Symptomatic treatment

The symptoms of MS which may be managed include:

• spasticity (1,2):
  • physiotherapy
  • consider oral baclofen as a first-line drug treatment to treat spasticity in people with MS who have specific treatment goals such as improving mobility or easing pain and discomfort. Take into account any contraindications, comorbidities and the person's preferences (2)
  • if oral baclofen is not tolerated or does not provide adequate relief, consider gabapentin as a second-line option to treat spasticity in people with MS (2)
  • when using oral baclofen or gabapentin to treat spasticity in people with MS, explain to the person that they should (2):
    • increase the dose gradually in at least 2-week increments to optimise symptom improvement or until they reach the maximum dose they can tolerate
    • stop taking the medicine if there is no benefit at the maximum tolerated dose (explain that baclofen can cause harm if stopped suddenly and that special precautions may be needed when stopping specific medicines)
    • have their medicines reviewed at least annually once the optimal dose has been reached
    • see the BNF and the summary of product characteristics for baclofen and gabapentin for advice on optimising dosage and stopping treatment and, if relevant, treating people with renal impairment and older people. For more information on reviewing and withdrawing gabapentin, see NICE's guideline on medicines associated with dependence or withdrawal symptoms
  • consider a combination of oral baclofen and gabapentin for people with MS if:
    • individual medicines do not provide adequate relief or
    • side effects from individual medicines prevent the dose being increased
    • see the BNF and the summary of product characteristics for baclofen and gabapentin. Use caution when using these medicines in combination because of the risk of severe respiratory depression (see the 2017 MHRA advice on gabapentin: risk of severe respiratory depression). For guidance on safe prescribing of gabapentin and managing withdrawal, see NICE's guideline on medicines associated with dependence or withdrawal symptoms
  • if spasticity is causing significant impairments in mobility, posture or function and initial treatments are unsuccessful, refer to a multidisciplinary team experienced in the management of spasticity for assessment and treatment planning
  • for guidance on THC:CBD spray for treating spasticity in people with MS, see the recommendations on spasticity in NICE's guideline on cannabis-based medicinal products
• oscillopsia
  • is a symptom of jumbling eye movements, manifested as blurred vision when walking or running, and is caused by poor stabilization of the retinal image during head movement
  • consider gabapentin as a first-line drug to treat oscillopsia in people with MS (2)
  • refer the person with MS for specialist advice if there is no improvement in oscillopsia after treatment with gabapentin and memantine or if side effects prevent continued use (2)
    
    
• urinary frequency and incontinence:
  • anti-cholinergics:
    • oxybutynin hydrochloride
    • tricyclic antidepressants e.g. amitriptyline
  • intermittent self-catheterisation
    
    
• bowel symptoms:
  • stool softeners
  • high roughage diet
• impotence:
  • intracavernosal injection of papaverine
  • sildenafil
• paroxysmal episodes of altered sensation:
  • anti-convulsants
• seizures - anti-convulsants
• cerbellar tremor:
  • is a lack of evidence for pharmacological management of ataxia and tremor in people with MS (2)
• depression:
  • depression and anxiety (see NICE's guidelines on depression in adults with a chronic physical health problem and generalised anxiety disorder and panic disorder in adults
  • NICE suggest that 'consider amitriptyline to treat emotional lability in people with MS..' (1,2)
  • the Multiple Sclerosis Society give valuable support
• fatigue:
  • options of therapeutic interventions to treat fatigue include
    • non-pharmacological management of mobility problems and fatigue
      • consider vestibular rehabilitation for people with MS who have fatigue or mobility problems associated with limited standing balance
      • consider supervised exercise programmes involving moderate progressive resistance training and aerobic exercise to treat people with MS who have mobility problems or fatigue
      • help the person with MS continue to exercise, for example, by referring them to a physiotherapist with expertise in MS or to exercise referral schemes
      • if more than 1 of the interventions recommended for mobility or fatigue are suitable, offer treatment based on which the person prefers and whether they can continue the activity after the treatment programme ends
      • encourage people with MS to keep exercising after treatment programmes end for longer-term benefits
    • amantadine
      • amantadine 100 mg bd helps 40% of patients
      • offer amantadine to treat fatigue in people with MS (1)
      • consider supervised exercise programmes involving moderate progressive resistance training and aerobic exercise to treat people with MS who have mobility problems and/or fatigue
      • most commonly reported side effects are nausea and dizziness (3)
    • modafinil, except in people who are pregnant or planning pregnancy (2)
      • use the lowest effective dose
      • follow the MHRA safety advice on modafinil and pregnancy for people who are able to get pregnant, including explaining the risks, advising on effective contraception and explaining that modafinil may reduce the effectiveness of steroidal contraceptives
    • selective serotonin reuptake inhibitor (SSRI)
      • use the lowest dose recommended for licensed indications
  • in June 2022 this was an off-label use of amantadine, modafinil and SSRIs (2)

Consult full NICE guideline NICE (June 2022).Multiple sclerosis in adults: management for more details

Reference:

• NICE (November 2019). Multiple sclerosis management of multiple sclerosis in primary and secondary care.
• NICE (June 2022).Multiple sclerosis in adults: management
• Generali JA, Cada DJ. Amantadine: multiple sclerosis-related fatigue. Hosp Pharm. 2014 Sep;49(8):710-2. doi: 10.1310/hpj4908-710. PMID: 25477595; PMCID: PMC4252198