Recognizing and Managing Multiple Sclerosis:
Barry A. Singer, MD
Missouri Baptist Medical Center
St. Louis, Missouri
Joseph A. Lieberman III, MD, MPH
Jefferson Medical College
Thomas Jefferson University
Philadelphia, Pennsylvania
The questions below were submitted by your peers based on a recent CME activity.
The Course Director, Dr. Barry A. Singer, and Dr. Joseph A. Lieberman III, provide their answers below.
The Course Director, Dr. Barry A. Singer, and Dr. Joseph A. Lieberman III, provide their answers below.
What are your suggestions for ensuring treatment compliance in a patient with MS who is suffering from alcoholism or is a substance abuser?
Dr. Lieberman's Response:
To successfully treat substance abusers, strict limits must be set. Patients will only modify their behavior when they are ready to do so, but strategies can be employed that will encourage them to contemplate making a change. A firm contract must be made with the patient committing to abstinence from the drug of choice (or other non-prescribed chemicals), following the practitioner’s orders explicitly. Firm limits must be set, and the contract made dependent on strict adherence. The patient’s involvement in a 12-step support group is likely to dramatically increase the odds of success.
As busy primary care doctors, how can we quickly identify the signs and symptoms of MS in a brief (10-minute) office visit?
Dr. Lieberman's Response:
This is not always easy as the symptoms of MS are common to a number of other problems frequently encountered in primary care. However, there are certain symptoms which should alert the practitioner to the possibility that his/her patient may have MS. Specifically, over one third of MS patients have sensory disturbance as their initial symptom, while 16% will report visual disturbances and 13%, weakness. Additional symptoms that are less common, but still somewhat frequently encountered include: fatigue, pain, vertigo, depression, bladder, bowel and/or sexual dysfunction, gait impairments, and cognitive dysfunction.
The presence of any one of these symptoms should alert the practitioner to the possibility of MS; a number of them, in any one patient, should certainly increase that index of suspicion.
Dr. Singer's Response:
Lyme disease does not increase an individual’s risk of developing MS; however, Lyme disease can mimic MS. Therefore, a good history should be taken from the patient regarding previous exposure to tick bites including associated rash. Lyme disease often presents with facial droop or radicular symptoms from leptomeningeal disease. Parenchymal involvement in the brain or spinal cord can mimic multiple sclerosis. To assess for Lyme disease, both serology and cerebrospinal fluid Lyme titers are useful.
How would you approach an MS patient who has failed frontline therapy with disease-modifying therapy, appears unable to tolerate natalizumab, and is unwilling to accept the risks associated with mitoxantrone treatment? Is such a patient a candidate for a clinical trial with experimental therapy?
Dr. Singer's Response:
Someone failing current FDA-approved treatments for MS should definitely consider enrolling in a clinical trial. Other clinical trial candidates include patients with MS who have had worsening disability and/or more relapses on several FDA-approved medications and are unwilling to accept the risks of other treatments, such as progressive multifocal leukoencephalopathy with natalizumab therapy and leukemia and cardiac toxicity with mitoxantrone therapy.
The greatest advantage of participation in clinical trials is access to new potential treatment options. Clinical trials clearly can advance our knowledge of MS treatment. A placebo-controlled trial is a definite concern since a patient who is failing current therapy will likely have poor disease control on placebo. Some MS trials do have an active comparator arm in which all patients in the trial receive some form of treatment. The unknown and known serious health risks of an experimental medication must be carefully considered before enrolling in a clinical trial.