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