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MS Symptom Medications
A symptomatic therapy or treatment is usually a drug that addresses a particular aspect of a disease, but taking it doesn't change the underlying course or limit the damage caused by the disease. As implied by its name, a symptomatic treatment will only affect the symptoms, not its cause or etiology. It's usually aimed at reducing the signs and symptoms for the comfort and well-being of the patient, but it also may be useful in reducing the consequences and aftereffects of these signs and symptoms of the disease. In many diseases, even in those whose etiologies are known (e.g., most viral diseases, such as influenza), symptomatic treatment is the only one available so far.

Multiple sclerosis (MS) is associated with a variety of symptoms and functional deficits that result in a range of progressive impairments and handicap. Symptoms that contribute to loss of independence and restrictions in social activities lead to continuing decline in quality of life. There are many medications taken by those with MS to manage specific symptoms, such as spasticity, fatigue or depression.

It needs to be remembered that even though symptomatic therapies have benefits, their use is limited by possible side-effects. Beyond side-effects, many common disabling symptoms, such as weakness, are not helped or aided by drug treatments. However, neurorehabilitation has been shown to ease the burden of these symptoms by improving self-performance and independence.

The U.S. Food and Drug Administration (FDA) approved disease-modifying therapies (DMTs) are partially effective against many forms of MS, the symptomatic treatments are found to be necessary for the many different symptoms as a result of MS.

The FDA Approves Ampyra to Improve Walking in Adults with MS

The FDA approved Ampyra® (dalfampridine) extended release tablets on January 22, 2010 as a treatment to improve walking in patients with MS. In clinical trials, patients treated with Ampyra had faster walking speeds than those treated with an inactive pill or placebo.

Ampyra is the first and only prescription MS therapy that has been specifically approved by the FDA to improve walking in people with MS. More than 400,000 people in the U.S. and nearly 2.5 million people worldwide are living with MS, and for the majority of those people, the disease affects their ability to walk. Walking difficulties can happen to anyone with MS, and can lead to difficulty in keeping up with family and friends, or having difficulty crossing the street.

"Trouble with walking is one of the most debilitating problems people with MS face," said Russell Katz, M.D., director of the Division of Neurology Products in the FDA's Center for Drug Evaluation and Research.

Ampyra (pronounced amPEERah) is a tablet containing a sustained-release formula of 4-aminopyridine, which blocks tiny pores, or potassium channels, on the surface of nerve fibers. This blocking ability may improve the conduction of nerve signals in nerve fibers whose insulating myelin coating has been damaged by MS.

Ampyra, when given at doses greater than that recommended (10 mg twice a day), can cause seizures. The most common adverse reactions reported by patients taking Ampyra in clinical trials include urinary tract infection, insomnia, dizziness, headache, nausea, weakness, back pain, balance disorder, swelling in the nose or throat, constipation, diarrhea, indigestion, throat pain, and burning, tingling or itching of skin.

Ampyra should not be used in patients with moderate to severe kidney disease. In these patients, blood levels with the drug approach those associated with the occurrence of seizures.
Symptomatic MS Treatments
The following list is courtesy of the USCF Multiple Sclerosis Clinic:

Depression

Depression is a very common symptom in MS. Depression is characterized by feelings of hopelessness, the inability to enjoy things that once were pleasurable, feelings of worthlessness, disruption of sleep, crying, feelings of sadness or irritability, social isolation, decreased sexuality, and in some cases, suicidal thoughts. If these symptoms persist occur every day for two weeks or more, or include suicidal thoughts, medical attention is required immediately. Regardless of whether the depression is reactive (i.e., as a result of having a serious illness), genetic (endogenous depression), or a manifestation of the illness itself, medications can be helpful. Individual psychotherapy can also be helpful, either by itself or in combination with medication. However, studies suggest that in MS patients, depression usually requires some form of treatment - it's unlikely to spontaneously remit. In addition to an alteration of mood, depression may contribute to the fatigue experienced by patients with MS and this also may respond favorably to antidepressant medications. Useful agents in the treatment of depression include the selective serotonin reuptake inhibitors, the tricyclic antidepressants, and the non-tricyclic antidepressants.

