Peak Development for ...

Medication Administration

Vol. 16 Issue 12
December 2015

Drug Overview: Treating Multiple Sclerosis

Peak Development Resources
P.O. Box 13267
Richmond, VA 23225
Phone: (804) 233-3707
Fax: (804) 233-3705
Email: editor@peakdev.com

Peak Development for Medication

Administration and Competency
Assessment Tool for Medication
Administration are components of
a site license for the Peak
Development Resources
Competency Assessment System
for Medication Administration
and may be reproduced for this
individual facility only. Sharing
of these components with any
other freestanding facility within
or outside the licensees corporate
entity is expressly prohibited.

The information contained in

Peak Development for Medication
Administration is intended only as
a guide for the practice of
licensed nursing personnel who
administer medications. Every
effort has been made to verify the
accuracy of the information
herein. Because of rapid changes
in the field of drug therapy, the
reader is advised to consult the
package insert, facility pharmacist
or patients physician for relevant
information. This is particularly
important for new or seldom used
drugs. Use of professional
judgment is required in all patient
care situations. It is the readers
responsibility to understand and
adhere to policies and procedures
set forth by the employing
institution. The editor and
publisher of this newsletter
disclaim any liability resulting
from use or misuse of
information contained herein.
Copyright 2015

After completion the learner should be able to:

1. Identify appropriate indications for use of
multiple sclerosis drugs.
2. Relate general characteristics of multiple
sclerosis drugs to specific patient situations.
3. Apply nursing process considerations for
multiple sclerosis drugs to patient situations.
4. Correctly calculate dosage for multiple
sclerosis drugs.
Multiple Sclerosis
Multiple sclerosis (MS) is a chronic,
inflammatory neuromuscular condition that
results from damage to the nerve fibers in the
central nervous system, and the myelin sheath
that covers them. The myelin sheath is the fatty
coating around the nerve fibers that serves to
insulate the fibers and increase the speed of
nerve transmission. Damage occurs when the
immune system attacks the myelin sheath,
causing inflammation and damage to the myelin
coating and nerve fibers. This leaves sclerosed,
or scarred and hardened, areas along the nerve
fiber. Therefore, multiple sclerosis is a disease
of multiple sclerosed, or scarred, nerve areas.
Nerve impulses cannot be transmitted normally
with these lesions, resulting in a wide variety of
symptoms that may occur throughout the body.
Even though peripheral nerves also have a
myelin sheath, only nerves in the central
nervous system (CNS) are affected by MS. The
myelin sheath surrounding peripheral nerves is
made by different cells and has a different
composition than myelin in the CNS.
The cause of MS is unknown, but is believed
to be a combination of genetic and environmental factors that trigger the abnormal
immune response in susceptible individuals.
Possible environmental factors include
smoking, viruses, and lack of sunlight and
vitamin D. The possible connection with

sunlight/vitamin D has been proposed because

MS is more common in areas further from the
equator, such as Europe, Canada, the northern
US and southern Australia. MS is most
commonly diagnosed in people ages 2050,
but can occur at any age. It affects more
women than men, and more whites than people
of other races.
There is no single test to confirm diagnosis of
MS, however, tests are ordered to rule out
other conditions, such as Lyme disease, HIV/
AIDS, sarcoidosis, brain tumors and vitamin B12 deficiency. Along with the history and
examination, tests that help to confirm a
diagnosis of MS include MRI, testing of
cerebrospinal fluid, and visual evoked
potentials, all of which may (or may not) show
changes characteristic of MS.
The effects of MS on an individual may range
from mild to severe. For many people, the first
symptom is visual change, such as blurred or
double vision, loss of vision in an eye, or pain
with eye movement. Other common symptoms
include fatigue, dizziness, muscle stiffness and
spasms, constipation, heat intolerance, poor
memory and attention, mood swings and
chronic pain. Less commonly, tremors,
seizures, respiratory distress, and speech and
swallowing problems may occur.
There are four types of MS, based on the
pattern of symptoms:
Relapsing-remitting MS (RRMS): Symptoms
occur during acute inflammatory attacks
(relapses), followed by periods of minimal to no
symptoms (remission). This is the most
common type, affecting 85% of people with MS.
Secondary-progressive MS (SPMS): For most
people, this type follows RRMS. The disease
progresses more steadily, with increasing
disability, with or without relapses. There is less

