SLIDE 1
CASE PRESENTATION
Maya Zeineddine, Pharm D Multiple Sclerosis Certified Specialist American University of Beirut Medical Center March 19, 2016 Amman, Jordan
SLIDE 2 BJ is a 28-year-old white woman in the clinic for evaluation
- f 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
- rdered and shows several old lesions in the periventricular
white matter areas.
1.
BJ's symptoms are most likely consistent with which of the following?
A.
Relapsing-remitting MS
B.
Primary-progressive MS
C.
Secondary-progressive MS
D.
Progressive-remitting MS
SLIDE 3 BJ is a 28-year-old white woman in the clinic for evaluation
- f 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
- rdered and shows several old lesions in the periventricular
white matter areas.
1.
BJ's symptoms are most likely consistent with which of the following?
- A. Relapsing-remitting MS
B.
Primary-progressive MS
C.
Secondary-progressive MS
D.
Progressive-remitting MS
SLIDE 4 BJ is a 28-year-old white woman in the clinic for evaluation
- f 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
- rdered and shows several old lesions in the periventricular
white matter areas.
2.
You would like to start BJ on a disease- modifying drug (DMD) regimen as soon as
- possible. From the following options, please
select the best treatment option for BJ.
A.
Natalizumab
B.
Glatiramer acetate
C.
Mitoxantrone
D.
Methylprednisolone
E.
B and C
SLIDE 5 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
- rdered and shows several old lesions in the periventricular
white matter areas.
2.
You would like to start BJ on a disease-modifying drug (DMD) regimen as soon as possible. From the following options, please select the best treatment
A.
Natalizumab
C.
Mitoxantrone
D.
Methylprednisolone
E.
B and C
SLIDE 6 3.
BJ has been taking the DMD you recommended and 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
for BJ's current symptoms?
A.
IV methylprednisolone
B.
Adrenocorticotropic hormone
C.
Natalizumab
D.
Mitoxantrone
E.
None of the above
SLIDE 7 3.
BJ has been taking the DMD you recommended and 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
for BJ's current symptoms?
B.
Adrenocorticotropic hormone
C.
Natalizumab
D.
Mitoxantrone
E.
None of the above
SLIDE 8 4.
In her follow-up clinic visit, BJ states that she has heard about oral medications for the treatment of MS. She has just seen an advertisement about the medication teriflunomide. Which
the following statements regarding the use of teriflunomide for the treatment of MS is/are correct?
A.
Teriflunomide is an oral tablet taken twice a day.
B.
A negative tuberculin test is required before initiating therapy with teriflunomide.
C.
Teriflunomide can cause macular edema.
D.
Teriflunomide is contraindicated in patients with history of myocardial infarction within 6 months of therapy initiation.
SLIDE 9 4.
In her follow-up clinic visit, BJ states that she has heard about oral medications for the treatment of MS. She has just seen an advertisement about the medication teriflunomide. Which
the following statements regarding the use of teriflunomide for the treatment of MS is/are correct?
A.
Teriflunomide is an oral tablet taken twice a day.
negative tuberculin test is required before initiating therapy with teriflunomide.
C.
Teriflunomide can cause macular edema.
D.
Teriflunomide is contraindicated in patients with history of myocardial infarction within 6 months of therapy initiation.
SLIDE 10
5.
Which of the following DMDs would be the most appropriate treatment options for BJ if she wishes to become pregnant?
A.
Teriflunomide
B.
Interferon Beta 1a SC 3 times weekly
C.
Natalizumab
D.
Fingolimod
SLIDE 11 5.
Which of the following DMDs would be the most appropriate treatment options for BJ if she wishes to become pregnant?
A.
Teriflunomide
Beta 1a SC 3 times weekly
C.
Natalizumab
D.
Fingolimod
SLIDE 12 6.
After discussing her options with her physician, 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
- ffice with vision loss in her left eye. VA is 20/200.
No other findings on examination. What should be done first?
A.
Ophalmology consult
B.
Call her OB/GYN
C.