Fatigue

Fatigue is characterized by diminished energy and endurance. Many patients with MS also experience an overwhelming sense of exhaustion that requires them to sit, recline, or fall asleep. This symptom is often aggravated by elevated temperature and can be reversed by cooling. Fatigue in MS can be severe and disabling. It affects almost 90% of patients to some degree and is characterized as moderate to severe in over half. It accounts (in part or in whole) for the disability in approximately 65% of patients unable to work. It is also multifactorial. Thus, depression can often contribute to a patients fatigue and may be managed successfully with anti-depressant medications. Patients who expend exceptional effort to accomplish basic ADLs may experience substantial fatigue and may benefit from assistive devices, from help in the home, or from successful management of their spasticity. Not infrequently, patients with MS have nighttime sleep disturbances that translate into day time fatigue. As one example, patients with frequent nocturia (and, thus, frequent nocturnal awakenings) may benefit from an anticholinergic medication at bedtime to prevent these night time arousals and improve the quality of their night time rest. In addition to these other sources of fatigue in MS, however, there is also an extreme lassitude that is more specifically related to the disease. This fatigue can be the sole manifestation of an attack and is often difficult to treat. Several effective medications are now available for the treatment of fatigue. These medications include amantadine (Symmetrel) 200 mg/day; methylphenidate (Ritalin) 5-25 mg/day, modafinil (Provigil) 200-400 mg/day, and armodafinil (Nuvigil) 50-250 mg/day. A cooling vest or cap may be helpful when symptoms are provoked by exposure to elevated temperatures.

Spasticity

Spasticity (muscle stiffness) is usually accompanied by weakness, slowness of movement, poor coordination, and spontaneous spasms. Spasticity poses a considerable problem for the management of MS patients. Over 40% of patients describe their spasticity as moderate to severe. Typically it is most severe in the lower extremities and often interferes substantially with a patients ability to ambulate, to work, and to perform even the most basic activities of daily living. It's often painful and frequently associated with painful extensor (occasionally flexor) spasms. At times, however, the increased stiffness of the muscles may be helpful to patients by providing non-volitional support during ambulation. In such a circumstance, overly aggressive treatment may actually do more harm than good. Non-pharmacological approaches to the management of spasticity include physical therapy, regular exercise, and stretching, which can provide substantial relief. The avoidance of nociceptive inputs from a variety of sources (e.g., infections, fecal impactions, bed sores, etc.) is an extremely important first principal in patient management because such inputs are known to increase markedly the severity and extent of spasticity. Effective pharmacological agents for reducing both spasticity and spasms include lioresal (Baclofen) 20-120 mg/day; diazepam (Valium) 2-40 mg/day, and tizanidine (Zanaflex) 8-32 mg/day. Several other medications have also been reported to provide occasional benefit for patients with spasticity including clonazepam, carbamazepine, phenytoin, gabapentin, tetrahydrocanabinol, barbiturates, and alcohol. However, the efficacy of these agents is not well established.

When the spasticity is particularly severe and the patient already has limited use of their lower extremities, a surgically implanted lioresal (Baclofen) pump (delivering the medication directly into the spinal fluid that bathes the spinal cord) can often provide substantial relief. This may also allow for improved hygiene and, thereby, reduce the frequency of urinary infections and bed sores. Destructive procedures such as selective rhyzotomy, tenotomy, myotomy, and phenol injections should be reserved for only the most extreme cases that are unresponsive to other measures.

Pain

Pain is an under appreciated symptom of MS. Over half of MS patients complain of pain and, in a substantial fraction, the pain is described as severe, at least at times. MS-related pain can be experienced as jolts of electricity, continuous dull burning, disagreeable tingling, or raw sensations. An improved understanding of the mechanisms that produce pain of central origin has produced several successful approaches to its management, including the anticonvulsant drugs, the antidepressant drugs, or the anti-arrhythmic drugs. If these treatments are unsuccessful, some patients may respond to a comprehensive pain management program. Such persons may be referred to the UCSF Clinical Pain Research Center.

