and 2, followed by 0.5 mg oral OD on day 3, 0.75 mg oral OD on day 4, and 1.25 mg oral OD on day 5. The recommended maintenance dosage is 2 mg per day on day 6.
• Side effects: Headache, hypertension, increased serum ALT, AST

Teriflunomide

• Brand name: Aubagio
• Dose: 7 or 14 mg PO once daily
• Side effects: Headache, diarrhea, nausea, alopecia, paresthesia, abdominal pain, elevated LFTs, neutropenia, leukopenia, hepatic failure, acute renal failure, toxic epidermal necrolysis

Other medications used in multiple sclerosis are:

• Corticosteroids such as prednisone, dexamethasone, and prednisolone to reduce inflammation. It helps decrease symptoms and induce remissions.
• Antianxiety agents, such as chlordiazepoxide hydrochloride (Librium), may be prescribed to manage mood swings.
• Baclofen (Lioresal) or dantrolene (Dantrium) to relieve muscle spasticity.
• Patients with urinary symptoms may also require bethanechol (Urecholine) or oxybutynin (Ditropan).

Patient Teaching About Multiple Sclerosis

As a healthcare provider, you should teach the patient about their disease and how to cope with it. 

Sensory perceptual deficits in the visual field due to multiple sclerosis can cause dizziness, headaches, and injuries. Patching each eye and alternating with the other several times a day can improve balance and visualization.

The patient’s peripheral vision may be affected. Therefore, teach them to scan the environment and remove potential sources of injury.

Ask the patient to look out for hot surfaces and hot water to which they might not be sensitive.

Make sure that the patient knows the importance of taking rest. And make them understand not to get over fatigued or overheated. Ask them to have alternate periods of rest with activity and not to overexert themselves. Discuss that frequent rest periods need to be a permanent lifestyle change.

Explain to the patient that showers and long baths can help relieve symptoms. But sometimes, they can exacerbate multiple sclerosis symptoms.

Conduct a range of motion exercises at least twice daily. If needed, teach the patient how to use a walker or a cane.

If the patient has a neurogenic bladder, instruct them to consume 1500 mL of fluid daily and void every 3 hours. For urine retention, teach intermittent self-catheterization with a clean technique to the capable patient. Some patients, however, are incontinent.

To avoid skin breakdown, teach the patient to use skin pads.

Guide the patient in developing a regular bowel pattern by having bowel elimination 30 minutes every morning after breakfast. If there is a need to activate reflex bowel activity, insert a glycerine suppository. Should the patient be unable to insert it, assist them.

Patients with multiple sclerosis need nursing and mental counseling because day by day they lose mobility. They might also lose their roles as a parent or a spouse. Therefore, listen to them, respect their fears and abilities, and give positive encouragement.

The Bottom Line

Multiple sclerosis is a progressive disease that affects a person’s mobility and function. You need to be empathetic and lend a listening ear.

In rapidly progressive forms of MS, the patient might have impairment of cognitive functioning. However, touch and voice tone can convey concern and care when the meaning of words gets lost.

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