Managing MS Symptoms

Bladder dysfunction is a very common MS symptom. Bladder symptoms can be caused by a failure to store urine, a failure to empty completely, or a combination of the two. The cause of the symptom will direct the management strategy to be used. Sometimes it can be managed through changes in habits related to diet and fluid intake, through medications, and where necessary, intermittent or continual catheterization.

Key Healthcare Professionals: Family physician, urologist, neurologist, and nurse

Symptom Management	Generic Medication Name	Examples of Brand Names	Available in Canada (Note: includes both approved and off label indications for use)*
Urinary antispasmodic	Tolterodine	Detrol	Yes
	Oxybutynin	Ditropan
	Propantheline	Pro-Banthine
	Flavoxate	Urispas
	Baclofen	Lioresal
	Tizanidine	Zanaflex
	Imipramine	Tofranil
Promote the flow of urine	Tamsulosin	Flomax	Yes
	Prazosin	Minipress
	Darefenasin	Enablex	No
Suppression and Treatment of Urinary tract infections	Sulfamethoxazole	Bactrim, Septra	Yes
	Ciprofloxacin	Cipro
	Nitrofurantoin	Macrodantin
Urinary suppressant	Desmopressin	DDAVP
Intermittent self-catheterization or indwelling catheter	-	-	Discuss with your urologist

Bowel dysfunction – constipation or incontinence - is not uncommon in MS. This symptom can often be managed by good habits related to diet, bowel schedule, fluid intake, and activity, as well as through medication.  As a new symptom, any change in bowel function should be evaluated by a physician to rule out non MS causes of the symptom.

Key Healthcare Professionals: Family physician, nurse, nutritionist, pharmacist or if required a gastroenterologist.

Symptom Management	Generic Medication Name	Example of Brand Names	Available in Canada (Note: includes both approved and off label indications for use)*
Stool softener	Docusate oral	Colace	Yes, no prescription required
	Docusate stool-softener enema	Enemeez Mini Enema
Constipation	Bisacodyl	Dulcolax
	Sodium phosphate	Fleet Enema
	Psyllium hydrophilic mucilloid	Metamucil
	Magnesium hydroxide	Phillips’ Milk of Magnesia

Approximately half of those with MS will experience some degree of cognitive change.  Only 5-10% of individuals will have moderate to severe change.  Cognitive change can be managed through cognitive rehabilitation.

Key Healthcare Professionals: Family physician, nurse, psychologist, neuropsychologist, occupational therapist speech/language pathologist

Symptom Management	Generic Medication Name	Example of Brand Names	Available in Canada (Note: includes both approved and off label indications for use)*
Cognitive rehabilitation	-	-	Consult with health professionals for compensatory strategies, and/or improving function

Depression is common in MS. It will affect over 50% of people with MS at some point in their illness.  Depression is a serious condition and should be distinguished from normal grieving associated with the diagnosis of MS. Depression can be managed through counselling and/or medication.

Key Healthcare Professionals: Family physician, nurse, psychologist, psychiatrist, neurologist, social worker

Treatment Options (Not an exhaustive list)	Generic Medication Name	Example of Brand Names	Availability in Canada (Note: includes both approved and off label indications for use)*
Tricyclic antidepressant	Amitriptyline	Elavil	Yes
	Imipramine	Tofranil
	Nortriptyline	Aventyl
SSRI	Fluoxetine	Prozac
	Paroxetine	Paxil
	Sertaline	Zoloft
	Venlafaxine long acting	Effexor XR
	Duloxetine	Cymbalta
	Citalopram	Celexa
	Escitalopran	Lexapro
Counselling	-	-	Psychologist, psychiatrist

According to some studies, over 90% of people with MS experience fatigue.

Fatigue can be a primary symptom (due to active inflammatory disease) or a secondary symptom (the result of other symptoms or conditions such as sleep disorders, depression, or muscle weakness) and managed by changes in lifestyle (e.g., employing energy effective strategies), as well as medication.

