Multiple Sclerosis Practice Case

Asal Ardalan Part 1. Multiple Sclerosis Practice Case BJ is a 35-year-old female with symptoms of bilateral weakness in lower extremities and fatigue diagnosed with Multiple Sclerosis at the age of 24. Family history: Lives with her husband. Latino descent born in Los Angeles. Social history: No alcohol, no illicit drugs, she has smoked 1 pack of cigarettes a day for 15 years. PMI: At the age of 16 she lost hearing from her left ear and had vision loss resulting in the need for glasses. Due to lack of medical insurance, she did not receive much medical help. The PCP she saw could not explain the sudden hearing or vision loss. She intermittently complained of numbness in her legs, but due to lack of insurance she did not seek comprehensive medical care. At the age of 24, she was seen in the emergency department with complaints of numbness and tingling in her arms and feet. At the time, an MRI was ordered, and it revealed several MS lesions. She was diagnosed with relapsing remitting MS. She is looking forward to getting back to her old routine, as well as gaining back the independence. What factor(s) put(s) BJ at a higher risk for developing MS? • • Gender (BJ is a 35-year-old female) Cigarette smoking What are the signs and symptoms of MS in which BJ has exhibited? • • • • • Numbness and tingling in the arms and feet Sudden vision and hearing loss Fatigue Financial problems Bilateral weakness in the lower extremities BJ’s physician decides to initiate interferon beta-1b (Betaseron) 0.25mg SQ every other day. BJ comes to the pharmacy to pick up the prescription. At present, BJ clearly looks overwhelmed by her diagnosis and appears apprehensive about taking her medication. What would you counsel the patient? What would be some monitoring parameters that should be done for BJ? Counseling: Must be used immediately after reconstitution. If not used immediately, can refrigerate up to 3 hours. Monitor: LFTs at 1,3, and 6 months with initiation and as needed thereafter, CMP, CBC with diff, thyroid function every 6 months with the history of thyroid dysfunction or clinically necessary, flulike symptoms, injection site reactions, allergic or anaphylactic reactions, signs/symptoms of depression, worsening of cardiac symptoms ( in the heart failure patients ). What can be recommended to manage BJ’s fatigue? • In patients who are suffering form both fatigue and depression, consider a more activating antidepressant such as fluoxetine Asal Ardalan • • • Amantadine: used often and may offer significant relief Ginkgo biloba possibly effective for reducing fatigue in MS CNS stimulants: o Modafinil, armodafinil o Dextroamphetamine, Methylphenidate Later, BJ was switched to teriflunomide since Betaseron did not work for her. After 2 years on Teriflunomide, BJ and her husband decide to have a child. What would you recommend to BJ and her husband? • • Teriflunomide: This medication will stay in your blood for up to 2 years after stopping use Drug elimination procedure: o To achieve <0.02 mg/l of teriflunomide, administer either for the following:  Cholestyramine: 8g every 8 hours for 11 days, if it’s not tolerated, you can decrease to 4g every 8 hours for 11 days  Then 11 days do not need to be consecutive unless plasma concentrations need to be lowered rapidly Part 2. Information on Additional MS medications Using evidence-based resources, provide the information below for two of these four medications. Please make sure to include appropriate citation. • • • • Ozanimod Ponesimod Diroximel fumarate Monomethyl fumarate Medica�on 1 Labeled indica�on(s): relapsing MS, ulcera�ve coli�s Generic name: ozanimod Dose (for MS treatment): Ini�al: 0.23 mg once orally daily on days 1-4; then 0.46 mg once daily on days 5-7 Maintenance: 0.92 mg once daily star�ng on day 8 Brand name: Zeposia Adverse Drug Reac�ons (at least 5): Cardiovascular effects Cutaneous malignancies Hepatotoxicity Lymphocytopenia Macular edema Monitoring parameters: CBC, hepa�c monitoring, ECG, HR, BP, s/sx of bradycardia, ophthalmologic exam, respiratory func�on Administra�on: oral; swallow capsules whole, with or without food Asal Ardalan Medica�on 2 Generic name: diroximel fumarate Brand name: Vumerity Labeled indica�on(s): relapsing MS Dose (for MS treatment): Ini�al: 231 mg twice orally daily; a�er 7 days, increase to the maintenance dose of 462 mg twice daily Adverse Drug Reac�ons (at least 5): Flushing, abdominal pain, diarrhea, nausea, infec�on Monitoring parameters: CBC, LFTs, MRI, latent infec�on screening, s/sx of severe GU reac�ons, hypersensi�vity, infec�ons, and/or PML Administra�on: oral; administer with or without food. If administered with food, limit fat and calories to ≤ 30g and ≤ 700 calories, respec�vely. Swallow capsule whole; do not crush, chew, or open Resource Citation (in AMA Format): • Lexicomp. (2023). Lexicomp Online. Wolters Kluwer. https://online.lexi.com/lco/action/home