Diagnosis and management of multiple sclerosis: case studies.

Although substantial capabilities have emerged in the ability to globally manage patients who have MS, clinicians continue to be confronted with formidable challenges. Reduction in disease activity and its impact on dis-ability progression remains the central objective of disease-modifying therapy and most current MS research initiatives. Nevertheless, the principal factors that determine the day-to-day limitations on functional capabilities(activities of daily living, work performance, quality of life, and so forth)are a derivative of the pathophysiology of the disease process itself. The substrate for these limitations is inherent in the pathology of demyelination and axonal dysfunction. Identifying measures that can optimize the performance and fidelity of axonal conduction mechanisms may translate into a reduction in MS-related symptoms. Chronic neurologic disease management (with MS representing a signature example) can be optimized when all members of the care team (including patients and their families) collaborate in the co-ordination of interdisciplinary care models that address all aspects of suffering.

Extrapyramidal symptoms with concomitant use of amitriptyline and amiodarone in an elderly patient.

BACKGROUND: Amitriptyline is a tricyclic antidepressant useful for the treatment of depression. Amiodarone is a class III antiarrhythmic agent used for the treatment of cardiac dysrhythmias. OBJECTIVE: The objective of the current report is to describe the case of a previously asymptomatic patient receiving amitriptyline who developed extrapyramidal symptoms within 1 month of initiating concomitant treatment with amiodarone for atrial fibrillation. CASE SUMMARY: An 82-year-old, right-handed, white woman was brought to the medical center's emergency department with speech difficulty suggesting stroke. She was noted to have continuous orobuccal dyskinesias, upper and lower extremity shaking, and dry mouth. Once it was determined that no other focal neurologic findings indicated stroke, her medications were reviewed. The patient had been taking amitriptyline 50 mg/d for the past year for insomnia without any adverse events. However, 1 month before presentation, she also initiated treatment with amiodarone 200 mg/d for atrial fibrillation and had developed the symptoms of concern shortly thereafter. The patient's amitriptyline treatment was discontinued and she received benzotropine for extrapyramidal symptoms from amitriptyline toxicity. She experienced complete resolution of dysarthric speech and limb shaking within 2 days. A total score of 7 was achieved using Naranjo's adverse drug reaction causality algorithm, suggesting amitriptyline was a probable cause of these adverse events. CONCLUSION: This was a probable case of extrapyramidal symptoms in an elderly woman who began using amiodarone while also taking amitriptyline.