Key Healthcare Professionals: Family physician, nurse, neurologist, occupational therapist, physiotherapist, social worker

Method of Action	Generic Medication Name	Example of Brand Names	Available in Canada (Note: includes both approved and off label indications for use)*
CNS stimulant	Amantadine	Symmetrel	Yes
	Methylphenidate	Ritalin
	Modafinil	Alertec

Numbness of the face, body or extremities (arms and legs) is one of the most common symptoms of MS. (There are no medications approved to relieve numbness but corticosteroids have been used to try to reduce the symptoms especially during acute exacerbations). Fortunately, however, most instances of numbness are not disabling, and tend to remit on their own.

Key Healthcare Professionals: Family physician, nurse, neurologist, occupational therapist

Symptom Management	Generic Medication Name	Example of Brand Names	Available in Canada (Note: includes both approved and off label indications for use)*
	Corticosteroids (in very severe cases). Prednisone or Solumedrol may be used.	Deltasone	Yes

More than half of those diagnosed have experienced pain as a symptom of MS.

Pain in MS can be managed, but it requires careful identification of the type of pain, and often persistence in determining the best medication and/or dosage.  Acute, paroxysmal pain responds well to medication.  “Chronic pain is more difficult to manage and is often poorly treated.  It frequently requires multidisciplinary input and, if severe, may benefit from the expertise of a pain clinic.”[1]

Key Healthcare Professionals: Family physician, nurse, neurologist, physiotherapist

Symptom Management	Generic Medication Name	Example of Brand Names	Available in Canada (Note: includes both approved and off label indications for use)*
Neuropathic pain and paresthesias	Amitriptyline	Elavil	Yes
	Nortriptyline	Aventyl
	Gabapentin	Neurontin
	Pregabalin	Lyrica
	Carbamazepine	Tegretol
	Phenytoin	Dilantin
	Cannabis sativa L. extract	Sativex
	Cyclobenzaprine	Flexeril
Muscle relaxant	Methocarbamol	Robaxin
	Baclofen	Lioresal
Analgesics and anti-inflammatory agents	Acetaminophen	Tylenol	Yes, no prescription required
	Ibuprofen	Advil
Narcotics	Oxyontin		Yes
	Codeine
	Oxycodone

Relapses are medically defined as the appearance of new or worsening of old symptoms, lasting at least 24 hours. 

Relapses are often treated with corticosteroids (also known as steroids)which are medications used to reduce the severity of an individual relapse of MS, and hasten recovery.

Key Healthcare Professionals: Family physician, nurse, neurologist

Method of Action	Generic Medication Name	Example of Brand Names	Available in Canada (Note: includes both approved and off label indications for use)*
Reduce inflammation that occurs in the CNS during an MS relapse	Prednisone	Deltasone	Yes
	Methylprednisone intravenous (IV)	Solu-Medrol

Sexual symptoms can occur in MS for both men and women.  These symptoms can be primary (stemming directly from disease activity in the Central Nervous System), or secondary (due to fatigue, spasticity, body image etc). 

Sexual dysfunction can be managed with medications, products (e.g., lubrication for women), and the re-evaluation of ideas and practices related to intimacy and sexuality.

Key Healthcare Professionals: Family physician, nurse, neurologist, urologist, psychologist, sex therapist

Symptom Management	Generic Medication Name	Example of Brand Names	Available in Canada (Note: includes both approved and off label indications for use)*
Erectile dysfunction	Alprostadil	Caverject, Muse, Prostin VR	Yes
	Papaverine	-
	Sildenafil	Viagra
	Tadalafil	Cialis
	Vardenafil	Levitra
Decreased vaginal lubrication	Water soluble lubricants	KY Jelly
Relief of dysethesias (pain)	Carbamazepine	Tegretol
	Phenytoin	Dilantin

Spasticity refers to feelings of stiffness.  It is one of the more common symptoms of MS. While spasms – painful, cramp-like muscle contractions – are often associated with spasticity, they are not the same thing.  See the section on Pain for spasms.

