Instructor: Sandra Andrews, CPhT
2.5 million, 1.2 million, 2,844 deaths are staggering numbers no matter what they relate to, but even more daunting when you consider how they relate to the disease state known as multiple sclerosis (MS). 2.5 million people worldwide are diagnosed with MS each year, 1.2 million people in the United States. 2,844 deaths each year are from MS related symptoms. Multiple sclerosis is a chronic disease state that is often restricting to those who experience its symptoms. The central nervous system (CNS), which encompasses the brain, spinal cord, and optic nerves, is the principal system affected by MS. Thoughts, movements, sight, and sensations are all controlled through the central nervous system, so it is no wonder this disease can have such a profound effect on those who are impacted by it. Once thought to be an autoimmune disease, scientists now argue that multiple sclerosis is actually an immune-mediated disease. Simplistically, an immune-mediated disease is an overreaction of the body's immune system, while overreaction and an autoimmune disease is a subgroup of immune mediated diseases. While science continues to debate whether MS should be labeled generally as an immune-mediated disease or more specifically as an autoimmune disease, the National Multiple Sclerosis Society maintains that MS is an immune-mediated disease. So, what is multiple sclerosis and more importantly how does it affect the lives of those with it? What are its symptoms? Is there a cure? How is MS diagnosed? What drugs are available to treat the disease? Do the drugs treat the disease or just the symptoms? Finally, what role does pharmacy play in the containment and treatment of the disease? These are all questions we need to explore, which need to be answered. As previously mentioned, multiple sclerosis, per definition from the National Multiple Sclerosis Society, is an immune mediated disease. Immune-mediated diseases attack the body's central nervous system and therefore alter spinal cord, brain, and optic nerve responses. The central nervous system is responsible for processing sensory information that allows our bodies to move about and complete the tasks associated with daily life. The brain and the spinal cord, the two main organs of the central nervous system, work in tandem with one another to perform the jobs most of us take for granted, for example, walking. The brain is made up of three key areas, the forebrain, the midbrain, and the hindbrain. The forebrain is responsible for functions related to language and understanding. Located within the region of the forebrain are the thalamus, hypothalamus, cerebrum (the largest section of the brain), and the cerebral cortex. The cerebral cortex is the central processing center for the brain, much like a motherboard for a computer. The midbrain, which is the bridge between the forebrain and the hindbrain, works to ensure auditory and visual functions are properly working in the brain. The midbrain and the hindbrain function together to form the brainstem, which with the cerebrum connects the brain to the spinal cord. The spinal cord then assists the brain in the neurological responses needed to engage the body in walking (for example). Finally, the hindbrain extends from the spinal cord and allows for the synchronization of movement and the balancing of equilibrium. Also housed within the hindbrain is the medulla oblongata. The medulla oblongata controls the autonomic functions of the body, such as digestion, breathing and heart rate. Without the medulla oblongata, the brain and the spinal cord could not share the responses that allow us to perform the daily functions of living, many of which we often do not think about. It is clear, then, that the brain and spinal cord's involvement in our daily lives is monumental; so when these systems are compromised, the results can be devastating. Multiple sclerosis throws barriers in the path of those just trying to lead a normal life. Loss of coordination, blurred vision, tremors, extreme fatigue, slurred speech, numbness in the fingers and toes, inability to concentrate or hampered memory and, in extreme cases, blindness and even paralysis are just a few of the symptoms patients diagnosed with multiple sclerosis experience everyday. The etiology of multiple sclerosis has managed to evade science, but through the study of immunology, epidemiology and genetics, scientists have been able to gather clues that shed a bit more light on why MS affects some people, not others. Understanding the origins of the disease is key to understanding how to control its symptoms and, one day, possibly even finding a cure. Immunology, the study of the body's immune system, seems to have given the most insight to the causes of MS. As previously mentioned, there has been some debate within the health profession and science as to how to categorize the disease. Because the National Multiple Sclerosis Society states that MS is an immune-mediated disease we will also describe it that way. The theory surrounding immunology as a central cause of multiple sclerosis involves the myelin (protective sheathing) that