Nursing Grand Rounds: Multiple Sclerosis
Multiple sclerosis (MS) is a highly variable, unpredictable disease and one of the most life-altering diagnoses a person can receive. Because it usually strikes in the prime of life, frequently progresses to disability, and has no cure, MS can make a strong emotional impact—not only on those who suffer from it, but also the healthcare team. Because MS is such a complex, multifaceted disorder, nurses who care for people with MS are faced with numerous clinical challenges. Many of the challenges are unique to MS, demanding, and time-consuming. Well-informed nurses are positioned to evaluate and explain the disease process, assist in the alleviation of symptoms, educate partners and families, and help improve quality of life. A case example can help nurses understand the real-life concerns of a person with MS.
Multiple sclerosis (MS) is a highly variable, unpredictable disease and one of the most life-Multiple sclerosis (MS) is a chronic neuroimmunologic disease of the central nervous system (CNS) that affects the brain, spinal cord, and optic nerves. It is characterized by the occurrence of random patches of inflammation that result in the loss of myelin—the insulating substance that surrounds nerve fibers in the white matter of the CNS. Loss of myelin, however, is no longer the only hallmark of the disease. In recent years, it has been discovered that axons become irreversibly damaged as a consequence of the immune system's attacks on myelin early in the disease. This axonal loss may be a major cause of the persistent neurological deficits in MS. Early treatment with disease-modifying agents is especially recommended in light of this evidence (National Multiple Sclerosis Society, 2003).
Three injectable immunomodulating agents—interferon beta-1a (Avonex, Rebif) and glatiramer acetate (Copaxone)—have emerged as encouraging treatment advances for relapsing MS since interferon beta-1b (Betaseron) was first approved for relapsing MS by the Food and Drug Administration (FDA) in 1993. These agents reduce the number of relapses by up to 30%, reduce the severity of attacks, and possibly delay the onset of disability. In November 2004, the FDA approved a new drug for use in MS. Natelizumab (Tysabri) is a monoclonal antibody administered intravenously. Another drug approved by the FDA for use against MS is mitoxantrone (Novantrone). This chemotherapeutic agent is administered to those whose relapsing MS is worsening, as characterized by more frequent or severe relapses, limited recovery after relapses, or a steady decline with relapses (i.e., secondary progressive MS).
Most people with MS suffer episodic acute symptomatic attacks, also known as exacerbations or relapses. These episodes last from one day to several days or weeks and represent new disease activity. Temporary worsening of symptoms due to elevated body temperature from infections and viral illnesses are called "pseudo-exacerbations" and remit as the fever is reduced and the underlying cause dissipates. But when severe worsening of existing symptoms or emergence of new symptoms are not associated with fever or infection, such attacks usually are considered to be exacerbations and are treated with intravenous (IV) methylprednisolone. The most common treatment course is 1,000 mg over 2 hours daily for 4–6 days (van den Noort, 1999), though the schedule may vary. High-dose IV steroids usually are tapered and may be followed by a course of oral steroids. Short courses of IV steroids are usually well tolerated and safe.
These agents, along with innovations in symptom management, have improved the quality of life (QOL) for people with MS. They also have intensified the challenges of treatment management for nurses providing care. Because the effects of MS are so variable, each case is unique and presents its own set of symptoms and challenges. A case report illustrates the diverse problems faced by nurses and other members of the healthcare team and demonstrates how effective management strategies can significantly improve outcomes for patients with MS.
Multiple sclerosis (MS) is a highly variable, unpredictable disease and one of the most life-altering diagnoses a person can receive. Because it usually strikes in the prime of life, frequently progresses to disability, and has no cure, MS can make a strong emotional impact—not only on those who suffer from it, but also the healthcare team. Because MS is such a complex, multifaceted disorder, nurses who care for people with MS are faced with numerous clinical challenges. Many of the challenges are unique to MS, demanding, and time-consuming. Well-informed nurses are positioned to evaluate and explain the disease process, assist in the alleviation of symptoms, educate partners and families, and help improve quality of life. A case example can help nurses understand the real-life concerns of a person with MS.
Multiple sclerosis (MS) is a highly variable, unpredictable disease and one of the most life-Multiple sclerosis (MS) is a chronic neuroimmunologic disease of the central nervous system (CNS) that affects the brain, spinal cord, and optic nerves. It is characterized by the occurrence of random patches of inflammation that result in the loss of myelin—the insulating substance that surrounds nerve fibers in the white matter of the CNS. Loss of myelin, however, is no longer the only hallmark of the disease. In recent years, it has been discovered that axons become irreversibly damaged as a consequence of the immune system's attacks on myelin early in the disease. This axonal loss may be a major cause of the persistent neurological deficits in MS. Early treatment with disease-modifying agents is especially recommended in light of this evidence (National Multiple Sclerosis Society, 2003).
Three injectable immunomodulating agents—interferon beta-1a (Avonex, Rebif) and glatiramer acetate (Copaxone)—have emerged as encouraging treatment advances for relapsing MS since interferon beta-1b (Betaseron) was first approved for relapsing MS by the Food and Drug Administration (FDA) in 1993. These agents reduce the number of relapses by up to 30%, reduce the severity of attacks, and possibly delay the onset of disability. In November 2004, the FDA approved a new drug for use in MS. Natelizumab (Tysabri) is a monoclonal antibody administered intravenously. Another drug approved by the FDA for use against MS is mitoxantrone (Novantrone). This chemotherapeutic agent is administered to those whose relapsing MS is worsening, as characterized by more frequent or severe relapses, limited recovery after relapses, or a steady decline with relapses (i.e., secondary progressive MS).
Most people with MS suffer episodic acute symptomatic attacks, also known as exacerbations or relapses. These episodes last from one day to several days or weeks and represent new disease activity. Temporary worsening of symptoms due to elevated body temperature from infections and viral illnesses are called "pseudo-exacerbations" and remit as the fever is reduced and the underlying cause dissipates. But when severe worsening of existing symptoms or emergence of new symptoms are not associated with fever or infection, such attacks usually are considered to be exacerbations and are treated with intravenous (IV) methylprednisolone. The most common treatment course is 1,000 mg over 2 hours daily for 4–6 days (van den Noort, 1999), though the schedule may vary. High-dose IV steroids usually are tapered and may be followed by a course of oral steroids. Short courses of IV steroids are usually well tolerated and safe.
These agents, along with innovations in symptom management, have improved the quality of life (QOL) for people with MS. They also have intensified the challenges of treatment management for nurses providing care. Because the effects of MS are so variable, each case is unique and presents its own set of symptoms and challenges. A case report illustrates the diverse problems faced by nurses and other members of the healthcare team and demonstrates how effective management strategies can significantly improve outcomes for patients with MS.