Drugs for Multiple Sclerosis (MS)
Which assessments are essential before a patient receives a second dose of mitoxantrone [Novantrone]? (Select all that apply.) A. Pregnancy test B. Echocardiogram C. Complete blood count D. T3, T4, and TSH levels E. Ophthalmic examination F. Magnetic resonance imaging (MRI)
A. Pregnancy test B. Echocardiogram C. Complete blood count Mitoxantrone [Novantrone] can cause a variety of adverse effects. Myelosuppression, cardiotoxicity, and fetal injury are the greatest concerns. Consequently, a pregnancy test and a complete blood count should be done, as well as an echocardiogram to determine the left ventricular ejection fraction. Thyroid function studies and MRI are not necessary. Ophthalmic examinations are necessary when the patient is experiencing macular edema, an adverse effect of fingolimod.
Which medications can be used to manage fatigue associated with multiple sclerosis? (Select all that apply.) A. Modafinil [Provigil] B. Clonazepam [Klonopin] C. Amantadine [Symmetrel] D. Carbamazepine [Tegretol] E. Dalfampridine [Ampyra]
A. Modafinil [Provigil] C. Amantadine [Symmetrel] Fatigue develops in about 90% of patients with multiple sclerosis, and the drugs most commonly used to manage this symptom include modafinil and amantadine. Clonazepam may be useful for alleviating tremor and ataxia associated with the disease. Carbamazepine, an antiepileptic drug, may be helpful for alleviating neuropathic pain. Dalfampridine may be given to improve walking.
Which complaint by a patient taking fingolimod [Gilenya] requires prompt evaluation by the prescriber? A. Hair loss B. Backache C. Dizziness and fatigue D. Blue-green tint to the skin
C. Dizziness and fatigue Fingolimod slows the heart rate and can cause bradycardia. Dizziness and fatigue may be consequences of bradycardia. Backache is an adverse effect that occurs in 12% of patients taking the medication, but it does not require prompt attention. Reversible hair loss and a blue-green tint to the skin are adverse effects of mitoxantrone [Novantrone].
What is Multiple Sclerosis?
Chronic, inflammatory, autoimmune disorder who's exact cause is unknown. Damages myelin sheaths of neurons in the CNS (making antibodies to the myelin sheath of neurons in CNS) --> wide variety of sensory and motor deficits Periods of acute clinical exacerbation/attack (relapses) alternating with periods of complete or partial recovery (remissions) Over time, symptoms grow progressively worse Pathology: -Multifocal regions of inflammation and myelin destruction (brain, spinal cord, optic nerve) -Demyelination: axonal/nerve conduction slowed or blocked After an acute attack: Inflammation subsides -Damaged tissue replaced by astrocyte-derived filaments that form scars known as scleroses (fill in gaps of damaged tissue with connective tissue, forming scars) -Some degree of recovery occurs (partial remyelination) Functional axonal compensation Development of alternative neuronal circuits that bypass the damaged region Recurrent episdoes: -Less complete recovery due to mounting astrocytic scarring, irreversible axonal injury, and death of neurons and oligodendrocytes Signs and Symptoms: Paresthesias -Numbness -tingling -pins and needles sensation Muscle or motor problems -Weakness -clumsiness -ataxia (impaired balance/coordination) -spasms -spasticity -tremors -cramps Visual impairment -Blurred vision -Double vision -Blindness Bladder and bowel symptoms -Incontinence -Urinary urgency -Urinary hesitancy -Constipation Other: -Sexual dysfunction -Disabling fatigue -Emotional lability, depression, and cognitive impairment -Slurred speech and dysphagia -Dizziness and vertigo -Neuropathic pain
The nurse is caring for a patient receiving glatiramer acetate [Copaxone] for MS. Which finding, if present in this patient, could be considered a potential adverse effect of this drug? A. Flu-like symptoms with fever B. Decreased neutrophil count C. Jaundice and elevated bilirubin D. Injection site pain and redness
D. Injection site pain and redness Injection site reactions, such as pain, erythema, pruritus, and induration, are the most common adverse effects of glatiramer. Unlike interferon, glatiramer does not cause flu-like symptoms, myelosuppression, or hepatotoxicity, which would be indicated in the other responses.
The nurse is teaching a patient about a new prescription for mitoxantrone [Novantrone]. Which statement made by the patient indicates a need for further teaching? A. "I volunteer at a local day care center once a week." B. "I drink grapefruit juice with breakfast each morning." C. "I enjoy walking and outdoor activities in the sun." D. "I understand this drug may cause my urine to turn blue."
A. "I volunteer at a local day care center once a week." Mitoxantrone can cause myelosuppression. Patients taking this drug should be advised to avoid contact with people who have infections, such as children in day care centers. The other statements are appropriate for patients taking this drug.
