1. Practical Management of MS in the Primary Care Office Setting Case Study 3

2. Case 3 Managing Adverse Events Ms. M, 23-year-old woman newly diagnosed with MS Initiated on interferon beta-1a IM weekly – 1st dose 48 hours ago Calls office today with complaints of horrible flu-like symptoms for over 24 hours after her 1st dose Discussion question: What triage questions should you ask her?

3. Case 3 Triage Questions Did she premedicate with any pain relievers/antipyretics? –Acetaminophen? NSAID? Did she take any medication (eg, acetaminophen or NSAID) around the clock after dosing? What dose of interferon beta-1a did she take?

4. Case 3 Patient Responses Ms. M did not premedicate She did not use acetaminophen or NSAID postdose She gave herself the full dose of interferon beta-1a; she did not know to titrate the dose

5. Case 3 Instructions to Patient Premedicate with naproxen 500 mg before administering interferon and then dose every 812 hours if needed Reduce interferon beta-1a dose to ½ for 2 weeks, then ¾ dose for 2 weeks, then full dose Follow up in clinic in about 1 month

6. Case 3 Clinic Follow-Up 5 Weeks Later Ms. M reports that she tolerated 1/2 dose and 3/4 dose without problem She is having minor flu-like symptoms with full dose

7. Case 3 Clinic Follow-Up 6 Months Later Ms. M reports being laid up for 24 or more hours each week after interferon beta-1a dose She is taking naproxen 500 mg before dosing and around the clock afterward She has skipped the last few interferon doses and is thinking about discontinuing treatment completely because it is just not worth it Discussion question: What options would you discuss with her?

8. Case 3 Options Discussed Switch to a different disease-modifying therapy (especially glatiramer acetate) Prednisone 10 mg weekly with interferon beta-1a IM dose No treatment –She should be informed of the benefits of early disease-modifying therapy, which she would be losing by choosing no treatment

9. Case 3 Ms. Ms Choice Ms. M is engaged in a discussion regarding all of her options She recognizes the benefits of early treatment, and indicates a desire to continue on some form of MS disease-modifying therapy She does not want to inject more than once weekly, so she decides to continue interferon beta-1a IM but with the addition of prednisone Another follow-up is scheduled in 1 month

10. Case 3 Clinic Follow-Up 1 Month Later Ms. M is tolerating interferon beta-1a at full dose She has had minimal to no side effects with prednisone