Subject: Table 3: Symptom Management in MS
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Date: Fri, 2 May 2008 12:42:55 -0600

Table 3:

Symptom Management in Multiple Sclerosis

Medication

Dose

Comments

Spasticity

baclofen

5-20 mg BID-QID

High doses may exacerbate weakness or ataxia; can be administered
by intrathecal pump

tizanidine

4-8 mg TID-QID

Less tendency to produce weakness compared to baclofen but more
sedating

gabapentin

300-900 mg TID-QID

Useful as adjunct therapy for spasticity when there is concomitant
neuropathic pain

diazepam

2-10 mg QD-TID

Useful for nocturnal spasms

clonazepam

0.5-5 mg QD-TID

Useful for nocturnal spasms

dantrolene

25-100 mg BID-QID

Least cerebral side effects but produces obligate weakness;
possible severe liver dysfunction limits use; Medication should be
combined with a regular stretching program

Neuropathic Pain

gabapentin

300-900 TID-QID

Well-tolerated but may require high doses; titrate to avoid
sedation

amitriptyline

25-150 mg QHS

Sedation and anticholinergic effects may be useful for
dose-limiting

nortriptyline

25-150 mg QHS

Less prominent sedation and anticholinergic effects compared to
amitriptyline

topiramate

25-200 BID

Slow titration (weekly) to minimize sedation

lamotrigine

25-400 QD

Slow titration (weekly) to minimize sedation

carbamazepine

200-400 mg TID

Seating and may exacerbate ataxiad

phenytoin

300-600 mg QD

Fatigue

amantadine

100 mg BID

Watch for livedo reticularis

mondafinil

100-200 mg QD

Also improves sleep

pemoline

18.75-75 mg QD

Second-line drug; hepatotoxicity probably rare but must be
monitored

fluoxetine

20-40 mg QD

Useful when there is concomitant depression
Methylphenidate and
dextroamphetamine/amphetamine are used by some clinicians, but there are
no published studies to support its use
Medication should be combined
with a regular exercise program. Need to rule out poor sleep, other
medical conditions, and medication side effects

Depression

SSRI

"Energizing" effect of SSRIs may be helpful with fatigue, although
any anti-depressant may be useful

Tricyclics

Useful when there is
concomitant pain, detrusor hyperactivity or sleep disturbance

Psychotherapy should
be considered in patients with depression or emotional
distress.

Vertigo

meclizine

25 mg Q6H

Sedating

diazepam

2-10 mg TID/QID

Sedating

isoniazid

800-1200 mg/d

Supplement with pyridoxine 25-50 mg/d

scopolamine
patch

Q3D

ondanestron

8 mg BID

Ataxic Tremor

gabapentin

300-900 TID

Medications usually not effective

clonazepam

0.5-5 mg QD-TID

Sedating

carbamazepine

200-400 mg TID

Sedating

ondansetron

8 mg BID

isoniazid

800-1200 mg/d

Supplement with pyridoxine 25-50 mg/D

primidone

100-250 mg TID-QID

Sedating

Detrusor Hyperactivity

oxybutynin

2.5-5 mg TID
or XL 5-30 mg
QD

Extended-release formulation is
useful

tolteridine

1-2 mg BID
or LA, 2-4 mg
QD

Less sytemic anticholinergic
side effects than oxybutynin but may not be as potent; Patients on
anticholinergic therapy need to be monitored for incomplete bladder
emptying. Fluid restriction in the evening or low-dose DDAVP may be useful
for nocturia but patients need to avoid restricting fluids during the
day

Flaccid
Bladder

bethanechol

10-50 mg BID-QID

Intermittenet catheterization
or urinary diviersion often are superior

Detrusor-sphincter Dyssynergia

terazocin

5-10 mg QHS

Often detrusor-sphincter
dyssynergua occurs with detrusor hyperactivity. In that setting terazocin
or intermittenet catheterization can be combined with anticholinergic
medication.

Constipation

bulk-forming
agents

lactulose

Needs to be combined with
adequate fluid, dietary fiber, and regular exercise

Bowel
Urgency

bulk-forming agents

Needs to be combined with
scheduled voiding; biofeedback is sometimes useful

Impotence

sildenafil

50-100 mg PRN

Largely has supplanted other
approaches. Need to rule out emotional factors, other medical conditions
or medication side effects

Adapted from Fox RJ, Cohen JA.
Cleve Clinic J of Med 2001;68:157-71.

Copyright 2002 The Cleveland Clinic
Foundation

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