Multiple Sclerosis: Pathophysiology, Symptoms, and Medication Analysis

This report presents a comprehensive analysis of a multiple sclerosis (MS) case study, focusing on a 34-year-old female patient experiencing symptoms consistent with relapsing-remitting MS (RRMS). The report delves into the pathophysiology of MS, including the role of the myelin sheath, immune system involvement, and the blood-brain barrier. It examines the patient's symptoms, such as blurred vision and bowel problems, linking them to the disease's neurological impact. The analysis evaluates various medications, including Interferon Beta (Avonex), Methotrexate, Teriflunomide (Aubagio), and Natalizumab (Tysabri), detailing their mechanisms of action and potential interactions. The report highlights the risks associated with Tysabri, particularly the increased risk of progressive multifocal leukoencephalopathy (PML) and potential adverse drug reactions. Furthermore, it addresses medication errors, such as the incorrect prescription of Avonex instead of Teriflunomide, and the importance of the seven rights of medication administration. The report concludes by outlining treatment goals, including symptom reduction and restoration of neurological function, and suggests adjustments to the drug therapy, such as discontinuing Tysabri, along with non-pharmacological treatments like physical therapies and herbal remedies. The report references several studies to support its findings.

Running head: MULTIPLE SCLEROSIS
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Name of the Student
Name of the university
Author’s note

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Q. 1
Tysabri augments the risk of a unusual type of brain infection known as progressive multifocal
leukoencephalopathy (PML) that can lead to mortality or severe disability (Lichtenstein et al.,
2012). Using Tysabri can cause this rare brain infection and the risk of getting PML get higher
if the patient is infected with the John Cunningham virus. As per the report by Fernández et al.,
(2012) a large portion of the patients under Tysabri are becoming positive to the antibodies for
the JC virus.
John Cunning ham virus can become prevalent in patient if the immune system of the
person is compromised due to a disease or due to the sage of the immunosuppressive
medications (Palazzo & Yahia, 2012). This virus can affect the brain. This affects the white
maters of the brain and attacks the cells in making the myelin sheath that normally protects the
nerve cells (Torkildsen et al. 2014). This is related to multiple sclerosis as it is a disease of the
central nervous system where the myelin sheath is attacked by the immune system (Loma &
Heyman, 2011). The underlying nerve fibers might get damaged due to this. The myelin sheath
may get infected and is gradually destroyed developing sclerosis or lesions.
Natazulimab is quite effective in reducing the relapses and delaying the disease
progression of multiple sclerosis. However it does so by suppressing the immune system.
Tysabri does so by binding to the alpha subunit of the integrin present on the surface of the

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lymphocytes (Fernández et al., 2012). This action obstructs the subunit binding of the receptors.
This prevents the entry of the lymphocytes in the central nervous system, which reduces the
pathological processes of multiple sclerosis. This suppression of the immunity increases the
chance of infection by the JC viruses (Fernández et al., 2012).
Question 2
Relapsing remitting Multiple sclerosis can be defined as attacks of new neurologic
symptoms. The attacks or the relapses or the exacerbations are followed by period of partial or
complete recovery. At the time of remissions all the symptoms can disappear and some of the
symptoms may persist and can even become permanent. RRMS can be further classified in to
active or inactive and worsening or non worsening range. The new lesions formed are de-
myelinating reacting with the myelin sheaths directly in the presence of the infiltrating T cells.
As per Høglund & Maghazachi, (2014), RRMS is caused by some genetic, environmental factors
or infectious agents. There are generally two types of immune responses that is the innate and the
adaptive immune response. The initiation of the innate immune response is brought about by the
microbial product that activates the specific receptors mainly the toll receptors. Activation of the
toll like receptors by the pathogens initiates the adaptive immune response. This helps in the
progression of the MS by affecting the effector function of the B and the T cells (Høglund &
Maghazachi, 2014).
The initiation of the adaptive immune response is again promoted by the presentation of
the antigen to the T- lymphocyte by the Antigen presenting cells like the dendritic cells,
microglia and the macrophages (Høglund & Maghazachi, 2014). This interaction initiates the
adaptive immune response in MS. The T cells produce several cytokines that promote

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inflammation and the chronic MS plaques. The presence of the T cells in the perivascular cells
and the parenchyma triggers the staffing of more T cells as well as the B cells, microglia and the
dendritic cells. The cytokines released by them damages the surrounding tissues (Høglund &
Maghazachi, 2014). Opsonisation and the complement deposition can cause de-myelination of
the neurons and cause neuronal damage. Axonal damage can also occur.
A crucial finding in the pathogenesis of MS is the interference in the blood brain barrier.
The blood brain barrier of the brain is the basic anatomical barrier that separates the blood from
the neurons (Goldenberg, 2012). MS lesions occur due to the migration of the leukocytes to the
brain and thus the inflammation occurs. (Goldenberg, 2012).
The symptoms of RRMS includes the blurred vision, numbness or tingling, bowel or
bladder problems that can be linked to the clinical manifestations shown by the Mrs. Jane
Robertson, who is a 34 years old female. It is revealed from the case study that the patient was
suffering from temporary blindness in one eye. This may happen in case the optic nerves of the
eye gets inflamed. People with multiple sclerosis might have bowel problem due to the nerve
damage or the aggravation caused by constipation. It is also caused by the action of certain
medications. Any individual suffering from long time physical complications might suffer from
depression. Apart from this MS can itself cause depression (Induruwa et al., 2015). According to
Siegert & Abernethy, (2015), MS is associated with the presence of the type of lesions in
particular regions of the central nervous system, such as lesions in the temporal lobe. Studies
have found that that the rate of depression is greater in patients with lesions than those without
lesions. This is how the pathophysiology is linked to the patient’s symptoms.
Question 3

