Title: Treatment issues in Pediatric Multiple Sclerosis
1Treatment issues in Pediatric Multiple Sclerosis
- Brenda Banwell, MD, FRCPC
- Director, Pediatric Multiple Sclerosis Clinic
- The Hospital for Sick Children
- University of Toronto
2Child with MS
Chronic immunosupression
Acute symptoms
Symptomatic treatment
MS-targeted therapies
3Management of the Acute Demyelinating Attack
4General Approach
- Ensure that symptoms are referable to
demyelination - Evaluate symptom severity
- Review prior response to acute management
- Review timing of last exposure to corticosteroids
5IV 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
6MS-targeted immunotherapies in children
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9Side effects
10Safety Monitoring
Contraception reminder
Contraception counseling
Liver function CBC
Liver function CBC
Liver function CBC
4 weeks
Baseline
monthly
11Chronic Immunosuppresion
12Cyclophosphamide
- 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
13Mitoxantrone
- 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
14Symptomatic Therapies
15Fatigue
- 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
16Treatment 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
17Rehabilitation
18Issues 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
19Acknowledgements
- 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