Depression management: Emotional Disorders in Multiple Sclerosis

Transcription

1 Depression management: Emotional Disorders in Multiple Sclerosis

2 MS ECHO Session 4: Recognizing and Managing an MS Relapse Gary Stobbe, MD Medical Director, MS Project ECHO Clinical Assistant Professor, UW Neurology

3 Conflict of Interest: Dr. Stobbe has no conflicts of interest to disclose 3

4 Educational Objectives: Define an MS relapse Understand how to evaluate relapses clinically Learn strategies to manage MS relapses 4

5 Areas of Management 5

6 Case A - Overview 19 yo female no prior hx/family hx Intermittent paresthesias R arm 2 weeks later, tingling in BUE when washing hair 1 week later, continuous numbness in L ulnar 1 month later tingling in pelvis/perineum with neck flexion (atypical Lhermitte's) ROS fatigue, balance complaints, headache Exam L hand intrinsic weakness; L C8T1 numbness Brain/c-spine MRI & CSF c/w MS diagnosis started on Copaxone

7 Corpus callosum and brainstem lesions

8 C3-4 enhancing lesion

9 Case A - Progress 4 months after starting Copaxone intermittent tingling into arms and legs weakness/numbness in hands when driving distances Next steps? 9

10 Definition of MS relapse Relapse (exacerbation, flare, attack): sudden new or worsening neurologic symptom(s) lasting at least 24 hours 50% recover fully within 6 month; residual deficits contribute to long term disability Examples optic neuritis, myelitis, brainstem/cerebellar, cerebral Pseudo-exacerbation : old deficit brought out by physiological or psychological stress (e.g. elevation in core temp, infection, heat, exertion, insomnia, etc.)

11 Evaluation of an MS relapse Rule out acute medical process (infection, dehydration, severe insomnia, medication SE) Role of neuroimaging Differentiate pseudo vs true relapse Quantify disease activity Assist in decision-making re: DMTs 11

12 Managing an MS relapse Treat or eliminate factors contributing to stress Acute therapy Supportive/symptom management IV methylprednisolone (1000 mg IV qd x 3-7 days) OR high-dose oral (1250mg prednisone) with/without taper Dexamethasone ( mg po/iv qd x 3-7 days) ACTH (more expensive, no empirical evidence of superiority) units IM/SQ qd (up to 2-3 weeks) If ineffective, consider IVIg (400 mg/kg qd x 5d) or PLEX (5-7 exchanges) 12

13 Managing an MS relapse (cont.) Rehabilitation Psychosocial support for individual and family Decision on long-term DMT 13

14 Case A - Progress 4 months after starting Copaxone intermittent tingling into arms and legs weakness/numbness in hands when driving distances IV methylprednisolone (1000 mg IV qd x 3d) given 3 months later Intermittent tingling persists, no new symptoms Year 1 No new symptoms; brain MRI with 1 new non-enhancing lesion; c- spine enhancement resolved 6 months later 1 month of new leg numbness, headache, blurry vision Exam with left afferent pupillary defect (APD) MRI no change Next steps?

15 Resources Kalb,R. The emotional and psychological impact of multiple sclerosis relapses. Journal of the Neurological Sciences: 256 (2007) S29 S33 Thrower BW. Relapse management in multiple sclerosis. Neurologist 2009;15(1):1-5. MS Diagnosis, Disease and Symptom Management app- relapse mgmt Professional Resource Center Professionals/Clinical-Care/Managing-MS/Relapse-Management UW MEDCON (WWAMI): For your Patients: MS Navigator Program (1-800 FIGHT MS) Walgreens infusion centers may exist in your area 15

16 Dr. Sheri Howell s case 37 yo caucasian male, no prior med hx 9/2014 shooting pains, LLE into calf/top of foot; dragging L foot at times Hx LBP 1995 different pain Exam unremarkable Medrol dosepak no effect Lumbar MRI mild bulging L2-3/L3-4 EMG/NCS unremarkable 2/15 notes shooting pain if turns head

17 Dr. Sheri Howell s case C-spine MRI (2/2015) Mild degen changes C6-7 increased T2 signal in the spinal cord C7

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