laurie weisensee md associate professor, sanford school of medicine of the university of south...
TRANSCRIPT
Two common Neurodegenerative diseases encountered in primary care practicesLaurie Weisensee MDAssociate Professor, Sanford School of Medicine of the University of South Dakota
Multiple Sclerosis
Demographics of Multiple sclerosis
Age at onset 15 to 45 years Gender 70% women US incidence 8,500 to 10,000
yr US prevalence 350,000 North South gradient
high prevalence 30+/100,000Northern US and Canada,
most of Europe, Southern Australia, New Zealand, Northern Russia
Economic burden of multiple sclerosis
Total Annual Cost world wide 6.8 to 13.6 billlion
Lifetime cost of 2million per patient in the
US
Pathology of Multiple Sclerosis
Immune-mediated disease in genetically susceptible individuals (HLA-DR1501 and HLA-DQ0601)
Axonal injury and destruction, It affects myelin of both white and gray matter. Damage to axons occurs early in MS. Persists at all times during course of disease, even in quiescence
Lesions, in periventricluar white matter, cerebral cortex, optic nerves, brain stem, cerebellum and spinal cord
Cause of demyelination and axonal loss in Multiple Sclerosis?
Activation of autoreactive CD4+ cells in the peripheral
immune system
Migration of cross-reactive T cells into CNS
Insitu reactivation by
myelin autoantigens
Inflammation, demyelination,
axonal transection,
degeneration
Sectretion of proinflammatory
cytokines, antibodies
Activation of macrophages by Th1 cells, B cell
by Th2 cells (CD4+ T cells
subtypes)
Prognostic factors in MS
Better Worse
Better Prognosis
FemaleOnset: relapsing-remitting, optic neuritis, sensory involvement
Age at onset < 30 yearsLow MRI T2 lesions burdenFrequent Attack
Worse Prognosis
MaleOnset: progressive course, pyramidal and or cerebellar involvement
Age at onset > 40 yearsHigh MRI T2 lesion burdenInfrequent attacks
Diagnosis of Multiple Sclerosis
Presenting symptomsSensory symptoms arms/legs 33%Unilateral vision loss 16%Multiple symptoms at onset 14%Diplopia 7%Acute Motor deficit 5%Other, e.g. bladder, heat intoler, fatigue, pain, movement disorder, dementia <5%
•Ultimately a clinical diagnosis, no definite laboratory test•Fits clinical profile•Laboratory evaluation•Evidence of lesions in Space and time•Exclusion of other diagnoses
McDonald Criteria
CLINICAL PRESENTATION
>2 attack, evidence of > 2 lesions or clinical evidence of 1 lesion with historical evidence of prior attack.
>2 attacks, clinical evidence of 1 lesion.
1 attack, clinical evidence of > 2 lesions
1 attack, clinical evidence of 1 lesion (CIS) clinically isolated syndrome. Clinical event > 24 hrs
ADDITIONAL CRITERIA FOR DIAGNSOSIS
None
Dissemination in space, > 1 T2 lesion in at least 2 or 4 MS regions, periventircular, juxtacortical, infratentorial, spinal cord.
Disseminated in Time, gadolinium enhancing lesions, and non-enhancing lesions.
Disseminated space and time
Disease modifying therapies
In the absence of curative therapy, treatment is limited to reducing CNS inflammation.
1. Reduce the frequency, severity and duration of relapses.
2. Reduce MRI enhancing lesions, brain atrophy and promote repair.
3. Delay disability due to disease.4. Manage clinical symptoms of the
disease.
DMT Usual Dose Primary Indication
Adverse affects
IFN beta-1aAvonex
30 mcg IM q week
CISRRMS
Flu-like symptoms, liver and bone marrow abnormalities, neutralizing AB
IFN beta-1aRebif
22 Or 44 mcg SQ
tiw
CIS,RRMS,SPMS
Same as above
IFN beta-1bBetaseron
0.0625MG to0.25mg qod SQ
CIS,RRMS,SPMS
Same as above
FinfolimodGilyena
0.5m PO daily RRMS bradycardia
Glatiramer acetate Copaxone
20mg SC daily CIS, RRMS
Local injection site, flushing
NatalizumabTysabri
300mg IV q 4 weeks
RRMS PML
MitoxantroneNovantrone
12mg/m2 IV q 3 months
Worsening RRMS, SPMS
cardiotoxicity
MS subtypes
RRMS relapsing remitting MSPPMS primary progressive MS
SPMS secondary progressive MS
?? Neuromyelitis optica (serum IgG autoantibody
Progression to Disability ( EDSS)0 Normal Neurological Exam
1.0-1.5 No Disabiltiy
2.0-2.5 Minimal Disability
3.0-3.5 Mild to Moderate Disability
4.0-4.5 Moderate Disability
5.0-5.5 Increasing limitations in ability to walk
6.0-6.5 Walking assistance is needed
7.0-7.5 Confined to a wheelchair
8.0-8.5 Confined to a bed/chair, self-care with assistance
9.0-9.5 Completely dependent
10 Death due to MS
Differential Diagnosis
Lyme diseaseNeurosyphilisPML, HIV, HTLV-1HHV-6SLESjogren’sOther CNS vasculitisSarcoidosisBechet’s disease
DDX continued
Metabolic: Vitamin B12 and E deficiencies
CADASILMELASCNS LymphomaSpinal Stenosis/HNPALSMyasthenia Gravis
Acute exacerbation RX
Most Importantly, look for underlying infection.
Indications for treatment of an acute exacerbation include:
Objective evidence of neurological impairment.
