C ASE P RESENTATION Maya Zeineddine, Pharm D Multiple Sclerosis Certified Specialist American University of Beirut Medical Center March 19, 2016 Amman, Jordan
BJ is a 28-year-old white woman in the clinic for evaluation of significant numbness in the palms of both hands. This symptom began about 2 months ago but has gradually improved. After further questioning, BJ also describes a similar episode of numbness in her legs that occurred when she was about 18 years old, during which she had difficulty walking. Magnetic resonance imaging (MRI) of the brain is ordered and shows several old lesions in the periventricular white matter areas. BJ's symptoms are most likely consistent with 1. which of the following? Relapsing-remitting MS A. Primary-progressive MS B. Secondary-progressive MS C. Progressive-remitting MS D.
BJ is a 28-year-old white woman in the clinic for evaluation of significant numbness in the palms of both hands. This symptom began about 2 months ago but has gradually improved. After further questioning, BJ also describes a similar episode of numbness in her legs that occurred when she was about 18 years old, during which she had difficulty walking. Magnetic resonance imaging (MRI) of the brain is ordered and shows several old lesions in the periventricular white matter areas. BJ's symptoms are most likely consistent with 1. which of the following? A. Relapsing-remitting MS Primary-progressive MS B. Secondary-progressive MS C. Progressive-remitting MS D.
BJ is a 28-year-old white woman in the clinic for evaluation of significant numbness in the palms of both hands. This symptom began about 2 months ago but has gradually improved. After further questioning, BJ also describes a similar episode of numbness in her legs that occurred when she was about 18 years old, during which she had difficulty walking. Magnetic resonance imaging (MRI) of the brain is ordered and shows several old lesions in the periventricular white matter areas. You would like to start BJ on a disease- 2. modifying drug (DMD) regimen as soon as possible. From the following options, please select the best treatment option for BJ. Natalizumab A. Glatiramer acetate B. Mitoxantrone C. Methylprednisolone D. B and C E.
BJ is a 28-year-old white woman in the clinic for evaluation of significant numbness in the palms of both hands. This symptom began about 2 months ago but has gradually improved. After further questioning, BJ also describes a similar episode of numbness in her legs that occurred when she was about 18 years old, during which she had difficulty walking. Magnetic resonance imaging (MRI) of the brain is ordered and shows several old lesions in the periventricular white matter areas. You would like to start BJ on a disease-modifying 2. drug (DMD) regimen as soon as possible. From the following options, please select the best treatment option for BJ. Natalizumab A. B. Glatiramer acetate Mitoxantrone C. Methylprednisolone D. B and C E.
BJ has been taking the DMD you recommended and 3. is tolerating it well. She was brought to emergency department today by her husband because she has been feeling weak for the past 2 days, having difficulty walking, and experiencing balance problems. MRI shows a new enhancing lesion in cerebellum. Which of the following is the most appropriate treatment option for BJ's current symptoms? IV methylprednisolone A. Adrenocorticotropic hormone B. Natalizumab C. Mitoxantrone D. None of the above E.
BJ has been taking the DMD you recommended and 3. is tolerating it well. She was brought to emergency department today by her husband because she has been feeling weak for the past 2 days, having difficulty walking, and experiencing balance problems. MRI shows a new enhancing lesion in cerebellum. Which of the following is the most appropriate treatment option for BJ's current symptoms? A. IV methylprednisolone Adrenocorticotropic hormone B. Natalizumab C. Mitoxantrone D. None of the above E.
In her follow-up clinic visit, BJ states that she has heard 4. about oral medications for the treatment of MS. She has just seen an advertisement about the medication teriflunomide. Which of the following statements regarding the use of teriflunomide for the treatment of MS is/are correct? Teriflunomide is an oral tablet taken twice a day. A. A negative tuberculin test is required before initiating B. therapy with teriflunomide. Teriflunomide can cause macular edema. C. Teriflunomide is contraindicated in patients with D. history of myocardial infarction within 6 months of therapy initiation.