Spasticity can be managed through stretching exercises, medication, and appropriate assistive devices. AN onset of spasticity as a new symptom should be evaluated by a physician to rule out secondary causes such as infection.

Key Healthcare Professionals: Physiotherapist, family physician, neurosurgeon

Method of Action	Generic Medication Name	Example of Brand Names	Available in Canada (Note: includes both approved and off label indications for use)*
Muscle relaxant	Baclofen (injection)	Intrathecal Baclofen (ITB  Therapy)	Yes
	Baclofen (oral)	Lioresal
	Dantrolene	Dantrium
	Diazepam	Valium
	Lorazepam	Ativan
	Tizanidine	Zanaflex

Speech and voice problems occur in approximately 25-40 percent of people with MS. There are two types of speech dysfunction: dysarthria, which refers to changes in the production of speech, including slurring, unclear articulation of words, and difficulty controlling loudness; and dysphonia, which involves changes in voice quality, such as hoarseness, breathiness, or nasality.  Assessment and management by a speech therapist is helpful, and in some cases communication aids may be useful.

Swallowing difficulties (dysphagia) can sometimes occur in MS.  Mild dysphagia is often easily managed with assessment and advice from a speech therapist.  More extreme cases are at risk of aspiration pneumonia.  In the most severe (and uncommon) cases, it may be necessary to acquire nutrients through a feeding tube.

Key Healthcare Professionals: speech/language pathologist, occupational therapist

Symptom Management	Generic Medication Name	Example of Brand Names	Available in Canada (Note: includes both approved and off label indications for use)*
Management strategies via a speech pathologist	-	-	Yes, contact the appropriate health professionals
Occasionally, medication may be used to dry a mouth that is over-secreting	Anticholinergics	Ditropan

Tremor is one of the more difficult symptoms to treat in MS.  The type of medication depends on the type of tremor (e.g., postural v/s intention).  The interventions below have been tried with varying degrees of success.

Key Healthcare Professionals: Physiotherapist, occupational therapist, family physician, neurologist

Symptom Management	Generic Medication Name	Examples of Brand Names	Available in Canada (Note: includes both approved and off label indications for use)*
Anticonvulsant	Primidone	Mysoline	Yes
Beta blocker	Propranolol	Inderal
Surgical intervention	-	-	Experimental

Vertigo or dizziness is sometimes experienced in MS.  When experienced at the same time as other symptoms such as double vision or in-coordination (ataxia), this can have a great impact on mobility and/or safety.  Medication can be helpful, as can physiotherapy exercises.

Key Healthcare Professionals: Physiotherapist, occupational therapist, family physician, neurologist

Method of Action	Generic Medication Name	Example of Brand Names	Available in Canada (Note: includes both approved and off label indications for use)*
Antiemetic	Dimenhydrinate	Gravol	Yes
	Ondansetron	Zofran
	Meclizine	Bonamine
	Prochlorperazine	Stemetil
Physiotherapy – including Cawthorne-Cooksey exercises	-	-	Available through appropriate health professionals

Vision problems, such as double vision, poor contrast, blurring, or eye pain are often the first symptoms of MS.

Vision problems usually resolve themselves.  Sometimes medication can be helpful.

Key Healthcare Professionals: Neuro-opthomologist, neurologist, occupational therapist, opthomologist

Medication Type	Generic Medication Name	Examples of Brand Names	Available in Canada (Note: includes both approved and off label indications for use)*
Prednisone or solumedrol can be used on their own, or in tandem (solumedrol first, then prednisone).	Corticosteroids	Solu-Medrol (IV)	Yes
		Deltasone (by mouth)

Difficulty with walking is among the most common mobility limitations in MS. Gait problems can be related to other symptoms such as spasticity, weakness, loss of balance, sensory deficit, and fatigue.

Most problems related to gait can be helped to some extent by physiotherapy, the use of appropriate assistive devices and, in some cases, medications related to particular symptoms.

Key Healthcare Professionals: Physiotherapist, occupational therapist, family physician