Table 3: Symptom Management in MS

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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=20 by intrathecal pump
tizanidine	4-8 mg TID-QID	Less tendency to produce weakness compared to baclofen = but more=20 sedating
gabapentin	300-900 mg TID-QID	Useful as adjunct therapy for spasticity when there is = concomitant=20 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;=20 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=20 sedation
amitriptyline	25-150 mg QHS	Sedation and anticholinergic effects may be useful for=20 dose-limiting
nortriptyline	25-150 mg QHS	Less prominent sedation and anticholinergic effects = compared to=20 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=20 monitored
fluoxetine	20-40 mg = QD	Useful when there is concomitant = depression Methylphenidate and=20 dextroamphetamine/amphetamine are used by some clinicians, but = there are=20 no published studies to support its use Medication should be = combined=20 with a regular exercise program. Need to rule out poor sleep, = other=20 medical conditions, and medication side effects
Depression
SSRI		"Energizing" effect of SSRIs may be helpful with fatigue, = although=20 any anti-depressant may be useful
Tricyclics		Useful = when there is=20 concomitant pain, detrusor hyperactivity or sleep = disturbance Psychotherapy should=20 be considered in patients with depression or emotional=20 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=20 QD	Extended-release = formulation is=20 useful
tolteridine	1-2 mg BID or = LA, 2-4 mg=20 QD	Less sytemic = anticholinergic=20 side effects than oxybutynin but may not be as potent; Patients on = anticholinergic therapy need to be monitored for incomplete = bladder=20 emptying. Fluid restriction in the evening or low-dose DDAVP may = be useful=20 for nocturia but patients need to avoid restricting fluids during = the=20 day
Flaccid=20 Bladder
bethanechol	10-50 mg = BID-QID	Intermittenet = catheterization=20 or urinary diviersion often are superior
Detrusor-sphincter = Dyssynergia
terazocin	5-10 mg = QHS	Often = detrusor-sphincter=20 dyssynergua occurs with detrusor hyperactivity. In that setting = terazocin=20 or intermittenet catheterization can be combined with = anticholinergic=20 medication.
Constipation
bulk-forming=20 agents lactulose		Needs to be = combined with=20 adequate fluid, dietary fiber, and regular = exercise
Bowel=20 Urgency
bulk-forming = agents		Needs to be = combined with=20 scheduled voiding; biofeedback is sometimes = useful
Impotence
sildenafil	50-100 mg = PRN	Largely has = supplanted other=20 approaches. Need to rule out emotional factors, other medical = conditions=20 or medication side effects
Adapted from Fox = RJ, Cohen JA.=20 Cleve Clinic J of Med = 2001;68:157-71.

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