surrounds and insulates the nerves of the central nervous system. It is thought that the myelin becomes damaged or compromised allowing the immune system to attack the CNS. Once damaged, it can no longer protect the nerves of the central nervous system, resulting in loss of function in patients. Further damage happens when scar tissue is formed where the myelin is attacked by the immune system. This scarring causes electrical impulse interruptions within the CNS, leading to symptoms associated with multiple sclerosis. Axons, fibrous nerves that myelin protects, along with neurons, become damaged, forming lesions along the central nervous system. These lesions interrupt nervous signals between the brain and body, causing symptoms such as tremors, bladder problems, numbness and slurred speech. Epidemiology as defined by the World Health Organization is the study of the distribution and determinants of health-related states of events and the applications of this study to control diseases and other health problems. In other words, it describes how the environment around us is related to a specific disease state. In this case, scientists have used epidemiology to develop hypotheses to understand the causes of multiple sclerosis as they relate to our environment. Epidemiologists take into consideration factors such as age, sex, ethnic background and migration patterns when trying to determine the underlying causes of a disease state. While scientists cannot definitively state what causes MS, there is evidence that proves a greater incidence of multiple sclerosis in countries with moderately cool climates whether in the northern or southern hemisphere. Further investigation has lead science to link this phenomenon to the migration patterns of Middle Eastern Europeans. North America has by far the highest number of multiple sclerosis cases; only the areas of Eastern Europe and Australia come close to the number of cases seen in North America. In conjunction with the migration patterns of our ancestors, researchers believe the depletion of sunlight and vitamin D, which our bodies produce naturally through the exposure to sunlight, are responsible for the higher occurrence of multiple sclerosis. This falls inline with a greater incidence of multiple sclerosis taking place north of the equator considering those who live closer to the equator are exposed to more sunlight and thus produce more vitamin D naturally. While multiple sclerosis occurs in all ethnic groups, African Americans, Asians and Hispanics or Latinos have seen the smallest incidence. Caucasians, in particular Caucasian women, are the most likely to be diagnosed with MS. In fact, women are two to three times more likely than men to be diagnosed with multiple sclerosis. It is because of this dynamic that researchers have started investigating the role hormones play in the development of multiple sclerosis. Even though the number of cases of MS in women is almost three times greater than in men, multiple sclerosis in men appears to progress faster and become more aggressive as the disease spreads. Genetics, which can be a primary factor in many disease states, has also been explored as a cause of multiple sclerosis. According to the National Multiple Sclerosis Society, the average person has a one in 750 chance of being diagnosed with multiple sclerosis. Sadly, the chance increases to one in 40 when a first degree relative, such as a parent or sibling, is diagnosed with the disease. Even more enlightening is the one in four chance seen by persons who share the same genes, such as an identical twin. Although genetics may be responsible for a small percentage of those diagnosed with multiple sclerosis, there are still too many variable factors to conclude that genetics is the sole determinant for being diagnosed with multiple sclerosis. Finally there have been some studies conducted that suggest infections of the CNS, which lead to an immune reaction in the area, instigate a trigger and result in MS. Scientists have not been able to isolate the culprit responsible for the infection, but Epstein-Barr, chlamydia, pneumonia, measles, canine distemper, and human herpes virus 6 remain candidates for the trigger. Of all the bacteria and viral infections mentioned, Epstein-Barr has shown the most promise for establishing a connection between multiple sclerosis and viral infections. It wasn't until the 19th century that MS was recognized as a disease state and it wasn't until the late 1960s that scientists understood the connection between the central nervous system's protective myelin and the deterioration that leads to a diagnosis of multiple sclerosis. It was also during the late '60s that researchers established the first guidelines for initiating a diagnosis of multiple sclerosis. Keeping these guidelines in mind, what establishes a diagnosis of MS? What factors must be seen in a patient's health exam in order to identify multiple sclerosis as solid diagnosis? According to the National Multiple Sclerosis Society, the following criteria should be met before a patient can be definitively diagnosed with multiple sclerosis. Find evidence of