Daily Diet – MS…and in general..:o)

Sclerosis is no longer a disease one is powerless about. Nowadays, even though the disease itself cannot be cured, there are different medical treatments, and the disease’s activity can be slowed down with immunomodulators. A healthy diet is advisable by many as well.. I will later on write some recipes for a “healthy MS diet”  but first, here are seven advises for a good ‘daily diet’ you should practice:

1.       Meat: lean, max twice a week.

2.       Egg: 1 egg max twice a week.

3.        Milk/cheese: low-fat, in moderate portions.

4.       Fish: gladly 2-3 times a week.

5.       Oil: 1-3 spoons of cold-pressed vegetable oil a day.

6.       Vegetables  & fruits: many times daily, fresh or frozen.

Whole-grain products are preferred

7.       Sugar, alcohol, smoking, other individual intolerances: reduce as much as possible.

* Regular meals and smaller snacks are recommended especially when having tiredness-related problems.

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The different MS Drugs – a comparison

Drug Name

Interferon beta-1a (Avonex)

Description

Prescribed in USA as Avonex, administered by IM route (Biogen). Avonex is indicated for treatment of patients with relapsing forms of MS to slow the accumulation of physical disability and to decrease the frequency of clinical exacerbations. Patients with MS in whom efficacy has been demonstrated include patients who have experienced a first clinical episode and have MRI features consistent with MS. Safety and efficacy in patients with chronic progressive MS have not been established. Believed to act via ability to counteract cell surface expression of proinflammatory or pro-adhesion molecules on immune cells, among other effects. More studies needed to fully understand mechanisms of action. Differs from interferon beta-1b (Betaseron, see below) only in that it has amino acid sequence identical to that of natural compound and is glycosylated. Presence of glycosylation is claimed to lead to structural stability and presumably to higher biological potency.
Interferons act through common receptor that activates Jak/Stat pathway of signal transduction molecules, which, in turn, leads to activation of interferon-responsive genes. Interferon beta may decrease expression of B7-1 (a proinflammatory molecule) on surface of immune cells and increase levels of TGF-beta (anti-inflammatory molecule) in circulation of patients with MS. Interferon beta-1a is the only ABCR drug administered on a weekly schedule.
Frequency of development of neutralizing antibodies against interferon is higher with interferon beta-1b than with interferon beta-1a, but clinical significance of neutralizing antibodies still unclear and controversial.
May delay progression of disease in patients that have only manifested one clinical attack but have MRI evidence of MS.

Adult Dose

30 mcg IM weekly

Pediatric Dose

Not established

Contraindications

Documented hypersensitivity; liver dysfunction; severe leukopenia; thrombocytopenia; lactation

Interactions

None reported

Pregnancy

X – Contraindicated; benefit does not outweigh risk

Precautions

Common adverse effect is flu-like reaction following administration, usually lasting minutes or hours; 88% of patients no longer experience this effect after second month of treatment
Flu-like effects can be minimized by taking over-the-counter acetaminophen or anti-inflammatory drugs such as aspirin or ibuprofen a few hours prior to and a few hours after injection; besides flu-like illness, patients may experience injection-site skin reactions which may range from mild (slight erythema) to severe (skin necrosis).
Adverse effects may include hepatotoxicity (liver enzyme elevation) and myelosuppression (leukopenia); caution in preexisting seizure disorder; cases of exacerbation of thyroid dysfunction have been described-caution when using in patients with uncontrolled thyroid dysfunction; interferons are abortifacients; data on human teratogenicity are limited; extreme caution in patients with severe depression

Drug Name

Interferon beta-1b (Betaseron in US, Betaferon in Europe)

Description

Indicated for treatment of relapsing forms of MS to reduce the frequency of clinical exacerbations (Europe indications include treatment of secondary progressive MS with active disease). Acts via ability to counteract cell surface expression of proinflammatory or pro-adhesion molecules on immune cells, among other effects. More studies needed to fully understand mechanisms of action. May decrease expression of B7-1 (proinflammatory molecule) on surface of immune cells and increase levels of TGF-beta (anti-inflammatory) in circulation of patients with MS.
Acts through common receptor that activates Jak/Stat pathway of signal transduction molecules, which, in turn, leads to activation of interferon-responsive genes.
Frequency of development of neutralizing antibodies against interferon is higher with interferon beta-1b than with interferon beta-1a, but interferon beta-1b nAbs disappear faster. The clinical significance of nAbs is still unclear and controversial.

