Multiple sclerosis

Multiple sclerosis is a chronic inflammatory disorder characterised by plaques of demyelination in central nervous system that cause neurological symptoms and disability.

Types of MS

• Relapsing-remitting (85%): intermittent relapses with subsequent total or partial recovery
• Primary progressive (15%): sustained, progressive disability from the start
• Secondary progressive: 65% of people with relapsing-remitting MS will develop secondary progressive MS with sustained, progressive disability

Clinical features

Any part of central nervous system can be affected but common deficits include:

• Optic nerve: reduced visual acuity, central scotoma
• Medial longitudinal fasciculus: internuclear ophthalmoplegia (disorder of lateral conjugate gaze)
• Cerebellum =DANISH:
  • Dysdiadochokinesia
  • Ataxia
  • Nystagmus
  • Intention tremor
  • Speech abnormality (slurring/scanning/staccato)
  • Hypotonia
• Spinal cord: spastic paraparesis, lower limb sensory loss, urinary symptoms

Investigations

Diagnosis requires demonstration of demyelinating lesions ‘disseminated in time and space’

• MRI brain/spinal cord: shows demyelination
• Evoked potentials: may reveal delayed visual/auditory/sensory potentials due to demyelination
• Cerebrospinal fluid analysis: oligoclonal bands

A patient presents to ED with chest pain and this trace. What would you do?

Interpretation management

Covered in OSCE Stations

Management

Management requires a multi-disciplinary approach (including neurologist, specialist nurse, physiotherapist, occupational therapist, GP, speech and language therapist)

Acute relapses

• Methylprednisolone (IV or oral)

Preventing relapses (disease-modifying agents)

Suitable for some patients depending on type of MS:

• Monoclonal antibodies: alemtuzumab, natalizumab, ocrelizumab
• Oral therapies: sphingosine 1-phosphate receptor modulators (e.g. fingolimod, siponimod), teriflunomide, fumarates (e.g. diroximel fumarate, dimethyl fumarate)
• Platform injection therapies: glatiramer, β-interferon

Symptomatic management

• Neuropathic pain: tricyclic antidepressants, gabapentin, pregabalin
• Incontinence: timed voiding, intermittent self-catheterisation for overflow, anticholinergics for urge
• Spasticity: physiotherapy, baclofen, gabapentin
• Oscillopsia: gabapentin
• Fatigue: exercise, diet, amantadine, modafinil, SSRI

Reference: NICE ‘NG220 Multiple sclerosis in adults: management’ 2022

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