Practical management issues in multiple sclerosis: what to do

while waiting for the neurologist.

Dr. Mal Fast

April 6, 2006

Most common problems of MS patients

• Bladder dysfunction

• Fatigue

• Spasticity

• Pain

• Depression

• Sexual dysfunction

MS patients usually under-treated!

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%

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

Treatment of fatigue

• Treat underlying medical conditions

• Mild exercise program, yoga

• Proper rest

• Cool environment (airconditioning)

• Immunomodulators

• Amantidine, alertec, caffeine

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

Treatment of spasticity in MS

• Passive and active stretching

• Exercise program

• Reduce pain, treat infections (bladder, skin)

• Medications: baclofen, tizanidine, keppra, botox

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

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

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

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

• Anticholinergics as per hyper-reflexic bladders

• PLUS Hytrin 2-10 mg OD

• Crede’s maneuver

Treatment of detrusor areflexia

• Hytrin 2-10 mg OD

• Urecholine 10-50 mg TID to QID (diarrhea, flushing, sweating)

• catheterization

When to refer to a urologist

• More than three UTI per year

• Post void residuals more than 200 ml

• When treatments don’t work

• *Remember that only 50% of bladder problems in MS patients are properly diagnosed on the basis of history alone.

Sexual dysfunction in MS patients

• Could be emotional, cognitive, or medication side effects

• Usually in patients with spinal MS

Erectile dysfunction men with MS

• 50-75% of men with MS

• Viagra effective in 90% of these men

• Intracavernous papervine, vacuum devices, SSRIs

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

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

Depression in MS patients

• 26-57% of MS patients (2-10x population)

• SSRIs and tricyclics

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

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’

What should the neurologist do while waiting for the family

doctor?