damage in at least two separate areas of the central nervous system, which includes, the brain, spinal cord and optic nerve Find evidence that the damages occurred at least one month apart Rule out all other diagnoses Make use of diagnostic tools, including: o MMR (magnetic resonance imaging) o VEP (visual evoked potential) o Cerebro spinal fluid (CSF) analysis Without the use of these diagnostic tools, multiple sclerosis can become difficult to definitively identify. The patient's medical history also becomes key to a substantiated diagnosis for multiple sclerosis. Patients who track MS attacks or who can provide their physician with a detailed history of their symptoms give the physician an advantage when diagnosing multiple sclerosis. There are two recognized levels of multiple sclerosis and knowing each level helps the patient to understand their disease state, including what they need to know in order to control the disease and the attacks that ensue. The two primary levels of MS are progressive multiple sclerosis and relapsing multiple sclerosis. Within each of these two categories are additional subcategories, which we will discuss further. People who have been diagnosed with progressive multiple sclerosis fall under one of three disease courses: primary progressive, secondary progressive or progressive relapsing. A steady stream of neurological degeneration marks the first course of primary progressive MS, giving the patient little, if any, time for remission from the disease. The patient may have recognized highs and lows, but will never really obtain remission from the disease's progression. Secondary progressive typically comes after a course of the most diagnosed form of multiple sclerosis, relapsing-remitting MS. Secondary progressive MS deteriorates the patient's physical state at steady pace. Patients who are diagnosed with secondary progressive MS may or may not have remission from the disease, but like primary progressive MS, the disease continues to progress. The key difference between primary and secondary progressive MS is that secondary progressive MS is secondary to relapsing-remitting MS and not a primary course of MS. The final course of progressive MS is progressive-relapsing MS and is the least common of the progressive courses of MS. As with the primary progressive and secondary progressive MS, progressive relapsing MS is marked by the continual advancement of the disease. However, unlike primary and secondary progressive MS the patient may have occasional relapses, which may not give the patient a time of recovery. Still, the disease continues to develop, a hallmark of the level of MS categorized as progressive. The next level of multiple sclerosis is relapsing MS, which is marked by bouts of remission and progression. Within this level of multiple sclerosis are three separate courses, relapsing-remitting, secondary-progressive, and progressive relapsing MS. The National Multiple Sclerosis Society estimates that up to 85% of all people who are diagnosed with multiple sclerosis fall under the category of relapsing-remitting multiple sclerosis. Relapsing-remitting MS has clearly defined lines of attacks and progressions, followed immediately by long periods of remission. During the patient's period of remission, the disease sees no progression. The next course of relapsing MS is secondary-progressive MS. Secondary-progressive MS usually follows a bout with relapsing-remitting MS and is marked by a continued progression of worsening disease state. The disease state may have occasional remissions, but will continue to be recognized by an indicated stream of progression. It is for this reason secondary-progressive MS is considered to be both progressive and relapsing. The final course of relapsing MS is progressive-relapsing MS. Progressive-relapsing MS is the least common of the relapsing courses of MS. Progressive-relapsing MS progresses from the beginning of the disease and continues throughout the course of the disease. Patients may or may not find relief from the disease through remission; however, the disease continues to progress, depleting the patient's physical state and overall health. Clearly multiple sclerosis is a disease of progression. The patient often sees periods of remission, where attacks from the disease are non-existent and the patient's disease course seems to improve. Still, a patient may have a course of the disease where they see no exacerbation of the disease, but the disease continues to advance, offering them highs and lows of the disease but no real relief. How is MS treated? There is no current cure for multiple sclerosis, although researchers are closer to understanding the disease. Most of the pharmaceutical treatments currently available for MS simply alleviate the symptoms, offering the patient temporary relief. When it comes to the treatment of multiple sclerosis, the drugs that treat the disease state can be broken down into three different categories: modifying disease course, treating exacerbations and managing the disease symptoms. The first category of drugs, those that modify the disease course, reduces the progression and