acute inflammation, but nerve damage causes symptoms to

worsen.
Primary-progressive MS (PPMS): This type accounts for
10% of cases. It is steadily progressive from the beginning,
with worsening neurologic symptoms and disease progression.
Progressive-relapsing MS (PRMS): Affecting about 5% of
those with MS, this type is characterized by steadily worsening
neurologic function with periodic exacerbations/relapses, but
without any remissions.
Drug Therapy for Multiple Sclerosis
Many different types of medications, such as steroids,
muscle relaxants and laxatives, may be used to manage MS
symptoms, acute exacerbations or complications of the
disease. For treatment of the underlying disease process,
however, disease-modifying drugs are used. While there is no
cure for MS, these drugs are approved by the FDA for use in
reducing the number of CNS lesions, delaying disease
progression, and reducing the severity and frequency of
exacerbations. These medications should be started as soon
as possible, since early treatment can help to prevent or delay
permanent neurologic damage. They are typically taken on a
long-term basis. The two types of disease-modifying drugs
used to treat MS are immunosuppressants, which depress
immune function, and immunomodulators, drugs that modulate
or normalize immune function. These agents are approved for
treatment of the three relapsing forms of MS. There are no
approved disease-modifying drug treatments for PPMS.
The only FDA-approved immunosuppressant drug for
treatment of MS is mitoxantrone (formerly Novantrone), an
antineoplastic drug that is typically used for severe, relapsing
forms of MS that have not responded to other treatment.
Administration is by IV infusion, every three months. The drug
carries a boxed warning for risk of cardiotoxicity, severe bone
marrow suppression, drug-induced leukemia, and severe
tissue damage with extravasation. Prior to each dose, an
echocardiogram is performed to assess for heart failure, and a
CBC for bone marrow suppression. Women who could
become pregnant should also have a pregnancy test before
each dose, and be cautioned to use effective contraception.
Novantrone may also give urine a blue-green discoloration, as
well as a bluish tint to the sclera.
Immunomodulators for treatment of MS include:
Alemtuzumab (Lemtrada): This drug is administered by IV
infusion. It carries a boxed warning that serious and/or fatal
adverse effects include autoimmune conditions, infusion
reactions and malignancies. Lemtrada is available only
through a restricted program, after two or more other drugs
have been used without significant improvement.

Beta Interferons: (Avonex, Rebif, Betaseron, Extavia,

Plegridy): These were the first drugs approved for
treatment of MS, beginning in 1993. They are selfadministered by sub-q injection, except for Avonex, which
is administered by IM injection. Common adverse effects
include flu-like symptoms and injection site reaction.
Depression/suicide, liver injury, bone marrow suppression
and allergic reaction may also occur.
Dimethyl fumarate (Tecfidera): Tecfidera is taken orally.
Serious adverse effects include anaphylaxis, reduced
lymphocytes and progressive multifocal leukoencephalopathy (PML), a potentially fatal brain infection.
Glatiramer acetate (Copaxone, Glatopa): These drugs are
self-administered by sub-q injection. Adverse effects
include sudden onset of flushing, chest pain, dyspnea, rash
and/or itching after injection, and injection site reaction or
skin damage, including redness, swelling or lipoatrophy.
Fingolimod (Gilenya): Approved in 2010, Gilenya was the
first oral MS drug. The first dose is taken under medical
supervision, since bradycardia may occur. An EKG is
obtained before the first dose and 6 hours later. Other
adverse effects include increased risk for infection and
PML.
Natalizumab (Tysabri): Tysabri is administered by IV
infusion. It carries a boxed warning due to risk of PML, and
is available only through a restricted program. Other
adverse effects include liver injury and risk of infections.
Teriflunomide (Aubagio): This drug is taken orally, once
daily. Aubagio carries a boxed warning due to risk of liver
injury and birth defects. Both males and females should be
cautioned to use effective contraception while taking the
drug. Other adverse effects include bone marrow
suppression and lung damage.
Medication education for the patient with MS includes the
importance of the prescribed drug therapy in preventing further
damage, possible adverse effects, when to seek medical
attention, how and when to take the drug, and the importance
of continued monitoring and compliance. Self-injection
techniques must also be taught for those drugs requiring it.
The patients first dose of self-injected medication should occur
under the supervision of a qualified healthcare professional.
The patients ability to afford the drug should also be explored,
as the cost of these agents can be very high.
Through careful education, management and monitoring,
the nurse can assist patients who are taking diseasemodifying drugs for MS to achieve maximum therapeutic
benefit and safety.

