Table 3 Treatment of common symptoms of multiple sclerosis (MS) listed in order of efficacy of treatment (most useful first)
SymptomFirst considerNon-drug treatmentFirst-line treatmentSecond-line treatment
Bladder—urgency or urge incontinenceIs there a urinary tract infection? Is the patient deliberately fluid restricting? Measure post-micturition residual bladder volume by ultrasound. Specialist continence adviceIntermittent self-catheterisation if the post-micturition residual bladder volume >100 mlOxybutinin (5 mg bd-qds), commonly causes dry mouth, constipation. Tolterodine (2 mg bd), rarely causes chest pain and peripheral oedemaIntravesical botulinum toxin in centres with experience. Long-term catheterisation only suitable if non-invasive methods do not work, and then suprapubic is better than in-dwelling. Do not use bladder wash-outs
Bladder—nocturiaSpecialist continence adviceSpecialist continence adviceDesmopressin 100–400 μg orally or 10–40 μg intranasally (for nocturia). Adverse effects are rare with correct dose: fluid retention, hyponatraemia
Bladder—recurrent urinary tract infections (>3 in one year)Always check culture and sensitivity, avoid long-term antibiotics. Consider bladder stonesSpecialist continence advice
Neuropathic painCarbamazepine specifically for trigeminal neuralgia. Consider musculoskeletal causes of pain, especially back pain secondary to spasticityTENS, cognitive behaviour therapyAmitripylline, gabapentin, pregabalinLamotrigine, phenytoin
Hypersomnolence (rare)Obstructive sleep apnoeaModafanil (100–200 mg bd), adverse effects common: abdominal pain and diarrhoea
SpasticityCheck for pain and infections (especially bladder). Careful check for contracturesPhysiotherapy, passive stretching,Baclofen (10 increasing to 80 mg daily in 2–3 divided doses)Tizanidine (starting at 2 mg, increasing by 2 mg every 3 days until on 4 mg tds and increase if still reporting benefit, to maximum of 24 mg dailyDiazepam, clonazepam, dantroleneIntrathecal baclofenIf limb function is already lost, then destructive surgery or phenol ablation of nerve rootsIn focal spasticity (eg hip adductors) botulinum toxin to paralyse appropriate muscles
Adverse effects: drowsiness, dizziness, dry mouth
Spastic foot dropFunctional electrical stimulator
ConstipationDiet sufficient? Is hydration a problem? Can mobility be improved?Increase fluid intake. Change dietOral laxativesSuppositories and enemas
DepressionConsider social factors, eg isolation and loss of status, as well as a direct manifestation of the MS.Support services (clinical psychology)Antidepressant medication
DysphagiaMeasure weight, formal swallow assessment, beware recurrent silent chest infectionsSwallowing techniques, change in dietAdjust position of seating, chest physiotherapy, enteral tube feeding
Chest infectionsIf recurrent, get formal swallow assessmentEnteral tube feeding
DysarthriaSpeech therapy
Erectile dysfunctionBeware depression, diabetes, vascular disease and medicationsSildenafil 25–100 mg. Adverse effects: flushing, gastrointestinal disturbance, oedemaAlprostadil or intra-cavernosal papaverine
Pressure ulcersCheck nutrition and wheelchair fitting
Faecal incontinenceIs this overflow from constipation? May need an abdominal x raySpecialist continence adviceOxybutinin or tolterodine may help
FatigueDepression, poor sleep, sedating drugsEnergy-conservation techniquesAmantadine 200 mg bd (marginal efficacy). Adverse effects: anorexia, anxietyFluoxetine
Poor mobilityIs it all due to MS?Aerobic training, rehabilitation, mobility aids
Diplopia and oscillopsiaGabapentin or baclofen may help
Poor cognitionAssess formally and early. May be due to depressionCognitive fatigue may improve with frequent rests (every 30 min) during high-performance mental tasks
EmotionalismExplain the condition to family and friendsTricyclic antidepressant, selective serotonin reuptake inhibitor
Ataxia and tremorSpecialist rehabilitation adviceA wide variety of proposed drugs (baclofen, isoniazid, carbamazepine, beta-blockers) have little or no effectThalamotomy and/or deep brain stimulation