Table 3: Symptom Management in MS

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.

Return to Multiple Sclerosis Chapter