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Interferon Beta (Avonex) IM 30mg once a week-
Use: It is a cytokine in the interferon that is used to treat multiple sclerosis.
Mode of action: Beta interferons (IFNβ) achieves its anti-inflammatory effects by inhibiting the
activation of the T-cells and the proliferation, apoptosis of the auto-reactive T cells and induction
of the regulatory T-cells, inhibiting the migration of the leucocytes across the blood brain barrier,
modulation of the cytokine and the potential antiviral property (Shirani et al., 2013).
Methotrexate (Methoblastin) 7.5mg once a week
Use- It is a toxic anti-metabolite that helps in the control of the autoimmune disease. It helps to
delay the progression of MS.
Mode of action- It helps by inhibiting the T cell activation and, inhibiting the enzyme that is
responsible for the purine metabolism and suppression of the intercellular adhesion molecular
expressions for inhibiting the immune attack.
Teriflunomide (Aubagio)
Use- It provides a therapeutic benefit in MS not causing clinical suppression of the immune
system.
Mode of action- Teriflunomide inhibits the dihydro-orotate dehydrogenase, which is a key
microbial enzyme used in the de novo pyrimidine synthesis pathway, resulting in the reduction
of the T cell proliferation without cell death (Bar-Or et al., 2014).
Natalizumab (Tysabri) injection 20 mg/mL, 15mL once a week

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Use- It is a monoclonal antibody that is used in multiple sclerosis by preventing the immune cells
in the CNS.
Mode of action- It inhibits the transmission of the lymphocytes in the central nervous system by
interfering with the α4 subunit of α4β1 integrins expressed on the leukocytes surface (except
neutrophils).
Question 4.
One of the issues regarding her medication is that the doctor had put her on a course of
Methotrexate and has suggested that she commences with Natalizumab. According to several
studies these two drugs may interact and can cause adverse drug reaction and hence are not taken
together usually (Hoepner et al., 2014). Natazulimab is a monoclonal antibody that weakens the
immune system, hence if taken with an immunosuppressant weakens the immune system further
and increase the chance of JC virus infection.
Natazulimab (Tysabri) class of the drug should be stopped immediately as she had
already developed PML and use of natazulimab with an immunosuppressant may further
aggravate the situation.
Question 5
The seven rights of medication involved right medication. In this case study it seems that
the pharmacist has delivered her a wrong mediation as it was written Avonex over the package.
Avonex belongs to the class interferon beta 1-a. whereas Teriflunomide is an active metabolite
that blocks the pyrimidine synthesis (He et al., 2012). Hence these two drugs are different hence
the pharmacist has prescribed a wrong medicine. Furthermore, with the name printed on the

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package it seemed that the medication had been delivered to the wrong patient as the name
printed in the package was Mrs. Jayne Roberts. The route of administration via orally has been
correct. Patient was given the right dosage of medicine. No report of documentation has been
mentioned in the case study.
Question 6
Goals- The goal is to reduce the symptoms of the relapsing remittig form of the multiple
sclerosis and to relive the neurologic deficients such that the patient can resume to her normal
life (Torkildsen et al., 2016).
Drug dosage form, route and schedule and duration therapy for the treatment-
Alemtuzumab
Dosing- 12mg/day 5 consecutive days which is followed by 12 mg/day for 3 consecutive days
one year later.
Route - Intravenous.
Avonex
Dosing- 30 mcg weekly
Route- Intramuscular.
Aubagio
Dosing- 7.0 mg and 14.0 mg; qd
Route- Orally.

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Adjustments in the drug therapy- One of the major adjustments in the drug therapy is to stop the
therapy of Tysabri along with other immunosuppressant, as the patient has already been
diagnosed JC virus.
Non pharmacological therapies- Non pharmacological treatment in Multiple sclerosis involves
physical therapies such as acupunctire, yoga or relaxation by meditations. Herbal remedies can
also ne applied. Proper nutritional assessment can alleviate the MS symptoms. People with MS
having regular massage therapy can be helpful for getting rid of the stress and depression (Heine
eta al., 2012). According to Torkildsen et al.,( 2016) evening primrose oil has ben found to be
effective in reducing the MS symptoms.

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