Ataxia/Tremor

Ataxia/Tremor is a common and often intractable symptom in MS that is difficult to treat effectively. Tremor may involve the hand, arm, leg, head, or voice. These movements may be barely noticeable or they can be severely incapacitating. Some medications are occasionally helpful including clonazepam (Klonopin), 1.5-20 mg/day, mysoline (Primadone) 50-250 mg/day, propranalol (Inderal) 40-200 mg/day, or ondansetron (Zofran) 8-16 mg/day. The use of weights on the wrists may occasionally reduce tremor in the arm or hand. Unfortunately, however, the success of most attempts at therapy is limited. Recently, there has been interest in the use thalamotomy and/or the placement of deep brain stimulators to control tremor. However, even in the best of hands the response to this intervention is often partial, the response rate is limited (~50%), the duration of any therapeutic benefit is unknown. Moreover, the surgical procedure itself carries risk.

Bladder Dysfunction

Several different types of bladder dysfunction occur in MS. Not infrequently, different types of dysfunction co-exist in the same patient and, as a result, urodynamic testing can often provide useful clinical information. During normal reflex voiding there is a coordinated relaxation of the bladder sphincter that is precisely timed to the detrusor muscle (bladder wall) contraction. The urinary stream is stopped by a reversal of the above mechanisms with bladder wall relaxation coordinated with sphincter contraction. The bladder reflex is activated by stretch of the bladder wall during filling and it can be voluntarily inhibited. Symptoms of bladder dysfunction are present in over 90% of patients with MS. Many of these symptoms occur only occasionally and are quite mild. In this circumstance, they don't require specific intervention. Nevertheless, over 30% of MS patients experience bladder symptoms of sufficient severity to result in episodes of incontinence weekly or more often. Fortunately, bladder symptoms are among the easiest MS symptoms to treat. These symptoms include (1) urinary frequency the need to go to the bathroom frequently; (2) urgency the need to go to the bathroom immediately; (3) hesitancy difficulty initiating the urine stream; and (4) retention the inability to completely empty the bladder. Most patients can regain continence or experience significant improvement in these symptoms.

The first type of bladder dysfunction, results from decreased inhibition of the bladder reflex. Symptomatically, this decrease causes urinary frequency (having to urinate more often than usual), urinary urgency (having to get to the bathroom right away when you feel the urge), and uncontrolled bladder emptying (incontinence). When these symptoms are mild they can sometimes be treated with fluid management techniques such as evening fluid restriction to prevent night time incontinence or the use of frequent voluntary voiding to prevent day time incontinence. If these simple approaches fail to control the problem, however, there are several medications available that can inhibit bladder wall contraction and thereby lessen the bladder reflex. These medications include propantheline bromide (ProBanthine) 10-15 mg/day; oxybutinin (Ditropan) 5-15 mg/day, hycosamine sulfate (Levsin) 0.5-0.75 mg/day and tolteridine tartrate (Detrol) 2-4 mg/day. Often the co-administration of an over-the-counter medication such as pseudoephedrine (Sudafed, 30-60 mg) which cause contraction of the bladder sphincter can help maintain continence.

The second type of bladder dysfunction, results from the loss of coordination and synchronization between the bladder wall and sphincter muscles (dyssynergia). This results in a difficulty initiating or stopping the urinary stream (hesitancy) and leads to the retention of residual urine in the bladder following voiding. Occasionally, this condition will respond to medications such as phenoxybenzamine (Dibenzyline, 10-20 mg/day) but more often this condition requires the use of intermittent or continuous catheterization. A third type of dysfunction, loss of reflex bladder wall contraction, generally results from a chronically over-filled bladder, which, itself, is often due to long-standing dyssynergia. This condition can occasionally respond to medications such as bethanecol (Urecholine), 30-150 mg/day, but often this condition also often requires intermittent or continuous catheterization.