the activity of the disease. Patients who have been diagnosed with relapsing forms of multiple sclerosis, including secondary progressive relapsing MS, see the most relief from this form of treatment. Interferon is the first category of drug modifying therapies and exists as either beta-1a or beta-1b. Biological miscellaneous is the second category in this class and currently Copaxone is the only brand available in the U.S. Interferon beta-1a has been proven to reduce the relapse of multiple sclerosis by 18-38%. Interferon beta-1a is commercially available under the names Avonex and Rebif. Avonex, which is produced by Biogen Idec, is a once-a-week treatment offered to the patient through the convenience of an injectable pen. While Avonex has been proven to provide relapse relief for the multiple sclerosis patient, it does have considerable side effects. Some of these side effects include seizures, infection, low or decreasing red and white blood cell counts, as well as decreased platelet counts and heart problems, including heart failure. Another common side effect of Avenox is flu-like symptoms such as fever, muscle aches, chills and fatigue. Rebif, produced by Pfizer, works along the same premise as Avenox and also comes as a once-a-week dose in a self-administered syringe. As with Avenox, the patient with MS sees relief from relapse, but not without the risk of some potentially alarming side effects such as thyroid issues, heart problems, decreasing blood counts and potential for decreased liver function. Both Avenox and Rebif offer patient support lines on the manufacturer websites. Patient support for Avenox can be found at http://www.avenox.com and for Rebif patient support can be found at http://www.rebif.com. Interferon beta-1b is the second group of interferon medications used to modify the disease state of multiple sclerosis. Betaseron and Extavia are two interferon beta-1b products commercially produced to modify the disease state of multiple sclerosis. Betaseron, which is produced by Bayer Health Care, works much the same way as Avenox and Rebif, helping to reduce the number of relapses a patient may have by modifying the disease. Interferon is a protein produced naturally by the body. When the production of interferon is disrupted in the body, it leaves a gap open in the immune system and in the case of multiple sclerosis, a vulnerability to demyelination. As we have learned, when the myelin is decreased, there is greater risk of damage to the nerves it protects. When the nerves become damaged, then the symptoms of MS become apparent. Betaseron and its counterpart, Extavia, produced by Norvartis, help to modify the patient's disease state and in turn reduce the number of relapses a patient may have. Both Betaseron and Extavia are produced as self-medicating, subcutaneous kits. Betaseron and Extavia are interferon beta-1b products and differ only from interferon beta 1a products by the slight difference in their amino acid structures. The manufactures of Betaseron and Extavia have set up patient-friendly help centers at each one of the drug websites, http://www.betaseron and http://www.extavia.com. Patients who have further questions or concerns about these drugs are encouraged to visit the site and follow up by a conversation with their neurologist and pharmacist concurrently. As with interferon beta-1a, interferon beta-1b also comes with a risk of potentially harmful side effects such as depletion of liver function, potential for increased depression, possible heart problems, including heart failure, as well as seizure, flu-like symptoms and injection site issues. Currently, research is not strong enough to argue for an interferon beta-1a product over an interferon beta-1b product. Such decisions should be made solely by the patient and their neurologist. Copaxone, or as it is known generically, glatiramer acetate, is also a disease-modifying drug, but falls under the category of biological miscellaneous. Copaxone, which is the only biological miscellaneous product approved in the United States, is produced by Teva Pharmaceuticals. The medication works along the same lines as the interferon groups, modifying the disease and in turn producing a decrease in disease relapse. The one significant difference between Copaxone and the interferon-based drugs is that the patient must inject Copaxone daily subcutaneously. For a patient who is already burdened by the symptoms of MS, this may very well be one more issue they are not willing to do. Copaxone has been on the market in the U.S. since 1996 and while it has offered the patients who use it relief, it does not come without warnings. Side effects when using Copaxone are primarily related to the daily need for patient-produced injection, specifically warnings against overuse of injection sites and the potential for infection. However, more serious side effects can occur include shortness of breath, heart palpitations, anxiety, skin rashes and dizziness. If patients recognize any of these symptoms after taking Copaxone they should seek medical attention immediately. Most reactions will occur within 15 minutes of injection, but