Clinical challenges – managing multiple sclerosis during War

C

By Filipa Serrazina

There are 22,000 people with multiple sclerosis (MS) living in Ukraine, according to the Ukrainian Community of people with Multiple Sclerosis (UCMS). Their lives and treatments, as well as the lives of others with long-term health needs, are currently a major challenge.

According to United Nations High Commissioner for Refugees (UNHCR), more than 3.5 million people, mostly women and children, have left Ukraine for neighbourhood countries since the beginning of the Russian invasion of Ukraine. Many others have been displaced inside the country. Each minute, more people are fleeing the terrifying reality of violence.

I think it is time to reflect on people with MS living through War, many having to leave their homes and country to live as displaced people or refugees. How can we manage their MS, beyond their concerns about the war and its impact on their lives?

Two studies from Israeli (Golan et al., 2008) and Lebanese (Yamout et al., 2010) cohorts, assessing the impact of exposure to war-related events in MS, found that relapses and MRI activity are more likely to occur during these periods, suggesting that major stressful events may cause exacerbations in patients with MS. Moreover, beyond exhaustion, anxiety, poor sleep and limited food, displaced people and refugees are highly vulnerable to infections, which may contribute to MS exacerbations. For all these reasons, it is critical to prioritize when dealing with refugees with MS. What do they need to carry in their bag to survive in a displaced/refugee camp to manage their MS?

Disease-modifying treatment

People with MS receiving infusion treatments, like natlaizumab, ocrelizumab or alemtuzumab may be unable to predict when it will be possible to resume their treatment programme. People on oral drugs like fingolimod, teriflunomide or dimethyl-fumarate may not have access to medication for long periods. The same may be said about injectables drugs like glatiramer acetate, interferon beta, with additional concerns related to storage conditions. We should also be concerned about the risk of rebound disease activity after the withdrawal of some of these drugs, such as fingolimod or natalizumab. Cladribine has its own set of challenges given laboratory testing for blood counts will unlikely be available, though drug administration in two short courses, each consisting of two weeks of treatment, repeated after one year, may appear attractive.

Relapse

During this violent period, people should also be prepared for the occurrence of relapses. Steroids may help to hasten relapse recovery – albeit without significant impact on the long-term course of MS. However, in this setting, it could be virtually impossible to administer standard intravenously methylprednisolone. As an alternative, it could be useful to store oral steroids e.g., methylprednisolone (500mg for 5 days) or prednisone (650 to 1250mg, followed by a taper over 1-2 weeks) (NICE guidelines, Morrow SA et al, 2004).

Pseudorelapse

Stress, heat, and/or fatigue may cause temporary symptom flares, which should not last more than 24h. If symptoms persist, especially in the setting of worsening of old symptoms, an MS pseudo-exacerbation should be suspected. In this case, it is important to consider whether there is infection, checking for new bladder symptoms, fever, or symptoms of flu or cold. Beyond basic concerns for dehydration prevention/treatment, it is important to have access to urine dipstick tests, antipyretic medications, antibiotics and, for a number of patients, catheters for intermittent or chronic catheterization.

Pain and spasticity

Pain in these patients is complex and has a multifactorial nature, with biological, psychological, and social iPain in pwMS can be complex and multifactorial, with biological, psychological, and social impact on well-being. To manage neuropathic pain, it could be useful to have access to antiepileptics (gabapentin, pregabalin) and antidepressant medication (duloxetine) while for musculoskeletal pain both analgesics and non-steroidal anti-inflammatory drugs (NSAIDs) can be used. For pain related to spasticity, muscle relaxants offer partial relief (baclofen or tizanidine).

Anxiety and Depression

During War, it can be particularly challenging to manage anxiety and depression. Examples of medication include escitalopram or sertraline. Specific anti-anxiety medications, including benzodiazepines, may be useful as per need, and could also help with insomnia. Above all this, of course, the single most important thing is the simple plea: to end the War and make peace.

Filipa Serrazina

My name is Filipa Serrazina, and I am undertaking an internship in Multiple Sclerosis at The Royal London Hospital, Barts Health NHS Trust. I am a Neurology resident from Portugal, completing my residency training in the Neurology Department of the Egas Moniz Hospital in Lisbon. I did my undergraduate medical training at the University of Coimbra, where I graduated in 2016. I have a particular interest in inflammatory disorders of the central nervous system, especially MS. With the current multiple innovations in MS, I am hopeful more pwMS will be able to live their lives without disability. I’m glad to have the opportunity to learn from World experts in MS will try and share this knowledge throughout my professional life.

Disclaimer: The views expressed here are those of the author and nobody else.

About the author

The MS Bloggger

6 comments

  • In 2019 I went to MS Sessions, a weekend conference for young people with MS (I still met the criteria then). There were three women from Ukraine signed up to attend. One had her flight cancelled so couldn’t make it, but remained active on the Facebook group for the event. I remember one of them saying next time we should meet in Kyiv. I keep checking their social media updates. The horror their country is going through. One is taking sedatives to help manage her stress and sleep.

    The other day I had a medication worry – last week I was away for work on the scheduled delivery date so it was rescheduled for later in the week. Then the driver didn’t turn up (couldn’t find my flat apparently, amazing how often this happens when I have my own front door anyone can just walk up to if they have legs they can use). Anyway, in the end I had completely run out of Tecfidera before more arrived. In the past this would have sent me into a spin. I’ve been so stressed out about deliveries not arriving even when I had a few days’ buffer. Probably thinking about my friends in Kyiv helped put things in perspective for me. I really hope they stay safe and get all the medication and medical help they need.

  • Ohhh que linda!! Sou suspeita mas que orgulho em puder privar contigo! PARABÉNS, Parabéns Parabéns muitas felicidades, é o que sempre te posso desejar para uma carreira de sangue, suor e lágrimas para o caminho de muito sucesso como profissional e pessoal! Beijinhos 💖 Sónia Palma, sempre ao teu dispor

Translate

Categories

Recent Posts

Recent Comments

Archives