It's also important to monitor patients for urinary tract infections and treat them promptly when they are identified. Patients who have large volumes of post-void residual urine in their bladders are predisposed to bladder infections and patients at risk for such complications may be identified by measuring a post-void residual volume. It's also often helpful to take steps to prevent infections. Acidification of the urine with cranberry juice or Vitamin C inhibits some bacteria. Prophylactic administration of antibiotics is sometimes necessary but may lead to bladder colonization by resistant organisms and can result in infections that are more difficult to treat. Intermittent catheterization may be necessary to allow complete bladder emptying and to prevent recurrent infections.

Bowel Dysfunction

Constipation is a common symptom in MS, occurring in over 30% of patients. High fiber diets (often with supplemental fiber) in addition to plenty of fluids is usually the best approach. Natural or other laxatives can also help. Fecal incontinence is much less common than constipation although 17% of patients (more so in men) report at least some episodes. If it's severe enough to warrant treatment, fecal incontinence may respond to a reduction in total dietary fiber.

Paroxysmal Symptoms

Several different paroxysmal syndromes occur in MS. These syndromes are distinguished by brief duration (30 seconds to 2 minutes); high frequency of occurrence (5-40 paroxysms/day); lack of any alteration of consciousness or change in background EEG during the events; a self-limited nature (generally lasting only months and then subsiding). They may be precipitated by hyperventilation or movement. These syndromes include the familiar L-Hermitte's sign (electric shock like sensations induced by neck flexion), tonic seizures, paroxysmal dysarthria/ataxia, paroxysmal sensory disturbances, and several other less well characterized syndromes. These syndromes are also distinguished by their marked responsiveness to very low dosages of anticonvulsant medications such as carbamazepine (Tegretol), 50-400 mg/day, phenytoin (Dilantin), 50-300 mg/day, or acetazolamide (Diamox) 200-600 mg/day. Patients with MS may also suffer from trigeminal neuralgia (tic douloureux) which often responds to similar medications.

Heat Sensitivity

Many symptoms are aggravated by exposure to heat or with fever. Keeping away from the direct heat of the sun and the use of air conditioning are often necessary to prevent these symptoms. Cooling vests or caps may be useful in select patients.

Weakness

The potassium channel blockers (e.g., 4-amino pyridine, 10-40 mg/day; and 3,4-di-amino pyridine, 40-80 mg/day) may help some MS symptoms (especially heat sensitive symptoms) and anecdotally some patients experience improved function. These drugs presumably work by prolonging the duration of the nerve action potential and, thereby, facilitating conduction through demyelinated fibers. At high enough doses they may also cause seizures for similar reasons. These agents are not FDA-approved but are currently available from one of several compounding pharmacies around the US. More definitive clinical trials, however, are needed to establish any therapeutic benefit.

Sexual Dysfunction

Sexual dysfunction was reported by over 60% of the women and over 75% of the men in a recent survey of MS patients in northern California. The greater dysfunction in men resulted not only from impotence (61%) but also from less sexual desire and less demonstrated interest by their partners. Nevertheless, sexual dysfunction can be a considerable problem for either gender. Women experiencing sexual dysfunction often experience numbness in the genital area, diminished orgasmic response, unpleasant sensations, and diminished vaginal lubrication. Men commonly report impaired genital sensation, delayed ejaculation, decreased force of ejaculation, and/or inability to achieve and maintain an erection. Approaches such as couples or psychological therapy may help in selected cases. Communication between partners is essential. Teaching your partner how you need to be touched or positioned can result in a return of pleasure and excitement instead of discomfort or pain. The use of water soluble lubricants may be an essential aid in genital stimulation and sexual arousal. The use of vibrators may provide pleasurable and sexually stimulating sensations. Spasms, pain, spasticity, fatigue, and bladder/bowel dysfunction may contribute to sexual dysfunction, and medications to alleviate these symptoms may help. Thus, the effective management of adductor spasticity, the use of devices (e.g., vibrators) to make up for loss of deep sensation, penile injections of papaverine or prostaglandin, or prosthetic devices to assist with maintaining erection may also be helpful in some circumstances. The biggest advance in treatment of impotence (erectile dysfunction), however, has been the introduction of phosphodiesterase inhibitor medications such as sildenafil (Viagra) 50-100 mg; tadalafil (Cialis) 5-20 mg; and vardenafil (Levitra) 5-10 mg ; taken orally 1-2 hours prior to sex.

