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Treatment issues in Pediatric Multiple Sclerosis

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Gillian Bone, Physiotherapy. Raymond Buncic, Neuroophthalmology. Peter Anderson, Neuropsychology. Lois Peltz, Psychiatry. Arlette Lefebvre, Psychiatry ... – PowerPoint PPT presentation

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Title: Treatment issues in Pediatric Multiple Sclerosis


1
Treatment issues in Pediatric Multiple Sclerosis
  • Brenda Banwell, MD, FRCPC
  • Director, Pediatric Multiple Sclerosis Clinic
  • The Hospital for Sick Children
  • University of Toronto

2
Child with MS
Chronic immunosupression
Acute symptoms
Symptomatic treatment
MS-targeted therapies
3
Management of the Acute Demyelinating Attack
4
General Approach
  • Ensure that symptoms are referable to
    demyelination
  • Evaluate symptom severity
  • Review prior response to acute management
  • Review timing of last exposure to corticosteroids

5
IV Solumedrol 20-30 mg/kg/dose X 3 days
Minimal or no improvement
Improvement
Prednisone start at 1 mg/kg/day, taken as a
single morning dose
IV Solumedrol 20-30 mg/kg/dose X 2 additional
days
Taper by 5 mg every 2-3 days
No improvement
Improvement
IVIg 2 mg/kg total dose if lt 50 kg or gt 50 kg
Relapse of SS during taper
Improved /stabilized
Initiate immunomodulatory treatment if patient
meets criteria for MS diagnosis
6
MS-targeted immunotherapies in children
7
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8
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9
Side effects
10
Safety Monitoring
Contraception reminder
Contraception counseling
Liver function CBC
Liver function CBC
Liver function CBC
4 weeks
Baseline
monthly
11
Chronic Immunosuppresion
12
Cyclophosphamide
  • Alkylating agent with cytotoxic and
    immunosuppressive properties
  • controversial efficacy in large studies
  • recent evidence suggests a role for
    cyclophosphamide in patients with frequent
    relapses who fail to respond to MS-disease
    modifying agents
  • Side effects include alopecia, hemorrhagic
    cystitis, infertility, opportunistic infections
    and an increased risk of future malignancy

13
Mitoxantrone
  • Potent immunosuppressant
  • typically prescribed at a dose of 12 mg/m2 IV
    every 3 months for 2 years)
  • cumulative risk of cardiotoxicity with increasing
    dose
  • no data in pediatric MS

14
Symptomatic Therapies
15
Fatigue
  • Definition sufficient fatigue, or a subjective
    sensation of reduced endurance, to interfere with
    enjoyable activities or impair concentration at
    school
  • typically manifests as withdrawal from social
    activities, after school naps, reduced ability to
    participate in sports
  • occurs in approximately 30 of pediatric MS
    patients

16
Treatment of Fatigue
  • Reduce wasted exertion
  • backpacks
  • home textbooks
  • occupational therapy
  • Modafinil (Provigil)
  • shown to improve fatigue in adults
  • well tolerated in pediatric MS (morning dosing)
  • subjective improvements noted
  • Amantidine
  • well-tolerated
  • little effect on nocturnal sleep

17
Rehabilitation
18
Issues to Consider
  • Cognition and academic progress
  • Career counseling and reconciliation of career
    goals with a chronic disease
  • Social integration and self-identity
  • Physical rehabilitation and mobility
  • Autonomy
  • the role of independence in medically fragile
    adolescents

19
Acknowledgements
  • Lynn MacMillan, Clinic Nurse
  • Jennifer Boyd, Clinical Nurse Specialist
  • Julia Kennedy, Research Manager
  • Jennifer Hamilton, Clinic Co-Ordinator
  • Gillian Bone, Physiotherapy
  • Raymond Buncic, Neuroophthalmology
  • Peter Anderson, Neuropsychology
  • Lois Peltz, Psychiatry
  • Arlette Lefebvre, Psychiatry
  • Rose Geist, Psychiatry
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