In her follow-up clinic visit, BJ states that she has heard 4. about oral medications for the treatment of MS. She has just seen an advertisement about the medication teriflunomide. Which of the following statements regarding the use of teriflunomide for the treatment of MS is/are correct? Teriflunomide is an oral tablet taken twice a day. A. B. A negative tuberculin test is required before initiating therapy with teriflunomide. Teriflunomide can cause macular edema. C. Teriflunomide is contraindicated in patients with D. history of myocardial infarction within 6 months of therapy initiation.
Which of the following DMDs would be the most 5. appropriate treatment options for BJ if she wishes to become pregnant? Teriflunomide A. Interferon Beta 1a SC 3 times weekly B. Natalizumab C. Fingolimod D.
Which of the following DMDs would be the most 5. appropriate treatment options for BJ if she wishes to become pregnant? Teriflunomide A. B. Interferon Beta 1a SC 3 times weekly Natalizumab C. Fingolimod D.
After discussing her options with her physician, 6. BJ was started on Interferon Beta 1a SC three times weekly. Several months after initiating treatment, she became pregnant. Interferon therapy was discontinued. At her 6-month of pregnancy, she presented at your office with vision loss in her left eye. VA is 20/200. No other findings on examination. What should be done first? Ophalmology consult A. Call her OB/GYN B. Obtain an MRI C. All of the above D.
After discussing her options with her physician, 6. BJ was started on Interferon Beta 1a SC three times weekly. Several months after initiating treatment, she became pregnant. Interferon therapy was discontinued. At her 6-month of pregnancy, she presented at your office with vision loss in her left eye. VA is 20/200. No other findings on examination. What should be done first? Ophalmology consult A. Call her OB/GYN B. Obtain an MRI C. D. All of the above
Corticosteroids are not indicated when a patient 7. is pregnant True A. False B.
Corticosteroids are not indicated when a patient 7. is pregnant True A. B. False
Her brain MRI showed two new enhancing 8. lesions. She was admitted to the hospital and received 3 days of IV methylprednisolone 1000mg after which she recovered completely. 3-month later, she delivered by C-section a healthy baby-boy. Since the patient had active disease before and during pregnancy, which is the best intervention at this point of time to avoid relapses? Give her IV methylprednisolone 1g immediately after A. delivery then every 2 weeks until resuming DMD Give her IV one dose of methylprednisolone 1g B. immediately after delivery Plasmapheresis C. Give her IV methylprednisolone 1g 2-weeks after D. delivery then every 2 weeks until resuming DMD
Her brain MRI showed two new enhancing 8. lesions. She was admitted to the hospital and received 3 days of IV methylprednisolone 1000mg after which she recovered completely. 3-month later, she delivered by C-section a healthy baby-boy. Since the patient had active disease before and during pregnancy, which is the best intervention at this point of time to avoid relapses? Give her IV methylprednisolone 1g immediately after A. delivery then every 2 weeks until resuming DMD Give her IV one dose of methylprednisolone 1g B. immediately after delivery Plasmapheresis C. D. Give her IV methylprednisolone 1g 2- weeks after delivery then every 2 weeks until resuming DMD
IF BJ is breastfeeding, what should you counsel 9. her on? Stop breastfeeding because methylprednisolone is A. contraindicated during breasfeeding Suspend breastfeeding for 24-48 hours after each B. methylprednisolone dose Suspend breastfeeding for 2 hours after each C. methylprednisolone dose Corticosteroids are not excreted in breast milk, thus, it D. is safe to breasfeed with methylprednisolone therapy
IF BJ is breastfeeding, what should you counsel 9. her on? Stop breastfeeding because methylprednisolone is A. contraindicated during breasfeeding B. Suspend breastfeeding for 24-48 hours after each methylprednisolone dose Suspend breastfeeding for 2 hours after each C. methylprednisolone dose Corticosteroids are not excreted in breast milk, thus, it D. is safe to breasfeed with methylprednisolone therapy
10. BJ received a total of 4 doses of IV methylprednisolone over a period of 2 months. She discontinued breastfeeding and expressed the desire to initiate therapy for her MS, but does not want an injection. Her physician started her on dimethyl fumarate treatment. Which of the following is an appropriate starting dose of dimethyl fumarate? 120 mg twice daily A. 240 mg twice daily B. 14mg once daily C. 240 mg once daily D.
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