Adult Dose

8 million U SC qod (high-dose, high-frequency interferon)

Pediatric Dose

Not established

Contraindications

Documented hypersensitivity; liver dysfunction; severe leukopenia; thrombocytopenia; lactation

Interactions

None reported

Pregnancy

X – Contraindicated; benefit does not outweigh risk

Precautions

Has adverse effect profile similar to Avonex (ie, flu-like reaction following administration tends to disappear after 2 mo on drug); flu-like effects can be minimized by taking over-the-counter acetaminophen or anti-inflammatory drugs such as aspirin or ibuprofen a few hours prior to and a few hours after injection; besides flu-like illness, patients may experience injection-site skin reactions
Adverse effects may include hepatotoxicity (liver enzyme elevation) and myelosuppression (leukopenia); cases of exacerbation of thyroid dysfunction have been described-caution when using in patients with uncontrolled thyroid dysfunction; interferons are abortifacients; data on human teratogenicity are limited; use with extreme caution in patients with severe depression

Drug Name

Glatiramer acetate (Copaxone)

Description

Mix of amino acids proposed to mimic myelin proteins when presented on surface of antigen-presenting cells. Copaxone is indicated for reduction of the frequency of relapses in patients with RRMS. In theory, lymphocytes reactive against CNS myelin would be diverted to bind to Copaxone in circulation, thus decreasing entry of immune cells across blood-brain barrier. Most mechanisms of action, however, remain unknown, and wider effect on immune system responsiveness may be at play. Has safest side effect profile of ABCRs.

Adult Dose

20 mg SC qd

Pediatric Dose

Not established

Contraindications

Documented hypersensitivity; pregnancy and lactation

Interactions

None reported

Pregnancy

B – Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Common adverse effects are sensation of chest tightness or flushing following administration; no evidence of heart arrhythmias, angina, or pleuritic involvement
Other adverse effects include palpitations, shortness of breath, hypertonia, sweating, diarrhea, insomnia, nausea, injection-site skin reactions, and lipoatrophic lesions

Drug Name

Interferon beta-1a (Rebif)

Description

Indicated for treatment of relapsing forms of MS to decrease the frequency of clinical exacerbations and delay the accumulation of physical disability. Believed to act via ability to counteract cell surface expression of proinflammatory or pro-adhesion molecules on immune cells, among other effects. More studies needed to fully understand mechanisms of action. Differs from interferon beta-1b (Betaseron, see above) only in that it has amino acid sequence identical to that of natural compound and is glycosylated. Presence of glycosylation is claimed to lead to structural stability and presumably to higher biological potency.
Interferons act through common receptor that activates Jak/Stat pathway of signal transduction molecules, which, in turn, leads to activation of interferon-responsive genes. Interferon beta may decrease expression of B7-1 (a proinflammatory molecule) on surface of immune cells and increase levels of TGF-beta (anti-inflammatory) in circulation of patients with MS.
Frequency of development of neutralizing antibodies against interferon is higher with interferon beta-1b than with interferon beta-1a, but clinical significance still unclear and controversial. For instance, neutralizing antibodies in patients taking interferon beta-1b disappear faster than those in patients taking interferon beta-1a.
May delay progression of disease in patients that have only manifested one clinical attack but have MRI evidence of MS.

Adult Dose

44 mcg/dose SC 3 times/wk (at least 48 h between each dose) (high-dose, high-frequency interferon)

Pediatric Dose

Not established

Contraindications

Documented hypersensitivity; liver dysfunction; severe leukopenia; thrombocytopenia; lactation

Interactions

None reported

Pregnancy

C – Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Common adverse effect is flu-like reaction following administration, usually lasting minutes or hours; 88% of patients no longer experience this effect after second mo of treatment
Flu-like effects can be minimized by taking over-the-counter acetaminophen or anti-inflammatory drugs such as aspirin or ibuprofen a few hours prior to and a few hours after injection; besides flu-like illness, patients may experience injection-site skin reactions, which may range from mild (slight erythema or stinging sensations) to severe (skin necrosis)
Adverse effects may include hepatotoxicity (liver enzyme elevation) and myelosuppression (leukopenia); caution in preexisting seizure disorder; cases of exacerbation of thyroid dysfunction have been described-caution when using in patients with uncontrolled thyroid dysfunction; interferons are abortifacients; data on teratogenicity are limited; extreme caution in patients with severe depression

