eMedicine Specialties > Emergency Medicine > Neurology

Multiple Sclerosis: Treatment & Medication

Author: Marjorie Lazoff, MD, Editor-in-Chief, Medical Computing Review
Contributor Information and Disclosures

Updated: Jul 16, 2009

Treatment

Prehospital Care

  • Evaluate and treat for dehydration. Administer crystalloid infusion until patient is euvolemic.
  • Consider airway protection in patients with altered mental status.

Emergency Department Care

  • Medical management goals are to delay onset of MS, slow disease progression, relieve symptoms, and ameliorate risk factors associated with an acute exacerbation. The last 2 goals are sometimes achievable in the ED.
  • Fulminant MS or disseminating acute encephalitis
    • Stabilize acute life-threatening conditions.
    • Initiate supportive care and seizure precautions.
    • Monitor for increasing intracranial pressure (ICP).
    • Consider emergent plasmapheresis. (One study suggested it may be superior to intravenous [IV] steroids in patients with acute fulminant MS.1 )
  • Identify and control known precipitants of MS exacerbation.
    • Aggressively treat infections with antibiotics.
    • In patients with a fever, normalize the body temperature with antipyretics. (Conduction through partially demyelinated fibers varies greatly with even small increases in temperature.)
  • Provide urinary drainage and skin care, as appropriate.
  • Preoperative considerations for emergency surgery in patients with MS
    • Gastric emptying may be delayed secondary to autonomic GI dysfunction.
    • Labile autonomic nervous system may precipitate hypotension during anesthesia and surgery.
    • Spontaneous ventilation may be disrupted.
  • Anti-inflammatory treatment may shorten an acute exacerbation of MS, but no evidence suggests that it changes the overall disease progression. Anti-inflammatory treatment may be more effective acutely in patients who have predominantly movement involvement rather than sensory involvement. Most common therapy is high-dose pulsed methylprednisolone.
  • Anti-inflammatory treatment for ON is very controversial. A multicenter trial showed short-term recovery, but the overall disease course and progression to MS were unchanged after 2 years. Most common therapy is methylprednisolone, followed by oral prednisone. Oral prednisone alone was found to be ineffective and may increase the likelihood of future MS attacks; therefore, avoid prescribing only prednisone.
  • Anti-inflammatory treatment for acute transverse myelitis and acute disseminated encephalitis is presented commonly in texts as an option; however, not many supporting data are given. Dexamethasone is a common treatment.

Consultations

  • Neurology
  • Ophthalmology, if indicated
  • Urology for urodynamics, if indicated
  • Home care assessment, if indicated

Medication

Treatment of progressive disease or prevention of relapses may involve use of interferon, cyclosporine, azathioprine, methotrexate, or other immunomodulatory agents. As disease-modifying agents, it is usually advocated to institute therapy with interferons or glatiramer acetate as early as possible in the disease course, though that may be clinically and radiographically challenging.2  Increasingly, treatment includes combination therapy using 2 or more of these agents.

Natalizumab (Tysabri) is a humanized monoclonal antibody approved in November 2004 to decrease the frequency of exacerbations in RR-MS. Marketing was temporarily suspended in February 2005 because of 3 cases of the rare, often fatal disease, progressive multifocal leukoencephalopathy (PML) when used concomitantly with interferon beta-1a. Natalizumab is now available under a special restricted distribution program. Additionally, as early as 6 days after the first dose, evidence of hepatotoxicity may occur and includes markedly elevated serum hepatic enzyme levels and elevated total bilirubin level. The combination of transaminase level elevations and bilirubin level elevation without evidence of biliary obstruction is recognized as an important predictor of severe liver injury that may lead to death or the need for a liver transplant in some patients.

Experimental treatments include stem cell transplantation.3

Use of these medications and treatments are beyond the usual scope of practice of emergency physicians, and they are not discussed further in this section.

Corticosteroids

Solu-Medrol is used in treatment of acute exacerbations of MS and ON in adults. Dexamethasone is used in the treatment of acute transverse myelitis and acute disseminated encephalitis.


Methylprednisolone (Solu-Medrol)

Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability.

Adult

High-dose pulsed: 500 mg IV for 5 d
A very controversial study4 supports PO regimen of 500 mg for 5 d; then taper over 10 d

Pediatric

Not established

Coadministration with digoxin may increase digitalis toxicity secondary to hypokalemia; estrogens may increase levels; phenobarbital, phenytoin, and rifampin may decrease levels (adjust dose); monitor patients for hypokalemia when taking medication concurrently with diuretics

Documented hypersensitivity; viral, fungal, or tubercular skin lesions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Hyperglycemia, edema, osteonecrosis, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, growth suppression, myopathy, and infections are possible complications


Dexamethasone (Decadron)

Used in treatment of various autoimmune disorders. By suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability, may decrease autoimmunity.

Adult

10 mg IV q6h

Pediatric

0.15 mg/kg IV q6h

Barbiturates, phenytoin, and rifampin decrease effects; decreases effects of salicylates and vaccines used for immunization

Documented hypersensitivity; untreated active infection

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Increases risk of multiple complications, including severe infections; monitor adrenal insufficiency when tapering drug; abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections are possible complications

More on Multiple Sclerosis

Overview: Multiple Sclerosis
Differential Diagnoses & Workup: Multiple Sclerosis
Treatment & Medication: Multiple Sclerosis
Follow-up: Multiple Sclerosis
Multimedia: Multiple Sclerosis
References
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References

  1. Rodriguez M, Karnes WE, Bartleson JD, et al. Plasmapheresis in acute episodes of fulminant CNS inflammatory demyelination. Neurology. Jun 1993;43(6):1100-4. [Medline].

