A 22-year-old woman comes to the physician with her husband for intermittent dizziness, weakness, and unsteady gait for the last several weeks. She has also had visual loss and pain in the right eye that worsens with eye movement for the past 2 days. A year ago, the patient had tingling and numbness of her right hand accompanied by unsteadiness, which improved spontaneously after 3-4 days. She has no other medical problems and does not take any medications. The patient has no significant social or family history. Her temperature is 37.2 C (99 F), blood pressure is 122/80 mm Hg, pulse is 82/min, and respirations are 16/min. On neurologic examination, her right eye has diminished visual acuity and an afferent pupillary defect. She also has a right arm intention tremor. Both lower extremities have spastic paresis, hyperreflexia, and positive Babinski sign. The patient has marked symptomatic improvement within a few days of initial treatment and is scheduled for physical therapy. Which of the following is the most appropriate long-term pharmacotherapy for this patient?

Question

A 22-year-old woman comes to the physician with her husband for intermittent dizziness, weakness, and unsteady gait for the last several weeks.  She has also had visual loss and pain in the right eye that worsens with eye movement for the past 2 days.  A year ago, the patient had tingling and numbness of her right hand accompanied by unsteadiness, which improved spontaneously after 3-4 days.  She has no other medical problems and does not take any medications.  The patient has no significant social or family history.  Her temperature is 37.2 C (99 F), blood pressure is 122/80 mm Hg, pulse is 82/min, and respirations are 16/min.  On neurologic examination, her right eye has diminished visual acuity and an afferent pupillary defect.  She also has a right arm intention tremor.  Both lower extremities have spastic paresis, hyperreflexia, and positive Babinski sign. The patient has marked symptomatic improvement within a few days of initial treatment and is scheduled for physical therapy.  Which of the following is the most appropriate long-term pharmacotherapy for this patient?

Quizplus · Accepted Answer

Explanation: Disease-modifying drugs (eg, beta-interferon, glatiramer acetate) are indicated for chronic maintenance therapy in patients with relapsing-remitting multiple sclerosis (MS) as they can decrease the frequency of relapses and reduce the development of brain lesions. (Choice B) Long-term glucocorticoids are generally not recommended due to their potential systemic side effects (eg, osteoporosis, cataracts). (Choice C) Pramipexole is a dopamine agonist used in the long-term treatment of Parkinson disease. The tremor of Parkinson disease may be unilateral at onset but usually occurs at rest. This patient's young age and other neurologic features (eg, optic neuritis, transverse myelitis) also make MS more likely. (Choice D) Rivastigmine is a cholinesterase inhibitor that may be useful in the treatment of mild to moderate Alzheimer dementia. This patient's young age and lack of cognitive dysfunction make Alzheimer dementia highly unlikely. (Choice E) Topiramate is an anticonvulsant that can be used for migraine prophylaxis or seizure disorder; neither is evident in this patient. Educational objective: Beta-interferon or glatiramer can decrease the frequency of exacerbations and reduce the development of brain lesions in patients with relapsing-remitting multiple sclerosis. References: Interferons-beta versus glatiramer acetate for relapsing-remitting multiple sclerosis. (http://www.ncbi.nlm.nih.gov/pubmed/25062935) The use of interferon Beta and glatiramer acetate in multiple sclerosis. (http://www.ncbi.nlm.nih.gov/pubmed/23709209)

A 22-Year-Old Woman Comes to the Physician with Her Husband