Multiple Sclerosis: A Therapeutic Overview

Mark H. J. Litzinger, BSc, BSc Pharm, RPh; Monica Litzinger, BSc, BSc Pharm, RPh

Disclosures

US Pharmacist. 2009;34(1):HS3-HS9. 

In This Article

Clinical Presentation and Diagnosis

MS can cause a variety of symptoms, including changes in sensation (hypesthesia), muscle weakness, spasticity, tremor, incoordination, ataxia, dysarthria, dysphagia, visual disturbances (e.g., nystagmus, optic neuritis, diplopia), fatigue, acute or chronic neuropathic pain (e.g., trigeminal neuralgia, dysesthesias), bladder/bowel difficulties, cognitive impairment, and affective lability.[13,14,15,16,17,18,19,20] The initial attack of MS is generally mild and self-limiting, and it is usually identified in retrospect once the diagnosis of MS is made. The wide array of signs and symptoms of MS is due to the variability of lesions within the CNS white matter. A patient may present with hypesthesia and diplopia during one relapse and tremors the next. As the demyelinative plaque burden increases, cognitive manifestations may appear. Depending on the type of MS, symptoms may result in progressive neurologic disability.

Patients are monitored over time with a meticulous neurologic exam, MRIs, and the use of the Kurtzke Expanded Disability Status Scale (EDSS).[21,22] Serial lumbar punctures (LPs) are not necessary once the diagnosis has been established. The neurologic exam assesses changes in motor/sensory function, reflexes, coordination, gait, and cranial nerves. Common abnormal signs include the Babinski reflex (a positive test in the patient has an upward curling of the toes), and the Romberg test (which examines proprioception from the lower extremities).

The most sensitive test to detect lesions and changes in the CNS of patients with MS is the MRI.[22] Neurologists use serial MRIs to confirm diagnosis and monitor worsening of symptoms. Gadolinium enhancement is used to detect a compromised BBB or lesions with active inflammation (Figure 2).[4] Once axonal loss occurs, dark zones (black holes) may appear within the plaques.

Figure 2.

MRI showing brain lesions (white) in a patient with multiple sclerosis.
Source: Courtesy of the Canadian Network of MS Clinics.

A LP or a spinal tap is used to rule out other diseases and also help confirm the MS diagnosis and prognosis.[23] The CSF typically shows an increase in IgG synthesis, oligoclonal banding, and elevation of myelin basic proteins. The EDSS measures the progression of MS using a rating scale between 0 and 10 (Table 1). A patient with a normal neurologic exam will rate a 0, whereas a patient who is unable to walk beyond five yards without aid and is mostly confined to a wheelchair would rate a 7.0 on the scale.[21]

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