Peak Development for Medication Administration

Drug Overview: Treating Multiple Sclerosis

Page 2

Peak Development for ...

Medication Administration
Competency Assessment Tool

Vol. 16 Issue 12
December 2015

Drug Overview: Treating Multiple Sclerosis

NAME:

DATE:

UNIT:

Directions: Place the letter of the one best answer in the space provided.
_____1. Multiple sclerosis (MS) is a disorder characterized by:
A. a genetic absence of myelin on the nerves, present since birth
B. failure of the myelin sheath to develop in childhood, due to poor nutrition
C. a fungal infection that causes encephalopathy and nerve destruction
D. nerve and myelin damage caused by attacks from the immune system
_____2. MS produces lesions on myelinated nerves in the central and peripheral nervous systems.
A. True
B. False
_____3. MS tends to affect more:
A. women than men
B. people who live close to the equator
C. Asian people than white or black people
D. all of the above
_____4. Which of the following is the most common initial symptom of MS:
A. difficulty walking
B. seizures
C. visual changes
D. speech problems
_____5. The most common type of MS, relapsing-remitting MS, is characterized by:
A. periods of acute symptoms, followed by periods of few or no symptoms
B. steadily worsening symptoms from the beginning
C. steady progression of disability, with periodic relapses
D. none of the above

_____6. All of the following drug groups may be used in management of MS. Which is considered a
disease-modifying drug group?
A. steroids
B. immunosuppressants
C. laxatives
D. muscle relaxants
_____7. There are currently no disease-modifying drugs approved for treatment of which form of
MS:
A. primary-progressive MS (PPMS)
B. progressive-relapsing MS (PRMS)
C. relapsing remitting MS (RRMS)
D. secondary-progressive MS (SPMS)
_____8. Which of the following MS drugs is taken orally:
A. alemtuzumab (Lemtrada)
B. the beta-interferons, such as Betaseron and Plegridy
C. dimethyl fumarate (Tecfidera)
D. mitoxantrone (Novantrone)
_____9. Education for a patient starting on fingolimod (Gilenya) should include which of the following:
A. the drug is administered by sub-q injection, and this technique will be taught
B. a pregnancy test is required before each dose
C. an EKG is obtained before and after the first dose
D. urine may have a blue-green discoloration
_____10. Drug Order: Tysabri (natalizumab) 300 mg in 100 ml 0.9% sodium chloride IV, infused over
one hour
Drug Label: Tysabri (natalizumab) 20 mg per ml
Amount of drug to be added to IV fluid:
A. 0.6 ml
B. 1.5 ml
C. 8 ml
D. 15 ml

Competency Assessment Tool

Drug Overview: Treating Multiple Sclerosis

Page 2

Peak Development for ...

Medication Administration

Month: December 2015

Issue:
Drug Overview:
Treating Multiple Sclerosis

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