Obtain an MRI
D.
All of the above
SLIDE 13 6.
After discussing her options with her physician, 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
- ffice with vision loss in her left eye. VA is 20/200.
No other findings on examination. What should be done first?
A.
Ophalmology consult
B.
Call her OB/GYN
C.
Obtain an MRI
SLIDE 14
7.
Corticosteroids are not indicated when a patient is pregnant
A.
True
B.
False
SLIDE 15 7.
Corticosteroids are not indicated when a patient is pregnant
A.
True
SLIDE 16 8.
Her brain MRI showed two new enhancing
- lesions. She was admitted to the hospital and
received 3 days
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?
A.
Give her IV methylprednisolone 1g immediately after delivery then every 2 weeks until resuming DMD
B.
Give her IV
dose
methylprednisolone 1g immediately after delivery
C.
Plasmapheresis
D.
Give her IV methylprednisolone 1g 2-weeks after delivery then every 2 weeks until resuming DMD
SLIDE 17 8.
Her brain MRI showed two new enhancing
- lesions. She was admitted to the hospital and
received 3 days
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?
A.
Give her IV methylprednisolone 1g immediately after delivery then every 2 weeks until resuming DMD
B.
Give her IV
dose
methylprednisolone 1g immediately after delivery
C.
Plasmapheresis
- D. Give her IV methylprednisolone 1g 2-
weeks after delivery then every 2 weeks until resuming DMD
SLIDE 18
9.
IF BJ is breastfeeding, what should you counsel her on?
A.
Stop breastfeeding because methylprednisolone is contraindicated during breasfeeding
B.
Suspend breastfeeding for 24-48 hours after each methylprednisolone dose
C.
Suspend breastfeeding for 2 hours after each methylprednisolone dose
D.
Corticosteroids are not excreted in breast milk, thus, it is safe to breasfeed with methylprednisolone therapy
SLIDE 19 9.
IF BJ is breastfeeding, what should you counsel her on?
A.
Stop breastfeeding because methylprednisolone is contraindicated during breasfeeding
breastfeeding for 24-48 hours after each methylprednisolone dose
C.
Suspend breastfeeding for 2 hours after each methylprednisolone dose
D.
Corticosteroids are not excreted in breast milk, thus, it is safe to breasfeed with methylprednisolone therapy
SLIDE 20
received a total
4 doses
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
the following is an appropriate starting dose of dimethyl fumarate?
A.
120 mg twice daily
B.
240 mg twice daily
C.
14mg once daily
D.
240 mg once daily
SLIDE 21
received a total
4 doses
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
the following is an appropriate starting dose of dimethyl fumarate?
B.
240 mg twice daily
C.
14mg once daily
D.
240 mg once daily
SLIDE 22
- 11. Which of the following adverse events is not
commonly associated with the use of dimethyl fumarate?
A.
Flushing
B.
Elevated liver enzymes
C.
GI upset
D.
Alopecia
SLIDE 23
- 11. Which of the following adverse events is not
commonly associated with the use of dimethyl fumarate?
A.
Flushing
B.
Elevated liver enzymes
C.
GI upset
SLIDE 24
- 12. Which of the following statement is correct
about dimethyl fumarate and pregnancy?
A.
DMF is pregnancy Category C; therefore, BJ should be instructed to use contraception
B.
No contraception is required since DMF is safe during pregnancy
C.
DMF should be discontinued when pregnancy occurs
D.
DMF can cause fetal abnormalities
SLIDE 25
- 12. Which of the following statement is correct
about dimethyl fumarate and pregnancy?
is pregnancy Category C; therefore, BJ should be instructed to use contraception
B.
No contraception is required since DMF is safe during pregnancy
C.
DMF should be discontinued when pregnancy occurs
D.
DMF can cause fetal abnormalities
SLIDE 26
THANK YOU
Maya Zeineddine, Pharm D Multiple Sclerosis Certified Specialist American University of Beirut Medical Center March 19, 2016 Amman, Jordan
