12.3 Treatments and Nutrition

Multiple sclerosis (MS) is a complex autoimmune disease affecting the central nervous system. Treatment focuses on managing symptoms and slowing disease progression through various medications, each with unique benefits and risks.

Nurses play a crucial role in MS care, monitoring patients, administering treatments, and providing education. Understanding the different drug classes, their mechanisms, and potential side effects is essential for effective patient care and support.

Drugs Used in the Treatment of Multiple Sclerosis

Classes of multiple sclerosis drugs

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• Disease-modifying therapies (DMTs) reduce inflammation and modulate the immune response
  • Interferon beta decreases T-cell activation and migration across the blood-brain barrier (Avonex, Rebif)
  • Glatiramer acetate modulates the immune response by inducing regulatory T-cells and shifts cytokine production from pro-inflammatory to anti-inflammatory (Copaxone)
  • Sphingosine 1-phosphate (S1P) receptor modulators sequester lymphocytes in lymph nodes, preventing entry into the central nervous system (CNS) (fingolimod, siponimod)
  • Monoclonal antibodies target specific immune cells or proteins involved in MS pathogenesis and reduce inflammation and prevent immune cell migration into the CNS (natalizumab, alemtuzumab, ocrelizumab)
    • Some monoclonal antibodies work through B-cell depletion, reducing the immune response
• Symptomatic treatments alleviate specific symptoms associated with MS
  • Muscle relaxants reduce muscle spasticity by inhibiting spinal reflexes (baclofen, tizanidine)
  • Anticholinergics manage bladder dysfunction by reducing involuntary bladder contractions (oxybutynin, tolterodine)
  • Antidepressants alleviate depression and other mood disorders associated with MS (SSRIs, TCAs)
  • Fatigue management medications improve alertness and reduce fatigue through various mechanisms (amantadine, modafinil)

Multiple Sclerosis Pathophysiology

• Multiple sclerosis is an autoimmune disease affecting the central nervous system
• The disease process involves demyelination, leading to impaired nerve signal transmission
• Inflammation and the release of cytokines contribute to the damage of myelin and nerve fibers
• Over time, MS can lead to neurodegeneration and axonal damage, resulting in progressive disability

Benefits vs risks of medications

• Interferon beta reduces relapse rate and disease progression but can cause flu-like symptoms, injection site reactions, and liver function abnormalities; contraindicated in severe depression and pregnancy
• Glatiramer acetate reduces relapse rate and MRI lesion activity but can cause injection site reactions and post-injection reactions (flushing, chest pain, palpitations); contraindicated in known hypersensitivity to glatiramer acetate or mannitol
• Fingolimod offers oral administration and reduces relapse rate and disability progression but can cause bradycardia, macular edema, and increased risk of infections; contraindicated in recent myocardial infarction, unstable angina, stroke, or heart failure
• Natalizumab is highly effective in reducing relapse rate and disability progression but carries a risk of progressive multifocal leukoencephalopathy (PML) and infusion reactions; contraindicated in active infections and immunocompromised patients
• Alemtuzumab is highly effective in reducing relapse rate and disability progression but can cause infusion reactions and increased risk of autoimmune disorders (thyroid, immune thrombocytopenia); contraindicated in HIV infection, active tuberculosis, and pregnancy

Nursing considerations for treatments

• Monitoring parameters include:
  1. Vital signs, especially heart rate and blood pressure (fingolimod, alemtuzumab)
  2. Liver function tests (interferon beta)
  3. Complete blood count (alemtuzumab, ocrelizumab)
  4. Thyroid function tests (alemtuzumab)
  5. Ophthalmic examinations (fingolimod)
  6. MRI for disease activity and PML risk (natalizumab)
• Potential drug interactions involve:
  • Immunosuppressants: Increased risk of infections when combined with MS therapies
  • Live vaccines: Avoid administration during treatment with immunomodulatory or immunosuppressive MS therapies
  • Antihypertensives: Potential additive effects on heart rate and blood pressure with fingolimod
  • Antiarrhythmics: Potential additive effects on heart rate and conduction with fingolimod
• Administration considerations include:
  • Proper injection technique and rotation of injection sites (interferon beta, glatiramer acetate)
  • Observation for infusion reactions (natalizumab, alemtuzumab, ocrelizumab)
  • First-dose monitoring for bradycardia (fingolimod, siponimod)
  • Patient education on self-administration and side effect management

Patient education for new medications

• Medication adherence strategies:
  • Emphasize the importance of taking medication as prescribed
  • Discuss strategies for remembering doses (pill boxes, alarms, medication apps)
  • Address potential barriers to adherence (cost, side effects, forgetfulness)
• Lifestyle modifications:
  • Encourage regular exercise and physical therapy to maintain mobility and manage symptoms
  • Discuss the importance of a balanced diet and adequate hydration
  • Stress the benefits of stress management techniques (relaxation, meditation, counseling)
  • Advise on heat sensitivity and strategies for staying cool (air conditioning, cooling vests)
• Safety precautions:
  • Inform patients about the increased risk of infections and the need for prompt reporting of symptoms
  • Provide guidance on avoiding live vaccines during treatment
  • Discuss the importance of regular monitoring and follow-up with healthcare providers
  • Educate on the signs and symptoms of serious side effects (PML, autoimmune disorders)
  • Encourage patients to wear medical alert bracelets or carry information about their MS treatment
• Support and resources:
  • Provide information on local and online MS support groups (National Multiple Sclerosis Society)
  • Share resources for financial assistance programs and medication copay cards (Patient Advocate Foundation)
  • Offer contact information for the healthcare team and emergency services