Treatment issues in Pediatric Multiple Sclerosis

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Treatment issues in Pediatric Multiple Sclerosis

• Brenda Banwell, MD, FRCPC
• Director, Pediatric Multiple Sclerosis Clinic
• The Hospital for Sick Children
• University of Toronto

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Child with MS
Chronic immunosupression
Acute symptoms
Symptomatic treatment
MS-targeted therapies
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Management of the Acute Demyelinating Attack
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General Approach

• Ensure that symptoms are referable to
  demyelination
• Evaluate symptom severity
• Review prior response to acute management
• Review timing of last exposure to corticosteroids

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IV Solumedrol 20-30 mg/kg/dose X 3 days
Minimal or no improvement
Improvement
Prednisone start at 1 mg/kg/day, taken as a
single morning dose
IV Solumedrol 20-30 mg/kg/dose X 2 additional
days
Taper by 5 mg every 2-3 days
No improvement
Improvement
IVIg 2 mg/kg total dose if lt 50 kg or gt 50 kg
Relapse of SS during taper
Improved /stabilized
Initiate immunomodulatory treatment if patient
meets criteria for MS diagnosis
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MS-targeted immunotherapies in children
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Side effects
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Safety Monitoring
Contraception reminder
Contraception counseling
Liver function CBC
Liver function CBC
Liver function CBC
4 weeks
Baseline
monthly
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Chronic Immunosuppresion
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Cyclophosphamide

• Alkylating agent with cytotoxic and
  immunosuppressive properties
• controversial efficacy in large studies
• recent evidence suggests a role for
  cyclophosphamide in patients with frequent
  relapses who fail to respond to MS-disease
  modifying agents
• Side effects include alopecia, hemorrhagic
  cystitis, infertility, opportunistic infections
  and an increased risk of future malignancy

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Mitoxantrone

• Potent immunosuppressant
• typically prescribed at a dose of 12 mg/m2 IV
  every 3 months for 2 years)
• cumulative risk of cardiotoxicity with increasing
  dose
• no data in pediatric MS

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Symptomatic Therapies
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Fatigue

• Definition sufficient fatigue, or a subjective
  sensation of reduced endurance, to interfere with
  enjoyable activities or impair concentration at
  school
• typically manifests as withdrawal from social
  activities, after school naps, reduced ability to
  participate in sports
• occurs in approximately 30 of pediatric MS
  patients

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Treatment of Fatigue

• Reduce wasted exertion
• backpacks
• home textbooks
• occupational therapy
• Modafinil (Provigil)
• shown to improve fatigue in adults
• well tolerated in pediatric MS (morning dosing)
• subjective improvements noted
• Amantidine
• well-tolerated
• little effect on nocturnal sleep

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Rehabilitation
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Issues to Consider

• Cognition and academic progress
• Career counseling and reconciliation of career
  goals with a chronic disease
• Social integration and self-identity
• Physical rehabilitation and mobility
• Autonomy
• the role of independence in medically fragile
  adolescents

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Acknowledgements

• Lynn MacMillan, Clinic Nurse
• Jennifer Boyd, Clinical Nurse Specialist
• Julia Kennedy, Research Manager
• Jennifer Hamilton, Clinic Co-Ordinator
• Gillian Bone, Physiotherapy
• Raymond Buncic, Neuroophthalmology
• Peter Anderson, Neuropsychology
• Lois Peltz, Psychiatry
• Arlette Lefebvre, Psychiatry
• Rose Geist, Psychiatry