Drug Name

Natalizumab (Tysabri)

Description

Three cases of progressive multifocal leukoencephalopathy (PML) associated with natalizumab use prompted temporary withdrawal from the market in 2005. Natalizumab was later reapproved in 2006 by the FDA for commercialization under a special restricted distribution program known as TOUCH.
The drug now carries a package insert black box warning about potential risks of opportunistic infections. Patients, physicians, and pharmacists must be involved in the TOUCH program in order to receive, prescribe, or dispense (respectively) natalizumab. Indicated as monotherapy for MS, not to be used with other immune system-modifying drugs. Because of risks of PML, natalizumab is now generally recommended for patients who have had an inadequate response to, or are unable to tolerate alternate MS therapies.
Recombinant humanized IgG4-1C monoclonal antibody produced in murine
myeloma cells. Binds to alpha-4 subunits of alpha-4-beta-1 and alpha-4-beta-7 integrins expressed on leukocyte surface, which inhibits alpha-4-mediated leukocyte adhesion to their receptors. Clinical effect in MS may be secondary to blocking interaction of alpha-4-beta-1 expressed by inflammatory cells with VCAM-1 on vascular endothelial cells and with CS-1 and/or osteopontin expressed by parenchymal brain cells. Indicated for relapsing MS and to reduce symptom exacerbation frequency.

Adult Dose

300 mg IV q4wk; dilute in 100 mL 0.9% NaCl and infuse over 1 h

Pediatric Dose

Not established

Contraindications

Documented hypersensitivity, current infections, concomitant use of immunosuppressors

Interactions

Interferon beta-1a decreases clearance by 30%

Pregnancy

C – Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Uncommon serious adverse effects include infections (eg, PML, pneumonia), hypersensitivity reactions, severe depression, and gallstones; common adverse effects include mild infections (eg, UTI, lower respiratory tract, GI, vaginal), headache, mild depression, joint pain, and menstrual disorders; excreted in breast milk; infusion-related adverse effects include urticaria, pruritus, and rigors (discontinue infusion and treat accordingly); can only be prescribed under the TOUCH program; clinically significant hepatotoxicity has been reported during postmarketing surveillance, monitor transaminase serum levels and bilirubin (discontinue if elevated or jaundice emerges)

Drug Category: Corticosteroids

These agents reduce acute inflammation and expedite recovery from acute exacerbations of MS. They may be used for “rescue” therapy as monthly boosters in patients who respond poorly to the ABC immunomodulators. Methylprednisolone, a glucocorticoid, has greater anti-inflammatory potency than prednisolone and even less tendency to induce water and sodium retention.

Drug Name

Methylprednisolone (Solu-Medrol, Depo-Medrol)

Description

For treatment of inflammatory and autoimmune reactions. By reversing increased capillary permeability and suppressing PMN activity, may decrease inflammation. Also may alter expression of some proinflammatory cytokines.

Adult Dose

500-1000 mg IV (mix in 150-200 mL isotonic saline or D5 isotonic saline) infused over 1-2 h for 3-5 d without prednisone taper

Pediatric Dose

Not established

Contraindications

Documented hypersensitivity; systemic fungal infections; severe bone density loss; hip osteonecrosis; cataracts; psychosis

Interactions

Cyclosporine may induce seizures; phenytoin, phenobarbital, or rifampin may reduce levels because of their hepatic enzyme-inducing effects; ketoconazole may increase levels; may decrease levels of salicylates; may increase or decrease levels of anticoagulants; may increase digitalis toxicity secondary to hypokalemia; estrogens may increase levels; monitor patients for hypokalemia when taking with diuretics

Pregnancy

C – Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution or discontinue in patients with early evidence of cataracts, bone density loss, hyperglycemia, psychosis, euphoria, emotional irritability, adrenal dysfunction, fluid retention, arrhythmias, or anaphylactoid reactions; monitor for decreased bone density in prolonged treatment; steroid-induced myopathy can occur, especially in underlying neuromuscular transmission disorders

Drug Category: Immunosuppressors

These agents are used for their ability to suppress immune reactions.