The nurse is caring for a patient with MS who is receiving interferon beta-1a [Rebif] by subcutaneous injection. Which laboratory tests should be performed regularly in this patient to monitor for a potential adverse effect? (Select all that apply.) A. Blood urea nitrogen B. Complete blood count C. Hemoglobin A1c D. Alkaline phosphatase E. Immunoglobulin G levels
B. Complete blood count D. Alkaline phosphatase When monitoring a patient receiving interferon, the nurse should watch for potential adverse reactions of hepatotoxicity (alkaline phosphatase) and myelosuppression (complete blood counts). The blood urea nitrogen value is an indicator of renal function, which is not affected by interferon beta-1a. The hemoglobin A1c test is a weighted average of the glucose level over the past several months. Glucose levels are not affected by interferon beta-1a. Immunoglobulin G levels might be assessed when making the diagnosis, but they are not used to monitor for adverse effects of interferon.
A patient with a history of numbness, weakness, and blurred vision recently was diagnosed with multiple sclerosis (MS). What does the nurse understand to be the underlying pathophysiology for these symptoms? A. An imbalance of dopamine and acetylcholine in the central nervous system B. Inflammation and myelin destruction in the central nervous system C. An inability of serotonin to bind to its receptors in the chemoreceptor trigger zone D. High-frequency discharge of neurons from a specific focus area of the brain
B. Inflammation and myelin destruction in the central nervous system The underlying pathophysiology of MS is related to myelin destruction and slowing of axonal conduction related to inflammation within the central nervous system. The demyelination leads to the characteristic neurologic symptoms associated with MS.
The nurse is caring for a patient hospitalized with an acute episode (relapse) of MS. Which agent is the preferred treatment during relapse? A. Interferon beta-1a [Avonex] IM B. Methylprednisolone [Solu-Medrol] IV C. Glatiramer acetate [Copaxone] subQ D. Natalizumab [Tysabri] IV infusion
B. Methylprednisolone [Solu-Medrol] IV During an acute relapse episode of MS, the treatment of choice is a high-dose IV glucocorticoid, such as methylprednisolone, to reduce the inflammation and diminish symptoms. The other agents are disease-modifying drugs that are used in the long-term management of MS.
Which medication used for the management of multiple sclerosis cannot be self-administered? A. Fingolimod [Gilenya] B. Natalizumab [Tysabri] C. Glatiramer acetate [Copaxone] D. Interferon beta-1b [Betaseron]
B. Natalizumab [Tysabri] Natalizumab [Tysabri] is administered by intravenous infusion over 1 hour. The patient must be observed during the infusion and also must be monitored for 1 hour after the infusion is complete. Before this medication can be prescribed and administered, everyone involved with the drug—patients, physicians, pharmacists, infusion nurses, and infusion centers—must be registered with the TOUCH Prescribing Program. The other medications can be self-administered: fingolimod (oral), glatiramer acetate, and interferon beta-1b (subcutaneous injection).
The nurse is caring for a patient with MS who is having worsening recurrent episodes of neurologic dysfunction followed by periods of partial recovery. How would this subtype be classified? A. Relapsing-remitting B. Secondary progressive C. Primary progressive D. Progressive-relapsing
B. Secondary progressive Relapsing-remitting MS is marked by defined episodes of neurologic dysfunction separated by periods of partial or full recovery. In secondary progressive MS, the patient with the relapsing-remitting subtype experiences declining function with or without occasional recovery of function. Primary progressive MS presents with progressive decline of function from the onset. Progressive-relapsing MS is rare and is similar to primary progressive but has acute episodes in addition to the progressively worsening dysfunction.
MS Symptom Management
Bladder dysfunction (when you think of MS, think of bladder dysfunction) Detrusor hyperreflexia -Tolterodine -Oxybutynin -Darifenacin -Solifenacin Detrusor-sphinctor dyssynergia Promote sphincter to relax, use in patients with BPH. -Tamsulosin -Terazosin Flaccid bladder With patients with repaired bladder emptying -Bethanechol Fatigue Stimulants: -Modafinil -Methylphenidate -Amphetamine mixture Selective serotonin reuptake inhibitors (SSRIs) Bowel dysfunction Constipation -Increase dietary fibers and fluids -Taking fiber supplements -Regular exercise -Bulk-forming laxative such as psyllium Fecal incontinence -Establishing regular bowel routine -Use bulk-forming laxative -Anticholinergic agent (hyoscyamine) to reduce bowel motility Depression -Fluoxetine -Sertraline -Bupropion -TCAs: Amitriptyline, Nortriptyline Spasticity Non-drug measures -Physical therapy -Stretching -Regular exercise Medications -Baclofen and tizanidine (caution: high doses of either agent can exacerbate MS-related muscle weakness) -Diazepam and botulinum toxin -Intrathecal infusion of baclofen Neuropathic pain Anti-epileptic drugs -Carbamazepine -Gabapentin -Oxcarbazepine Anti-depressants -Nortriptyline -Imipramine -Amitriptyline Cognitive dysfunction -Donepezil (cholinesterase inhibitor developed for AD) -Memantine (N-methyl-D-aspartate receptor blocker developed for AD) Dizziness and vertigo -Meclizine: used for motion sickness -Ondansetron: powerful antiemetic
Which statement made by a patient indicates a need for further teaching by the nurse about reducing injection site reactions from interferon beta? A. "I need to rotate my injection sites, so I'll need to keep a record of them." B. "I will apply hydrocortisone ointment to the injection site if it is itchy." C. "Applying a warm compress before giving the injection will reduce the risk of pain at the site." D. "I can take over-the-counter Benadryl if the injection site itches and is red."
