There is a 26 years old female client, Sabrina, with a clinical diagnosis of multiple sclerosis from the provided case study. The client is on follow-up clinics with her physician to treat and manage her condition and has one appointment soon approaching. However, she has some questions regarding her condition, and she decides to call the Nurse Helpline. An advanced practice nurse receives her call, and as she communicates, Sabrina realizes that her multiple sclerosis is also affecting her musculoskeletal and neurologic systems.
Despite being an autoimmune disorder, multiple sclerosis's adverse effects will eventually affect Sabrina’s neurologic and musculoskeletal systems. Therefore, treatment needs to be prescribed to address the musculoskeletal and neurologic disorders arising from multiple sclerosis. Hinkle and Cheever (2018) assert that there is no treatment for multiple sclerosis. The goals of treatment programs are to delay progression, treat acute exacerbations, and manage multiple sclerosis symptoms. Therefore, my first decision would be to prescribe dimethyl fumarate (Tecfidera), starting with the lowest dose (50 mg daily). My second decision would be to increase the dosage to 120 mg per day. Finally, my last decision would be to give the drug at the maintenance dose of 240 mg per day.
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I believe that the decisions I recommended for the patient in the case study are supported by evidence-based literature. The National Center for Biotechnology Information [NCBI] (2021) asserts that dimethyl fumarate is an immunomodulatory and anti-inflammatory agent indicated for the management and treatment of multiple sclerosis, especially the recurring forms. Furthermore, the drug is neuroprotective and with potentially radiosensitizing effects following its oral administration through the effects of its active metabolite monomethyl fumarate (NCBI, 2021). By preventing relapses, Tecfidera ensures that the musculoskeletal and neurologic systems are protected from severe symptoms that would bring damages and alterations in the above mentioned two systems. Dimethyl fumarate is also an antioxidant that protects the spinal cord and brain from damage through the Nrf2 response, a pathway that protects against oxidative stress (Medscape, 2021). Lastly, Mills et al. (2018) state that dimethyl fumarate exerts its actions by preventing the immune system's cells from damaging nerves and is, therefore, therapeutic in patients with multiple sclerosis.
Multiple sclerosis damages the musculoskeletal and neurologic systems leading to clinical manifestations. Some of the changes include loss of brain volume, reduced cognition, and compromised brain functioning (Cerqueira et al., 2018). Seizures, poor cognition, muscle weakness, tingling, and numbness are symptoms of neurologic and musculoskeletal symptoms associated with multiple sclerosis (U.S. National Library of Medicine, 2021). In my first, second, and third decisions, I was hoping to reduce musculoskeletal and neurologic involvement symptoms by the effects of multiple sclerosis. I also wanted to prevent future relapses and slow the progression of Sabrina’s condition. Dimethyl fumarate is indicated for patients with multiple sclerosis as it prevents relapses, slows the progression, offers neuroprotection, and prevent self-immune cells from damaging an individual’s nerves (NCBI, 2021).
In my first decision, I was hoping and expecting to achieve relief of symptoms associated with multiple sclerosis damage to the musculoskeletal and neurologic systems using the lowest possible dosage ( dimethyl fumarate 50mgs per day). However, the patient reported no alleviation of the symptoms. Sabina still had numbness, muscle weakness, pain, and poor cognition. Therefore, there was no health improvement, and this was against my expectations and aims. In the second decision, I increased the dosage to 120 mg per day. With this decision, I was expecting to achieve relief of the earlier mentioned symptoms. After an assessment, the client reported partial relief of symptoms such as numbness, poor cognition, tingling sensations, and pain. This was in line with my expectations. In my last decision, I adjusted the dosage to 240 mg per day. With that, I hoped to attain better relief of symptoms with minimal or no side effects. The client reported a significant improvement in her health status and alleviation of symptoms. She did not report severe adverse or adverse effects that would warrant dose reduction or drug discontinuation. This was as per my hope and expectation.
References
Cerqueira, J. J., Compston, D. A. S., Geraldes, R., Rosa, M. M., Schmierer, K., Thompson, A., Tinelli, M., & Palace, J. (2018). Time matters in multiple sclerosis: can early treatment and long-term follow-up ensure everyone benefits from the latest advances in multiple sclerosis? Journal of Neurology, Neurosurgery & Psychiatry , 89 (8), 844–850. https://doi.org/10.1136/jnnp-2017-317509
Hinkle, J. L., & Cheever, K. H. (2018). Brunner and Suddarth’s textbook of medical-surgical nursing . Wolters Kluwer India Pvt Ltd.
Medscape. (2021a). Tecfidera, BG-12 (dimethyl fumarate) dosing, indications, interactions, adverse effects, pharmacology, administration, and more . Reference.Medscape.com. https://reference.medscape.com/drug/tecfidera-bg-12-dimethyl-fumarate-999810#10
Mills, E. A., Ogrodnik, M. A., Plave, A., & Mao-Draayer, Y. (2018). Emerging understanding of the mechanism of action for dimethyl fumarate in the treatment of multiple sclerosis. Frontiers in neurology , 9 , 5.
National Center for Biotechnology Information. (2021). Dimethyl fumarate . Pubchem.Ncbi.Nlm.Nih.Gov. https://pubchem.ncbi.nlm.nih.gov/compound/Dimethyl-fumarate#section=Pharmacology-and-Biochemistry
U.S. National Library of Medicine. (2021b). Multiple sclerosis: MedlinePlus Medical Encyclopedia . Medlineplus.Gov. https://medlineplus.gov/ency/article/000737.htm