any reactions that occur at a later time should not be dismissed. Gilenya (sphingosine 1-phosphate receptor modulator) and Novantrone Antiplatic (agent/anthracenedione) are the next class, which modify MS. This class of drugs is generally reserved for patients with advanced stages of MS or those who have not responded to other treatment. Gilenya works by preventing nave immune cells from leaving the lymph nodes and circulating to other tissues in the body, such as the brain. As such, it prevents their action against myelin in the CNS. Careful consideration should be taken before beginning treatment with drugs in these two categories. Finally, there is the category that includes Tysabri (natalizumab), a monoclonal antibody selective adhesion molecule inhibitor. Tysabri is the only brand available in the U.S. and is usually a last course of action drug. This medication works by blocking integrin receptors, which prevents T cells of the immune system from entering the brain. Only patients who have not responded to any other treatment should begin this therapy. Stringent monitoring of therapy is essential. From drugs that modify the disease, we move to drugs that manage the symptoms of the disease. This specific set of drugs offers the patient temporary relief from the symptoms of their disease. Corticosteroids such as prednisone, methylprednisolone, dexamethasone and adrenocorticotropic hormone (ACTH) offer the patient the most relief from the inflammatory symptoms associated with multiple sclerosis. But once again, patients should be cautioned about the potential for harmful side effects and should be monitored carefully by their neurologist. Medication management should be a joint effort by the patient's physician(s) and pharmacist. Efforts made in such a manner reduce the potential of harm to the patient. Corticosteroids like prednisone and dexamethasone are effective for such symptoms as inflammation, but should be prescribed only as needed and not for over-extended periods of time. Overuse of corticosteroids may cause swelling, thinning of the skin and bones, endocrine and metabolic issues, allergic reactions of the skin and possible cardiovascular issues. When treating multiple sclerosis, three main categories of drugs exists: ones that modify the disease such as interferon-1a and 1b; drugs that treat the exacerbations or flair-ups of the disease, like corticosteroids for inflammation; and finally those drugs that manage the symptoms of the disease. This final category of drugs may be largest group of drugs available for treatment, due to the wide array of symptoms possible in a patient who has been diagnosed with MS. Some of the drugs approved by the FDA to treat the specific symptoms associated with multiple sclerosis include: Managing the symptoms of multiple sclerosis may sometimes be the most challenging aspect, for the benefit of one drug may increase the side effects of another, making it necessary for the patient to medicate yet again for another symptom. Often times it is the side effects that need the most management. It is no secret that over the last decade pharmacy has taken progressive steps toward a greater role in patient medication management. Federal laws such as the 1990 OBRA patient counseling laws and current pending federal regulation under the Affordable Care Act have forced the pharmacist into center spotlight as a primary manager for patient medication management (MTM). The significance and importance of a pharmacist/physician regulated patient MTM is all too evident in the overall well being of a patient diagnosed with MS. So what role does this leave for the pharmacy technician? As pharmacists continue to move towards more direct care roles, pharmacy technicians take on more traditional roles once filled by the pharmacist. Of course, a pharmacy technician should never move beyond the legal or structured elements of their position, but being aware of disease states and the drugs that treat them, particularly side effects and potential warnings, might very well keep a patient from harm. Take the following example: Jamie works at Parks Drug as a pharmacy technician. She has been a certified pharmacy technician for over five years and prides herself on staying informed of the latest changes in pharmacy law and disease states and the advancements made to treat those diseases. Jamie is also cautious to never go beyond her job duties, knowing the pharmacist is the only person who is legally capable of answering drug medication questions. One day when Jamie is working at the front counter of the pharmacy, Mrs. Banks walks into the pharmacy. Jamie does not recognize her as a regular customer and ask if she might be able to help her. Mrs. Banks tells Jamie her name, then continues by telling her that she has just moved to town and was given Parks Drug as reference. Mrs. Banks has two new prescriptions from her physician that need to be filled and three prescriptions from her old pharmacy that need to be transferred. Immediately Jamie begins by starting a new patient profile for Mrs. Banks. Jamie, upon gathering Mrs. Banks' information sees that one of the health