C. "Applying a warm compress before giving the injection will reduce the risk of pain at the site." Brief application of ice rather than warm compress application is indicated prior to injection. Warm compresses may be helpful following the injection. Injection sites should be rotated to decrease discomfort. Itching and erythema can be reduced by topical application of hydrocortisone or oral diphenhydramine.
A patient newly diagnosed with MS asks the nurse how a person gets this disease. Which response by the nurse is most accurate and appropriate? A. "Multiple sclerosis is a congenital condition that typically manifests itself in late adulthood." B. "Multiple sclerosis is a disease believed to be caused by exposure to drugs during a mother's pregnancy." C. "This is an autoimmune disease that occurs in people with certain genetic traits when they are exposed to some environmental trigger factor." D. "This disease is most often caused by an increase of rapidly dividing cells in the central nervous system."
C. "This is an autoimmune disease that occurs in people with certain genetic traits when they are exposed to some environmental trigger factor." Although the exact cause is unknown, MS is believed to have a genetic link. Susceptible individuals have an autoimmune response when exposed to environmental or microbial factors. It is more common among first-degree relatives of individuals who have the disease and is more prevalent among Caucasians. It also is more common in cooler climates, with increased incidence moving away from the equator. MS may also be associated with the Epstein-Barr virus, human herpesvirus 6, and Chlamydia pneumonia.
Natalizumab [Tysabri] is a very effective agent for treating MS. Which problem is associated with the administration of this drug, making it a second-line agent? A. Increased risk of sudden cardiac death B. Documented reports of necrotizing colitis C. Increased risk of Stevens-Johnson syndrome D. Rare cases of dangerous brain infections
D. Rare cases of dangerous brain infections Soon after natalizumab was released on the market, there were three reports of progressive, multifocal leukoencephalopathy. All patients who developed this problem were taking natalizumab in combination with another immunosuppressant. The drug is now available only through a specialized, carefully controlled prescribing program.
Drug Therapy for MS
Disease-modifying therapy -Used to treat acute relapse and manage symptoms -Immunomodulators and immunosuppressants (decease the frequency and severity of relapses. Immunomodulators means you are trying to get antibodies in right range, where as suppression you are tampering things down) -Reduce development of brain lesions -Decrease future disability -Help maintain quality of life -May prevent permanent damage to axons -Does not work for all patients -Most effective for patients with relapsing-remitting MS Relapsing-remitting: -Immunomodulators Secondary progressive: -Interferon beta -Mitoxantrone Progressive relapsing: -Mitoxantrone Primary progressive: -No disease-modifying therapy shown effective -Possible benefit from immunosuppressants Treating an acute episode (relapse) -Short course of high-dose IV glucocorticoid (preferred treatment) -IV gamma globulin (if you can't tolerate steroids) All 4 subtypes of MS have the same symptoms: -Fatigue -Spasticity -Neuropathic pain -Bladder dysfunction -Bowel dysfunction (constipation) -Sexual dysfunction
4 Subtypes of MS
Relapsing-remitting MS -Clearly defined episodes of neurologic dysfunction -Remission: periods of partial or full recovery -Symptoms develop over several days and then typically resolve within weeks -Affects twice as many women as men Secondary Progressive MS -Patient with relapsing-remitting MS develops steadily worsening dysfunction, with or without occasional plateaus, acute exacerbations, or minor remissions -Within 10 to 20 years of symptom onset, about 50% of patients with relapsing-remitting MS develop secondary progressive MS Primary progressive MS -Symptoms grow progressively more intense from the outset -Some patients may experience occasional plateaus or temporary improvement -Clear remissions do not occur Progressive-relapsing MS -Rare -Presents like primary progressive MS -Acute exacerbations superimposed on the steady intensification of symptoms