Examples: loss of vision, motor and or cerebellar symptoms, mild sensory attacks are often not treated, although sometimes necessary due to discomfort.
Glucocorticoids RX for acute
Most often 3-7 days of IV methylprednisolone 500mg-1000mg daily, with or without prednisone taper, that is most commonly done.
Large doses of orals in one study shows some similar outcomes, bioavailability of prednisone (1250 mg equal to 1000 mg IV methylprednisolone. More side affects w/oral
Parkinson Disease
Diagnosis Parkinson Disease
Rest TremorRigidityBradykinesiaPostual instability
Dopamine depletion from the basal ganglia results in major disruptions in the connections to the thalamus and motor cortex
Pathology
Insidious onset
About 60 % of the neurons in the Substantia nigra pars compact have been lost by the time a patient presents with PD concerns to their doctor.
Protein misfolding, aggregation and toxicity
Mutations in the gene that codes for alpha-synuclein have emerged as one of the most important elements of cell death in various neurodegenerative disorders, together knowns as SYNUCLEINOPATHIES.
Including Parkinsons, dementia with Lewie bodies, Multple system atrophy
Epidemiology of Parkinson Prevalence of PD is about 0.3 percent of
general population. Approx 1 percent of persons >60 years old Most studies show Male preponderance Greater age and greater risk Parkinson low prevalence of most cancer Inverse relationship to cigarette smoking
Coffee and caffeine intake, lower incidence PD.
High iron intake, especially combined with manganese associated with increase in PD
Excessive body weight, increase risk PD
Greater in industrial countries, esp copper and manganese.
Associated with Pesticide and Herbicides
Veterans (Agent Orange)
Genetics
Majority of PD appear to be Sporadic.
Observation 20-25% of patient with sporadic PD have at least one first degree relative
Clinical Subtypes of Parkison
Tremor dominantAkinetic-rigidPostural instability and gait difficulty
Tremor dominant associated with slower progression
Other Motor Features
Craniofacial Visual Musculosketal Gait
Hypomimia Blurred vision micrographia Shuffling
Decrease blink Impaired contrast
dystonia Short steps
Speech impairment
Hypometric saccades
myoclonus Freezing
Dysphagia Impaired vestibuoccular relfex
Stooped posture
Festination
Sialorrhea Impair upgaze Flexion thoracolumbar
Eyelid apraxia kyphosis
scoliosis
Difficult roll in bed
Non motor symptoms Parkinson
Cognitive dysfunction Psychosis and hallucinations Mood disorders including depression,
anxiety, apathy Sleep disorders Fatigue Autonomic dysfunction Olfactory dysfunction Pain Sensory disturbances Dermatologic findings (seborrhea)
Differential Diagnosis Parkinson Progressive Supranuclear Palsy (PSP) Lewie Body dementia Multiple System Atrophy (akinetic rigid
syndrome) prominent cerebellar, autonomic
Corticobasal degenerative, lower limb onset
Vascular Parkinsonism Normal Pressure hydrocephalus Other neurodegenerative disorders…list
long
Treatment
SYMPTOMATIC NEUROPROTECTIVE
????????
When to begin symptomatic RX
Effect of disease on dominant hand Degree disease interferes with
ADL’s,Work Significant bradykinesia Personal philosophy
Neuroprotective??
MAO B inhibitors
Selegiline (Eldepryl)Rasagiline
Appear to be modestly effective with early symptomatic treatment for PD. Inconclusive regarding neuroprotective. Numerous drug interactions
Symptomatic Treatment
Levodopa MAO B inhibitors Dopamine agonists COMT inhibitors Anticholinergic agents Amantadine
Levodopa—still Gold Standard
No evidence of in-vivo neuo –toxicity of Levo-dopa.
No substantial evidence that one should wait to initiate Levodopa
Formulations of Levodopa
Levodopa is combined with peripheral decarboxylase inhibitor to block conversvion to dopamaine in systemic circulation.
The Combination Cabidopa-Levodopa is available in
10/100, 25/100, 25,100 numerator= carbidoopa and denominator=Levodopa
Agonist
Bromocriptine Pramipexole, (Mirapex) Ropinirole, (Requip) Rotigotine, in Europe Injectable apomorphine
Complications of treatment
DyskinesiasConfusion, hallucinationsDopaminergic dysregulation syndromeImpulse control disorders
Adjunct Rx
COMT Inhibitors, tolcapone(Tasmar) and entacapone (Comtan)
For motor fluctuation and end- of dose wearing off.
It is the buddy pill for Sinemet
Anticholinergics--- Tremor dominant, younger age
Trihexyphenidyl, Benztropine
Surgical Treatment for Parkinson
Current therapy is DBS (Deep Brain Stimulation)
Subthalamic nucleus Globus Pallidus
This consideration when Motor fluctuations and dyskinesia become prominent about 5 yrs typically
Good Candidates
Healthy patients, younger age who previously responded well to Levodopa
?? How long do you wait. Some insurance companies will not pay after 70, any signs of dementia which is part of progression of PD
DBS
Typically do not get off PD meds, but reduce amount and have more on time
DBS expensive, pre-authorization work up is extensive
Works for at least 3-5 years Surgical complications are
infrequent, but do occur, infection, stroke, lack of response, memory decline, behavior change, depression, suicide.
Future treatments
Stem cells, little set back but research continues
Duodenal levodopa infusion Gene therapy Possible portal of delivery of
Levodopa directly to the brain, via same route as DBS electrode placement, under investigation
THANK YOU