Drug Name

Mitoxantrone (Novantrone)

Description

Anthracenedione compound used for SPMS and RPMS. Induces DNA cross-links and strand breaks and leads to apoptosis. Mitoxantrone also interferes with RNA and is a potent inhibitor of topoisomerase II, an enzyme responsible for uncoiling and repairing damaged DNA. Indicated for reducing neurologic disability and/or the frequency of clinical relapses in patients with secondary (chronic) progressive, progressive relapsing, or worsening relapsing-remitting MS (ie, patients whose neurologic status is significantly abnormal between relapses). Not indicated in the treatment of patients with primary progressive MS.

Adult Dose

5 mg/m2 and 12 mg/m2 IV every 3 mo (clinical trial)

Pediatric Dose

Not established

Contraindications

Documented hypersensitivity; heart disease; severe infections

Interactions

None reported

Pregnancy

D – Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Because of risk of severe myelosuppression and heart dysfunction, only clinicians experienced in chemotherapy should administer this medication
High risk of leading to long-term myocardial dysfunction; perform baseline and follow-up cardiac function tests (2D-echocardiography and ejection fraction measurements); increased risk of cardiotoxicity commonly seen after cumulative dose of 120-160 mg/m2, as observed in oncology studies; hair thinning, alopecia, and nausea usually mild but common; may cause menstrual disorders or infertility; GI bleeding and mucositis/stomatitis may occur; increases chances of infections

Drug Name

Cyclophosphamide (Cytoxan, Neosar)

Description

Metabolized in liver by mixed-function microsomal oxidase system.
Mechanism of action believed to involve DNA cross-linking. Has been used off-label for secondary progressive MS, especially for patients with dramatic, rapid progression. Thought to be more effective if given in early stage of progression.

Adult Dose

Induction phase: 600 mg/m2 IV qod for 5 d initial dose, accompanied by Solu-Medrol 1 g IV qd for 8 d
Monthly booster doses: adjust dose on basis of WBC counts on days 8, 11, and 14 after previous dose (to establish nadir) and WBC count before treatment; use following recommendations:
Total WBC nadir 1500-2000/�L: 1-day booster dose of 800 mg/m2/mo, accompanied by Solu-Medrol 1000 mg IV
Total WBC nadir <1500/�L, decrease dose by 100-200 mg/m2
Total WBC nadir >2200/�L, increase dose by 200 mg/m2
Total WBC count before cyclophosphamide dose should be >4000/�L
If 3000-4000/�L, 75% of dose
If 2000-3000/�L, 50% of dose
If <2000/�L, booster not given and WBC count checked in 1 wk
(Boosters should be given 1 day per mo for 12 mo, at which time effects of therapy should be reevaluated; if therapy working, give booster q6wk for another year, and then q2mo for a third year; authors do not advise administering cyclophosphamide for more than 3 consecutive years)

Pediatric Dose

Not established

Contraindications

Documented hypersensitivity; profound myelosuppression; active infections; hair thinning; alopecia; severe leukopenia; liver function abnormalities

Interactions

Long-term phenobarbital may increase metabolism of cyclophosphamide and ability to induce leukopenia; inhibits cholinesterases and thus potentiates effect of succinylcholine chloride

Pregnancy

D – Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Causes infertility; increased risks of bladder hemorrhage or cancer or other secondary malignancies; increased risk of opportunistic infections; patients should be hydrated adequately while receiving cyclophosphamide

Drug Name

Azathioprine (Imuran)

Description

This immunosuppressive antimetabolite drug is an imidazolyl derivative of 6-mercaptopurine. Cleaved in vivo to mercaptopurine and converted to 6-thiouric acid by xanthine oxidase. Generally used in treatment of transplant rejection or severe, active, erosive rheumatoid arthritis. Has been used off-label for MS.

