Management principles

• All patients should be referred to a neurologist for confirmation of the diagnosis, which must be accurate.

• Explanation about the disease and its natural history should be given.

• Acute relapses require treatment if causing significant disability.

• Depression and anxiety, which are common, require early treatment.

Relapses

Mild relapses

Mild symptoms such as numbness and tingling require only confirmation, rest and reassurance. Moderate relapses 10

For symptoms that are unpleasant or disabling use a short course of high-dose prednisolone.

• prednisolone 75 mg (o) once daily for 4 days, then 50 mg (o) daily for 4 days, then 25 mg (o) daily for 4 days

Severe relapses or attacks 10 11_

These attacks include optic neuritis, paraplegia or brainstem signs. Admit to hospital for IV therapy:

• methylprednisolone 1 g in 200 mL saline by slow IV injection (3 hours) daily for 3 to 5 days

Observe carefully for cardiac arrhythmias. Drugs to prevent relapses 11

Interferon beta-1b (SC injection) and beta-1a (IM injection) are effective (but expensive) for those with frequent and severe attacks. Copolymer-1 is still under evaluation.

Drugs to reduce progression 10 12

Current recommended treatment given under careful supervision:

• folic acid 5 mg (o), 3 days after each methotrexate dose

Immunosuppression can also be given with cyclophosphamide or azathioprine. 13

Treatment of symptoms 10

Spasticity

• physiotherapy

• for continuous drug therapy:

o baclofen 5 mg (o) tds, increasing to 25 mg (o) tds +

Paroxysmal, e.g. neuralgias

• carbamazepine or clonazepam

See references 10 and 12 for treatment of other symptoms.

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