A 50-year-old man is evaluated for a 12-year history of slowly progressive left leg weakness and trouble ambulating. There is no history of transient neurologic symptoms. He has a history of hypertension, coronary artery disease, and chronic low back pain. Current medications are sublingual nitroglycerin, atenolol, aspirin, and occasional NSAIDs.
On physical examination, vital signs are normal. The patient has moderately severe spastic paraparesis that is worse on the left, with prominent circumduction of the left leg during ambulation. He requires a cane to ambulate 100 meters.
Cerebrospinal fluid analysis reveals the presence of oligoclonal bands. MRIs of the brain and spine show lesions consistent with chronic multiple sclerosis.
Which of the following is the most appropriate treatment for this patient?
A) Glatiramer acetate
B) Interferon beta-1a
C) Natalizumab
D) Physical therapy
See first comment for correct answer with explanation.
See first comment for correct answer with explanation.
The answer is D.
ReplyDeleteThis patient has primary progressive multiple sclerosis (MS); no treatments have been shown to affect the disease course.
Therefore, physiatry consultation for evaluation and treatment of his spasticity and back pain are most appropriate at this time. His gradually worsening neurologic function is very likely due to a degenerative loss of axons in the central nervous system; active inflammation, the hallmark of clinical relapses, plays a much less significant role in primary progressive MS than in the relapsing-remitting type.
This patient’s function and pain could likely be improved substantially with a focus on symptomatic therapies, beginning with physiatry consultation for evaluation and treatment of his spasticity, impaired mobility, and musculoskeletal pain.
Symptomatic therapy in patients with multiple sclerosis can have a marked beneficial effect on patient comfort, function, and quality of life, even when further disease progression cannot be effectively stopped.
Beta interferons, glatiramer acetate, and natalizumab, the currently approved MS therapies, are all most effective in altering the immunologic mechanisms that underlie relapses and thus are only appropriate for relapsing-remitting disease.