Disease-modifying therapy for multiple sclerosis: Nursing pharmacology

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Notes

DISEASE-MODIFYING THERAPY for MULTIPLE SCLEROSIS
DRUG NAME
dimethyl fumarate (Tecfidera), teriflunomide (Aubagio), fingolimod (Gilenya), glatiramer (Copaxone, Glatopa) interferon beta-1a (Avonex, Rebif), interferon beta-1b (Betaseron, Extavia)
rituximab (Riabni, Rituxan), natalizumab (Tysabri), ocrelizumab (Ocrevus), alemtuzumab (Campath, Lemtrada)
CLASS
Immunomodulators
Monoclonal antibodies
MECHANISM of ACTION
Blunt inflammatory process → lessen the severity and frequency of relapses → slow disease progression, mitigate symptoms, and improve client’s quality of life
INDICATIONS
  • Multiple sclerosis
ROUTE(S) of ADMIN
  • PO: dimethyl fumarate, teriflunomide, fingolimod
  • IM, SubQ: glatiramer, recombinant human interferon beta-1a and interferon beta-1b
  • IV
SIDE EFFECTS
  • Bone marrow suppression 
  • Increased risk for infections 
  • Drowsiness, fatigue 
  • Nausea, vomiting, diarrhea
  • Injection site reactions
  • Stevens-Johnson syndrome, toxic epidermal necrolysis, anaphylaxis
  • Cardiotoxicity 
  • Hepatotoxicity 
  • Alemtuzumab (boxed warning): fatal infections, autoimmune effects, malignancy, fatal infusion reactions
  • Rituximab (boxed warning): fatal infusion reactions or mucocutaneous reactions, PML, reactivation of HBV
  • Natalizumab (boxed warning): PML
  • Teriflunomide (boxed warning): hepatotoxicity
  • Bone marrow suppression 
  • Increased risk for infections
  • Drowsiness, fatigue
  • Nausea, vomiting, diarrhea
  • Injection site reactions
  • Stevens-Johnson syndrome, toxic epidermal necrolysis, anaphylaxis
  • Cardiotoxicity
  • Hepatotoxicity
CONTRAINDICATIONS & CAUTIONS
  • Pregnancy, breastfeeding 
  • Immunosuppression
  • Cardiovascular, hepatic, or renal disease
  • Rituximab, natalizumab: hypersensitivity to murine proteins
NURSING CONSIDERATIONS for
DISEASE-MODIFYING THERAPY for MULTIPLE SCLEROSIS
ASSESSMENT & MONITORING
Assessment & monitoring: natalizumab

Assessment
  • Current symptoms: fatigue, problems with balance, visual impairment, urinary urgency
  • Weight, vital signs
  • Laboratory test results: CBC, renal and liver function tests

Administration / Intervention
  • Bring medication to room temperature
  • Peripheral IV
  • Emergency equipment and medications are readily available

Monitoring
  • Monitor hypersensitivity reaction during infusion and one hour after
    • Stop infusion, notify healthcare provider, administer emergency medications
  • Monitor for side effects
  • Evaluate for therapeutic response: decreased MS symptoms; improved quality of life
CLIENT EDUCATION
  • Purpose of medication: help treat their MS symptoms
  • Administration: IV every four weeks
  • Side effects to report
    • Hepatotoxicity
    • PML
  • Periodic MRIs needed
  • CSF analysis for JC virus
  • Regular follow-up visits
  • Lifestyle modifications
    • Identify and manage triggers
    • Infection control practices
      • Notify their healthcare provider for symptoms of infection
    • Establish regular activity and rest patterns
    • Stay well-hydrated
    • Minimize caffeinated beverages
    • Follow a nutritious, well-balanced diet

Transcript

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Multiple sclerosis, or MS for short, is a chronic and progressive demyelinating disease of the central nervous system. Myelin is the protective sheath that surrounds the axons of neurons, allowing them to quickly send electrical impulses. In MS, demyelination happens when the immune system inappropriately attacks and destroys the myelin. As a result communication between neurons breaks down, ultimately leading to various sensory, motor, and cognitive problems. Although there’s no cure for MS, disease-modifying therapy can be used to help slow the disease progression, as well as mitigate some of the symptoms, and ultimately improve the client’s quality of life.

Now, disease-modifying therapy for MS includes monoclonal antibodies and immunomodulators. The most commonly used monoclonal antibodies for MS include rituximab, natalizumab, ocrelizumab, and alemtuzumab, which are administered intravenously. On the other hand, immunomodulators for MS include dimethyl fumarate, teriflunomide, and fingolimod, which are administered orally, as well as glatiramer and recombinant human interferon beta-1a and interferon beta-1b, which can be injected intramuscularly or subcutaneously.

Once administered, these medications blunt the inflammatory process, which ultimately helps reduce the severity and frequency of relapses or exacerbation of multiple sclerosis.

Unfortunately, these medications can cause side effects like bone marrow suppression, which can result in anemia, thrombocytopenia, leukopenia, and an increased risk for infections. In fact, for alemtuzumab, that’s a boxed warning, with an increased risk of developing fatal infections, autoimmune effects, and malignancy.

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