Practical management issues in multiple sclerosis: what to do while waiting for the neurologist'

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Practical management issues in multiple
sclerosis what to do while waiting for the
neurologist.

• Dr. Mal Fast
• April 6, 2006

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Most common problems of MS patients

• Bladder dysfunction
• Fatigue
• Spasticity
• Pain
• Depression
• Sexual dysfunction

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MS patients usually under-treated!
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Fatigue

• A subjective lack of physical and/or mental
  energy that is perceived by the individual or
  caregiver to interfere with usual and desired
  activities.
• 75 of MS patients vs 30 of population
• Greatest impediment to mobility in 50

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Causes of fatigue in MS patients

• Deconditioning
• Overuse physical, mental, heat
• Sleep disturbances PLMS, hypersomnia, insomnia,
  sleep apnea
• Medications antispasticity, anxiolytics,
  antiepileptics, analgesics, interferons
• Depression, anxiety, social isolation, sense of
  helplessness
• Related to MS attack frontal cortex and BG

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Treatment of fatigue

• Treat underlying medical conditions
• Mild exercise program, yoga
• Proper rest
• Cool environment (airconditioning)
• Immunomodulators
• Amantidine, alertec, caffeine

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Spasticity

• Rigidity that increases with speed of movement
• Ranges from mild impairment with running to
  severe increases in adductor tone interfering
  with GU hygiene
• May be useful, allowing a patient to stand, pivot
  and transfer

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Treatment of spasticity in MS

• Passive and active stretching
• Exercise program
• Reduce pain, treat infections (bladder, skin)
• Medications baclofen, tizanidine, keppra, botox

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Bladder problems in MS patients

• Usually bladder problems in MS patients progress
  from hyper-reflexia of the detrusor muscle, then
  detrusor sphincter dyssynergia, then detrusor
  areflexia
• 50-80 of MS patients at sometime in the course
  of the disease
• Rule out other causes blockage (prostatic
  hypertrophy), infections

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Have MS patients keep a diary to help diagnose
bladder problems

• Voiding frequency, nocturia
• Urgency, incontinence
• Hesitancy, quality of stream
• Urinary volume
• With only a clinical history 50 of patients are
  misdiagnosed

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Treatment of hyper-reflexic bladder

• Reduce bladder stimulants caffeine, acids
• Careful attention to fluid intake, eg reduce when
  going out
• Timed voiding before the urge
• Ditropan 2.5-5 mg TID
• Probanthine 15 mg TID
• Imipramine 50-300 mg OD
• Detrol 2 mg BID

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Treatment of hyper-reflexic bladder with outlet
obstruction (dyssynergia)

• Anticholinergics as per hyper-reflexic bladders
• PLUS Hytrin 2-10 mg OD
• Credes maneuver

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Treatment of detrusor areflexia

• Hytrin 2-10 mg OD
• Urecholine 10-50 mg TID to QID (diarrhea,
  flushing, sweating)
• catheterization

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When to refer to a urologist

• More than three UTI per year
• Post void residuals more than 200 ml
• When treatments dont work
• Remember that only 50 of bladder problems in MS
  patients are properly diagnosed on the basis of
  history alone.

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Sexual dysfunction in MS patients

• Could be emotional, cognitive, or medication side
  effects
• Usually in patients with spinal MS

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Erectile dysfunction men with MS

• 50-75 of men with MS
• Viagra effective in 90 of these men
• Intracavernous papervine, vacuum devices, SSRIs

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Sexual dysfunction in women with MS

• 45-74 of women with MS
• Not related to duration or severity of disease
• Most common complaints are inadequate lubrication
  and decreased sensation
• Treat with vaginal creams and water soluble
  jellies
• Wellbutrin may increase libido
• Treat pain, spasticity, bladder problems, etc

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Pain in MS patients

• 55-65 of MS patients
• Usually either constant burning or paroxysmal
  stabs of pain
• Treat with anticonvulsants such as carbamazepine,
  gabapentin, topamax, lamotrigene, phenytoin

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Depression in MS patients

• 26-57 of MS patients (2-10x population)
• SSRIs and tricyclics

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Treatment of acute attacks

• IV solumedrol 500-1000 mg OD for 3 to 7 days
• Short (1 week) taper of oral prednisone
• Treat only functionally disabling attacks
• No long term benefit
• Repeated doses beware osteoporosis

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As important as this information is, it is worth
little unless a therapeutic alliance is
established with the patient. One must take time
to listen carefully to patients.

• Dr. Michael Kaufman, Treatment of Multiple
  Sclerosis

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What should the neurologist do while waiting for
the family doctor?