Adult Dose

1 mg/kg (50-100 mg)/d PO given bid or single-dose schedule
Dose can be increased gradually (0.5 mg/kg increments); not to exceed 2.5 mg/kg/d

Pediatric Dose

Not established

Contraindications

Documented hypersensitivity; pregnancy; previous treatment with alkylating agents such as chlorambucil, melphalan, or cyclophosphamide owing to possible increased risk of neoplasia

Interactions

ACE inhibitors may induce anemia or leukopenia; may inhibit anticoagulant action of warfarin; allopurinol inhibits drug’s detoxification pathway, thus reduce to one third to one quarter usual dose if used with allopurinol

Pregnancy

D – Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Patients with serious hematologic or hepatic disorders should not use this medication; causes leukopenia or thrombocytopenia, nausea, vomiting, or diarrhea; <1% of patients may develop hepatotoxicity; instruct patients to contact their physician if they develop fever or any other evidence of infection

Drug Name

Methotrexate (Rheumatrex)

Description

Immunosuppressive metabolite drug used for some neoplasias (including leukemia), psoriasis, and rheumatoid arthritis. Interferes with DNA synthesis, repair, and cellular replication. Inhibits dihydrofolic acid reductase, which participates in synthesis of thymidylate and purine nucleotides. Has been used off-label for MS.

Adult Dose

7.5-15 mg PO qwk

Pediatric Dose

Not established

Contraindications

Documented hypersensitivity

Interactions

Chloramphenicol interferes with intestinal absorption; NSAIDs and phenytoin elevate levels; probenecid impairs renal tubular transport of methotrexate

Pregnancy

D – Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Use caution in patients with history of alcohol abuse, liver dysfunction, or renal dysfunction; may cause neurotoxicity (leukoencephalopathy), renal or liver damage, pulmonary fibrosis or pneumonitis (fully reversible), diarrhea, ulcerative stomatitis, hemorrhagic enteritis, seizures, anemia, leukopenia, or thrombocytopenia; may cause alopecia and photosensitivity, but these rarely occur at doses used for treating MS

Drug Category: Antiviral, anti-Parkinson agent

This agent is used for treatment of fatigue in MS.

Drug Name

Amantadine hydrochloride (Symmetrel)

Description

Mechanism of counteracting fatigue unclear. May have antiviral effects by inhibiting replication of some viruses, including influenza A.

Adult Dose

100 mg PO bid

Pediatric Dose

Not established

Contraindications

Documented hypersensitivity

Interactions

Either triamterene or hydrochlorothiazide (or both) may increase plasma levels; thioridazine may worsen tremor in elderly patients with Parkinson disease

Pregnancy

C – Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Patients with history of seizure should be observed carefully for signs of seizure recurrence; because of its anticholinergic effects, use caution by prescribing limited quantities to patients at risk of overdosing; may induce suicidal ideation in some patients, or may exacerbate existing mental disorders; use with caution in patients taking CNS stimulants; acute withdrawal should be avoided in patients with Parkinson disease, as acute parkinsonian crisis may ensue; because excreted in urine, reduce dose in patients with renal insufficiency or who are aged 65 years or older

Drug Category: Central nervous system stimulants

These agents are used for treatment of fatigue without interfering with normal sleep architecture. They promote wakefulness.

Drug Name

Modafinil (Provigil)

Description

Mechanism of action currently unknown. Listed in Schedule IV of the Controlled Substances Act. Patients should be observed for signs of use or abuse, as drug has psychoactive and euphoric effects similar to those seen with other scheduled CNS stimulants (eg, methylphenidate).

Adult Dose

100-200 mg PO qd; some patients may require as much as 300 mg PO qd

Pediatric Dose

Not established

Contraindications

Documented hypersensitivity; history of left ventricular hypertrophy, ischemic ECG changes, chest pain, or arrhythmias as response to CNS stimulants

Interactions

Reversible inhibitor of drug-metabolizing enzyme CYP2C19, and therefore must be used with caution with other drugs metabolized by this enzyme, including diazepam, phenytoin, and propranolol; in individuals deficient in CYP2D6 (7-10% of Caucasian population), levels of CYP2D6 substrate drugs such as SSRIs and TCAs may be elevated, as these individuals may use CYP2C19 as ancillary elimination pathway
Effectiveness of oral contraceptives may be reduced during treatment and for 1 mo after discontinuing medication; methylphenidate may delay absorption; may increase levels of clomipramine; levels potentially can be altered by drugs such as carbamazepine, phenobarbital, rifampin, ketoconazole, or itraconazole; may decrease levels of cyclosporine; patients receiving CYPC29 substrates phenytoin or warfarin with modafinil should be monitored for signs of toxicity