Memory Problems

Cognitive problems, including problems with memory, are common in MS. Between 45 and 65% of people with MS will have some problems with cognitive functioning. Donepezil HCl (Aricept) is a cholinesterase inhibiting medication used to treat patients with early Alzheimers disease. Two small, non-randomized, uncontrolled studies have shown benefit for MS patients with memory problems taking 10 mg/day. Similar small, uncontrolled studies have also shown benefits for patients with memory problems due to traumatic brain injury. Larger, placebo-controlled studies are underway with both these populations. While this medication is not currently approved by the FDA for the treatment of memory problems in patients with MS, it may be of some benefit in some cases.



The following are some of the medications used to treat many of the symptoms caused by MS:

MS Symptoms Common Medications

Acute Exacerbations Decadron (Dexamethasone)
Deltasone (Prednisone)

Walking Ampyra (Dalfampridine)

Spasticity Baclofen (Lioresal)
Diazepam (Valium)
Botox (Onabotulinumtoxin A)
Clonazepam (Klonopin)
Dantronlene (Kantrium)

Muscular or Flexor Spacticity & Joint Spacticity Dantrium (Dantrolene)
Zanaflex (Tizanidine)
Ibuprofen
Anti-inflammatory

Optic Neuritis Solu-Medrol (Methylprodnisolone)
Oral Steroids

Fatigue Symmetrel (Amantadine)
Prozac (Fluoxetine)
Cylert (Pemoline)
Provigil (Mondafinil)
Nuvigil (Armodafinil)
Antidepressants

Pain Celebrex (Celecoxib)
Aspirin or acetaminophen
Antidepressants
Codeine

Pain (Neuropathic) Cymbalta (Duloxetine hydrochloride)

Pain (Dyesthesias) Burning Aching Pain Dilantin (Phenytoin)
Neurontin (Gabapentin)
Elavil (Amitriptyline)
Acetaminophen

Pain (Paresthesias) Elavil (Amitriptyline)
Pamelor (Nortriptyline)

Pain (Trigeminal Neuralgia) Tegretol (Carbamazepine)
Dilantin (Phenytoin)
Anticonvulsants

Tremor Laniazid / Nydrazid (Isoniazid)

Tremor Pain Spasticity Klonopin (Clonazepam)

Paroxysmal Itching Atarax (Hydroxyzine)

L-hermitte's Sign Anticonvulsants

Depression Cymbalta (Duloxetine Hydrochloride)
Effexor (Venlafaxine)
Paxil (Paroxetine)
Zoloft (Sertraline)
Prozac (Fluoxetine)
Wellbutrin (Bupropion)
Mirtazapine (Remeron)

Insomnia Sleeping Aides

Bladder Dysfunction Detrol (Tolterodine)
Diropan (Oxybutynin)
Enablex (Darifenacin)
Flomax (Tamsulosin)
Hytrin (Terazosin)
Vesicare (Solifenacin Succinate)

Sexual (Erectile) Dysfuntions Papaverine
Cialis (Tadalafil)
Caverject (Alprostadil)
Levitra (Vardenafil)
Viagra (Sildenafil)

Nausea & Dizziness Antivert-US / Bonamine-CA (Meclizine)

Constipation Mineral Oil
Colace (Docusate)
Dulcolax (Bisacodyl)