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MS ECHO Session 7: Fatigue in MS
Gary Stobbe, MD Medical Director, MS Project ECHO
Clinical Assistant Professor, UW Neurology
Conflict of Interest:
• Dr. Stobbe has no conflicts of interest to disclose
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Educational Objectives:
• Define MS related fatigue • Understand impact of fatigue in MS • Review treatment options of fatigue in MS
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Areas of Management
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Case A - Overview • 19 yo female • no prior hx/family hx • Intermittent paresthesias R arm – 2 weeks later,
tingling in BUE when washing hair – 1 week later, continuous numbness in L ulnar
• 1 month later – tingling in pelvis/perineum with neck flexion (atypical Lhermitte's)
• ROS – fatigue, balance complaints, headache • Exam – L hand intrinsic weakness; L C8T1 numbness • Brain/c-spine MRI & CSF c/w MS diagnosis – started on
Copaxone
Case A - Progress • Exacerbation 4 months after starting
Copaxone • Year 1 MRI – 1 new lesion • Attending masters program in social work
– Headaches twice weekly – Fatigue – “hits a wall” – Paresthesias on long days
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Case A - Progress
• Efforts to improve fatigue – Improved sleep with melatonin – Weight loss program – Stress levels reported as good
• Year 2 – new onset blurry vision, left hand numbness, increase in fatigue – brain MRI with 2 new lesions
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Fatigue in MS • Most common MS symptom
– 50 to over 90% – Common cause of early work departure
• MS fatigue – “lassitude” – Daily, worse later in the day – Abrupt onset, more severe than “normal” fatigue – Interferes with function – Made worse by heat – Not directly correlated with depression or motor
involvement
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Rating Fatigue in MS Modified Fatigue Impact Scale Component of the MSQLI Full length – 21 items (5-10 min); abbreviated – 5 items (2-3
min) “I have been less alert.” “I have been limited in my ability to do things away from home.” “I have had trouble maintaining physical effort for long periods.” “I have been less able to complete tasks that require physical
effort.” “I have had trouble concentrating.”
Full score has 3 subscales – physical, cognitive, psychosocial
Managing Fatigue in MS
Identify treatable medical conditions (thyroid, anemia) and associated symptoms (sleep, depression, pain)
Identify possible SE of other meds (including DMTs)
Consider speech (cognitive) therapy, OT, PT
Consider psychological interventions
Medications Amantadine, modafinil, methylphenidate Ampyra ? Vitamin D ? Antidepressants (bupropion, fluoxetine)
Case A - Progress
Switched Copaxone to Tysabri
Extended school (fewer classes)
Continued focus on exercise regimen
Opted not to take meds for fatigue
Resources
Modified Fatigue Impact Scale http://www.nationalmssociety.org/For-Professionals/Researchers/Resources-for-
Researchers/Clinical-Study-Measures/Modified-Fatigue-Impact-Scale-(MFIS)
Fatigue: What You Should Know
Program: Fatigue Take Control: http://www.nationalmssociety.org/Programs-and-Services/Resources/Fatigue-Take-Control-(dvd)?page=1&orderby=3&order=asc
MS Diagnosis, Disease and Symptom Management app- includes information about all symptoms
National MS Society flash drive includes publications for clinicians and patients related to symptoms. (See: Difficult Topics booklets, which model conversations about challenging topics including cognition, sexual dysfunction, stress, family issues.)
UW MEDCON (WWAMI): 1-800-326-5300
For your Patients: MS Navigator Program 1-800-344-4867 (1-800 FIGHT MS)
Dr. John Schaeffer Case 28 yo female
Hx bipolar on lamictal
Onset L side scalp/ear pain – constant ache
Exam normal/MRI unremarkable
ENT – Ramsay Hunt? (no vesicular lesions)
Poor response to gabapentin, good response to carbamazepine
Dr. Schaeffer Case (cont.) 6 mos later – neuropathic pain distal BLEs
Exam – reduced PP/temp distal to mid-calf B
EMG/NCS – mild axonal polyneuropathy
Serology – neg except B12 low (229)
Tx – B12 replacement; increase carbamazepine (pain improved)
Dr. Schaeffer Case (cont.) 20 mos later – R temporal/ocular pain with blurry vision
Ophtho – dx R optic neuritis – tx with IV steroids with prednisone taper – symptoms resolved
Neuro exam normal
Vit D – 18; anti-SSA/SSB, anti-gliadin, SPEP, lyme, TSH, B12, ESR, ANA, anti-Hu, anti-Yo, anti-Ri all negative
Brain/cervical/thoracic WNL (8/2014 and 12/2014)
CSF – positive OCBs, elevated IgG index
12/2014 – Axial T2
12/2014 – Axial T2 FLAIR
12/2014 – Axial T2 FLAIR
Dr. Jean Thomas Case 35 yo male
Hx IBS, anxiety/depression; meds – sertraline, xanax
Intention tremor x 10 yrs
2012 – vague diplopia, R facial numbness
Exam – WNL
CSF negative; Ach Ab neg
Brain MRI – white matter changes
Started on tegretol
10/2012 - T2 axial
10/2012 – T2 axial
10/2012 – T2 FLAIR
10/2012 – T2 FLAIR
10/2012 – T2 FLAIR
10/2012 – T2 FLAIR
Dr. Thomas Case (cont.)
2015 – weaned off CBZ; went off sertraline – feels great, no tremor; exam WNL
Repeat Brain MRI, 2/2015 – chiari; nonspecific lesions in CC (? Dysgenesis related to Chiari or demyelinating)
10/2012 - Cor T1
10/2012 - Sag T2 Special
10/2012 - Sag T2 Special
Dr. Thomas Case (cont.) Referral to Neurosurgery and C/T spine pending
? MS/? CIS/? other