Pregnancy

C – Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Dose should be reduced in patients with severe hepatic impairment; most common adverse effects are headache and anxiety, but both occur in <17% of patients; less common adverse effects are irritability, restless legs syndrome, epigastric discomfort, dizziness, infection, insomnia, and nausea; patients may be advised not to operate hazardous machinery or drive an automobile until reasonably clear that drug does not place them at risk because, in some patients, drug may affect judgment, motor skills, or thinking; used with caution in patients with recent myocardial infarction, unstable angina, or history of psychosis

MS Drugs, Prognosis & Pregnancy-related issues

Drugs:

  • Patients must understand that the ABCR immunomodulatory drugs are preventive, not curative. Early treatment is thus essential.
  • Patients should avoid exposure to extreme heat.
  • The impact of stress on MS exacerbations is thought to be minimal or noncontributory, and trauma has no demonstrated impact on the disease course.

Prognosis:

  • If untreated, more than 30% of patients with MS will develop significant physical disability within 20-25 years from onset. This prognosis is changing for these patients with the advent of new treatments.
  • Male patients with PPMS have the worst prognosis, responding less favorably to treatment and rapidly accumulating disability. The higher incidence of spinal cord lesions in PPMS is also a factor in the rapid development of disability.
  • Less than 5-10% of patients have a clinically milder MS phenotype, in which no significant physical disability accumulates despite several decades passing since onset (sometimes in spite of multiple new lesions by MRI). Detailed examination of these patients in many instances reveals some degree of cognitive deterioration.
  • The physician should remind patients that early treatment with some agents may help counteract the progressive brain atrophy seen on MRI.

Pregnancy:

  • For the patient with MS who wants to become pregnant, ABCR drugs should be discontinued.
  • If the patient becomes pregnant during treatment, the drug should be discontinued immediately.
  • The treatment can be resumed a few weeks after delivery or after the patient finishes her period of lactation.

MS presents itself with various symptoms…

a bit more about the various MS symtpoms…

  • MS may present in various forms. Some patients have a predominance of cognitive changes, while others present with prominent ataxia, hemiparesis or paraparesis, depression, or visual symptoms. Bipolar disorder and frank dementia may appear late in the disease course, but sometimes are found at the time of initial diagnosis. Symptoms can be exacerbated by intercurrent illness, including viral or bacterial upper respiratory or urinary tract infections. Trauma has no impact on disease exacerbation. The impact of emotional stress on exacerbations is probably minimal and remains controversial.
  • Optic neuritis presents clinically as orbital pain, at rest or during eye movement, and loss of vision. Patients may complain of “patchy loss of vision,” and upon examination, a cecocentral scotoma and an afferent pupillary defect may be found. Patients may experience color desaturation even with normal visual acuity, usually manifested as the perception of red color as different shades of orange or gray.
  • Patients with MS may present with facial palsies or trigeminal neuralgia. In fact, the presence of bilateral facial weakness or trigeminal neuralgia strongly suggests the diagnosis of MS. Facial myokymia also may be a presenting symptom. Nystagmus (direction-changing) and internuclear ophthalmoplegia signs are other manifestations.
  • Painful limb syndromes are important to recognize. Commonly, patients complain of numbness or tingling in one or more limbs, variable weakness, or sensory level-related symptoms. Some have difficulty describing weakness or numbness, as these symptoms are obscured by incapacitating fatigue.
  • Episodes of central (as opposed to peripheral) vertigo are not uncommon. The nystagmus accompanying central vertigo has a rapid onset, does not fatigue easily, and changes with direction of gaze. CNS vertigo usually is accompanied by other complaints that can be directly attributed to brainstem or cerebellar pathway involvement (eg, diplopia, dysarthria).
  • An often overlooked manifestation of MS is the pseudobulbar affect, whereby patients have difficulty controlling their emotions (laughing, crying) and are perceived to act inappropriately by coworkers or friends.
    • Behavioral/cognitive symptoms also may include social disinhibition, dementia, or depression.
    • A greater tendency for attempting and committing suicide in MS is not related exclusively to a reactive depression, since this tendency is higher than that of patients with other devastating neurological disorders such as chronic inflammatory demyelinating polyradiculopathy (CIDP).
    • The neurologist should be aware that patients with conversion reactions and inappropriate affect, such as “la belle indifference,” may on occasion have an underlying organic illness such as MS.
  • Urinary retention and incontinence are common. Bowel habit changes may occur, but bowel incontinence is less frequent.
  • Sexual dysfunction affects the great majority of patients with MS and includes symptoms such as lack of desire, erectile dysfunction, impaired sexual responsiveness, premature ejaculation, impaired genital sensation, or inability to physically interact with the partner due to painful leg adductor muscle spasms.