  2. Pandey K, Lublin FD. Clinically isolated syndrome and multiple sclerosis: rethinking the arsenal. Curr Treat Options Neurol. May 2009;11(3):193-202. [Medline].

  3. Liang J, Zhang H, Hua B, Wang H, Wang J, Han Z, et al. Allogeneic mesenchymal stem cells transplantation in treatment of multiple sclerosis. Mult Scler. May 2009;15(5):644-6. [Medline].

  4. Sellebjerg F, Frederiksen JL, Nielsen PM, Olesen J. Double-blind, randomized, placebo-controlled study of oral, high-dose methylprednisolone in attacks of MS. Neurology. Aug 1998;51(2):529-34. [Medline].

  5. Bar-Or A, Vollmer T, Antel J, Arnold DL, Bodner CA, Campagnolo D. Induction of antigen-specific tolerance in multiple sclerosis after immunization with DNA encoding myelin basic protein in a randomized, placebo-controlled phase 1/2 trial. Arch Neurol. Oct 2007;64(10):1407-15. [Medline].

  6. Brown MG, Kirby S, Skedgel C, Fisk JD, Murray TJ, Bhan V. How effective are disease-modifying drugs in delaying progression in relapsing-onset MS?. Neurology. Oct 9 2007;69(15):1498-507. [Medline].

  7. Confavreux C, Hutchinson M, Hours MM, et al. Rate of pregnancy-related relapse in multiple sclerosis. Pregnancy in Multiple Sclerosis Group. N Engl J Med. Jul 30 1998;339(5):285-91. [Medline].

  8. Edlich RF, Hammarskj M. Multiple sclerosis. In: Tintinalli JE, ed. Emergency Medicine [book on CD-ROM]. 4th ed. 1997:chap 197.

  9. Fazekas F, Deisenhammer F, Strasser-Fuchs S, et al. Randomised placebo-controlled trial of monthly intravenous immunoglobulin therapy in relapsing-remitting multiple sclerosis. Austrian Immunoglobulin in Multiple Sclerosis Study Group. Lancet. Mar 1 1997;349(9052):589-93. [Medline].

  10. Francis GS, Evans AC, Arnold DL. Neuroimaging in multiple sclerosis. Neurol Clin. Feb 1995;13(1):147-71. [Medline].

  11. [Best Evidence] Kappos L, Polman CH, Freedman MS, Edan G, Hartung HP, Miller DH. Treatment with interferon beta-1b delays conversion to clinically definite and McDonald MS in patients with clinically isolated syndromes. Neurology. Oct 10 2006;67(7):1242-9. [Medline].

  12. Kelley J, ed. Demyelinating diseases. In: Textbook of Internal Medicine [book on CD-ROM]. 3rd ed. Lippincott-Raven; 1996:chap 437.

  13. Little N. Special neurologic problems: demyelinating disease. In: Rosen P, ed. Emergency Medicine [book on CD-ROM]. 3rd ed. Mosby; 1992:chap 95.

  14. Lublin FD, Whitaker JN, Eidelman BH, et al. Management of patients receiving interferon beta-1b for multiple sclerosis: report of a consensus conference. Neurology. Jan 1996;46(1):12-8. [Medline].

  15. Noseworthy JH, Lucchinetti C, Rodriguez M, Weinshenker BG. Multiple sclerosis. N Engl J Med. Sep 28 2000;343(13):938-52. [Medline].

  16. PRISMS Study Group. Randomised double-blind placebo-controlled study of interferon beta-1a in relapsing/remitting multiple sclerosis. PRISMS (Prevention of Relapses and Disability by Interferon beta-1a Subcutaneously in Multiple Sclerosis) Study Group. Lancet. Nov 7 1998;352(9139):1498-504. [Medline].

  17. Pryce G, Baker D. Emerging properties of cannabinoid medicines in management of multiple sclerosis. Trends Neurosci. May 2005;28(5):272-6. [Medline].

  18. Thompson AJ, Polman CH, Miller DH, et al. Primary progressive multiple sclerosis. Brain. Jun 1997;120 ( Pt 6):1085-96. [Medline].

  19. Trapp BD, Peterson J, Ransohoff RM, et al. Axonal transection in the lesions of multiple sclerosis. N Engl J Med. Jan 29 1998;338(5):278-85. [Medline].

  20. Tullman MJ, Lublin FD. Combination therapy in multiple sclerosis. Curr Neurol Neurosci Rep. May 2005;5(3):245-8. [Medline].

  21. Vastag B. Not so fast: research on infectious links to MS questioned. JAMA. Jan 17 2001;285(3):279-81. [Medline].

  22. Weinshenker BG. The natural history of multiple sclerosis. Neurol Clin. Feb 1995;13(1):119-46. [Medline].

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Further Reading

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Keywords

multiple sclerosis, MS, central nervous system, CNS, neurologic disorder, idiopathic inflammatory demyelinating disease of the CNS, optic neuritis, transverse myelitis, internuclear ophthalmoplegia, paresthesias, relapse-remitting MS, RR-MS, chronic progressive MS

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Contributor Information and Disclosures

Author

Marjorie Lazoff, MD, Editor-in-Chief, Medical Computing Review
Marjorie Lazoff, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, American Medical Informatics Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Edmond A Hooker II, MD, DrPH, FAAEM, Assistant Professor, Department of Health Services Administration, Xavier University; Associate Clinical Professor, Department of Emergency Medicine, University of Louisville; Assistant Clinical Professor, Department of Emergency Medicine, Wright State University
Edmond A Hooker II, MD, DrPH, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American Public Health Association, Society for Academic Emergency Medicine, and Southern Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

J Stephen Huff, MD, Associate Professor, Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia Health Sciences Center
J Stephen Huff, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

 
 
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