Various forms of MS..

    • I haven’t heard of these forms prior to today… the other diseases that are “similar” to MS I’ve mentioned before..but not these.
  • MS may present in an acute and clinically fulminant form (termed Marburg variant of MS) or may present with concomitant optic nerve involvement and necrotizing myelopathy (ie, neuromyelitis optica [NMO] or Devic disease, considered by some to be an MS variant). However, MS must be distinguished from other neuroinflammatory disorders, including acute disseminated encephalomyelitis (ADEM), Schilder disease, and Baló concentric sclerosis.
  • ADEM is considered an isolated postinfectious or postvaccinial autoimmune attack on the CNS that leads to diffuse demyelination. It is often devastating, and occasionally has a fulminant hemorrhagic component (in which case it is termed acute hemorrhagic encephalomyelitis or leukoencephalitis of Weston Hurst).
  • Schilder disease is characterized in children and young adolescents by massive demyelination, presenting often as asymmetrical foci (often the size of an entire lobe) in the white matter by MRI, and presenting with a malignant course (ie, deterioration over months or a few years with cortical blindness, hemiplegia, or paraplegia). Some patients, however, may respond to steroids and immunosuppressive therapy.
  • Baló concentric sclerosis is considered by some authors to be a variant of Schilder disease, with MRI lesions showing a characteristic alternating pattern of spared and damaged white matter that suggests progression of the disease process from the ventricles outward. Baló disease often is associated with a more inflammatory CSF and a more fulminant progression than typical MS.

    When & how to take vitamins?

    Take vitamins with food!

    Did a bit of research on when to take vitamins since I’ve got about 40 to take a day ever since I started the “orthomolecular” treatment…this is what I found…

    Generally, most vitamins are best tolerated and absorbed when taken with food.

    Vitamins are best taken in dosages spaced throughout the day rather than all at once to maintain proper levels of intake. If you must take them all at once be sure to take them with your largest meal of the day. You should note that the absorption of minerals can be inhibited by fiber supplements.

    Fat-soluble vitamins (A, D, E and K) require fat, either animal or vegetable, to be present in the stomach for them to be optimally absorbed. These vitamins are best taken with meals.

    Water-soluble vitamins (B and C) do not require fat to be optimally absorbed by the body. B vitamins require an acidic environment to be absorbed. As such, if you are currently taking drugs that deplete stomach acid, you may have a decreased ability to absorb B vitamins.

    B Complex vitamins will often cause some mild nausea. This may be avoided by taking the B Complex vitamins with a light meal. A heavy greasy meal may interfere with absorption, so keep it light. The exceptions to this are B12 and folic acid which should be taken on an empty stomach.

    Zinc: Taking too much zinc at once can cause stomach cramping and nausea. Some people can tolerate the RDA (15 mg) at one time and no more, so it may be beneficial to consider the amount of zinc per capsule of multivitamin or mineral. However, if the zinc does not upset your stomach, it is beneficial for a number of conditions and the unpleasant effects can be lessened by taking it with food. More than 100 mg of zinc should not be taken in one day.

    Herbal remedies: Unless it is specifically noted on the label or you are instructed to do so by your doctor, herbal remedies are generally best taken away from food for maximal absorption and effect. This means 20 to 30 minutes before meals or one and a half to two hours after.

    Calcium: Some studies suggest that calcium is best taken before bed to have the most beneficial effect on building bone strength and mass. Taking a calcium/magnesium supplement before bed may also help promote better sleep as it is a natural muscle relaxant and can calm the mind.

    Probiotics (acidophilus and bifidus) are best taken on an empty stomach, upon rising or before bed. As well, these products usually need to be kept in the refrigerator. Check the product when you purchase it; if the label says it is supposed to be refrigerated and it is not, the live bacterial cultures have most likely been rendered ineffective.

    Green foods are usually best taken on an empty stomach for their beneficial alkalinizing and nutritional effects.

    A lot of the bioflavanoids and phytochemicals are best absorbed on an empty stomach. Bioflavonoids and phytochemicals have several potential therapeutic benefits, and it is probably best to take them on an empty stomach for maximum benefit.