issues she has listed is multiple sclerosis. Reviewing the patient's list of prescriptions to be transferred she notices a prescription for Avonex, prednisone, Effexor, and Symmetrel, as well as Ditropan. Because the new prescriptions Mrs. Banks has given Jamie are for Betaseron and Ditropan XL, Jamie notices a potential problem. Jamie politely excuses herself and then speaks to the pharmacist on duty about her concerns with Mrs. Banks' prescriptions. Knowing that Mrs. Banks has listed multiple sclerosis as a health issue and that Avonex and Betaseron are both approved treatments for the relapse of multiple sclerosis, Jamie is concerned Mrs. Banks might be receiving duplicate treatments. She also informs the pharmacist Mrs. Banks has been prescribed Ditropan and Ditropan XL. The pharmacist notes Jamie's concerns about Mrs. Banks' medications, thanks Jamie, and goes to speak with Mrs. Banks. Mrs. Banks, who did not realize she could have potentially duplicated medication therapies, thanks the pharmacist and Jamie for being so proactive in her care. In this instance, because Jamie sought to maintain her skills as a certified pharmacy technician through educational resources, the risk of harm to a patient was eliminated. Jamie's recognition of MS treatments and the drug categories they fall into helped her see a risk potential. Not only did Jamie help the patient, but also certified her skills as a pharmacy professional. Multiple sclerosis is a disease state that can be debilitating to the patient as well as the ones who love and care for them. Treatments such as interferon beta-1a and interferon beta-1b work to modify the disease state, while corticosteroids like prednisone and methylprednisolone help to manage the symptoms of multiple sclerosis. Drugs like Ditropan, a drug commonly prescribed for bladder control, and Effexor, often prescribed for depression, work to control the symptoms of multiple sclerosis. Still the need to develop better treatment plans continues to grow; one of the most significant developments taking place at Northwestern University. Recently, Northwestern University Feinberg School of Medicine has had great success with a drug therapy currently known as MW151. In phase 1 human clinical trials, it was the first drug therapy which decreased brain inflammation and the first MS drug to target CNS functions. MW151 prevents the overproduction of pro-inflammatory cytokines. Initially developed for Parkinson's disease, MW151 may prove to serve a dual purpose. Special populations such as pregnant women and children have their own specific set of concerns when it comes to the treatment of multiple sclerosis. Women who are pregnant and have been diagnosed with MS seem to have relief from MS symptoms during their second and third trimesters. Researchers believe this is do to the increased level of natural steroids and immune activity. Pregnant women who experience relapse post partum have had success with therapies that include intravenous steroids and IVIG. During pregnancy, Tysabri and interferon are contraindicated and have been known to cause fetal harm. The situation is not much better for glatiramer Copaxone, which cannot rule out fetal harm. Corticosteroids may be used, but only under strict supervision by a physician. Before therapy with corticosteroids begins, the physician should consult with the specialty pharmacist and determine whether the benefits of the drug outweigh the potential of risk. Corticosteroids have been linked to cleft palate when administered during the first trimester and patients beginning them should be clearly warned of this possibility. Other concerns for women who have MS and are pregnant include lower birth weights for children and a higher incidence of Cesarean sections. Patients should be consulted in order to understand all therapies available as well as the safety of those therapies. Coordination of therapy between the patient's neurologist and obstetrician as well as the benefit of the pharmacy specialty services is essential for the safety of the patient and the fetus. Children are also susceptible to MS's reach, but there are some who are at a greater risk. Children who live in the northeastern U.S. are at the greatest risk and Caucasian children have a higher incidence than any other ethnic group and, of course, girls more than boys. Researchers attribute these risks to a possible genetic link, especially when a parent or sibling has been diagnosed with MS. Decreased vitamin D and geographic areas where sunlight is often not as prevalent as well as children whose parents smoke are risk factors for being diagnosed with MS. Some of the symptoms that adults experience may be the same in children. CNS involvement is generally at the center of these symptoms. Cognitive functions and walking abnormalities are just a few of the concerns associated with MS in children. Treatment may become a challenge as well. Most MS therapies are not FDA-approved for pediatric use and the side effects associated with the treatments may not be worth the benefits. Most of a treatment's value will be depend upon the child's ability to tolerate the treatment. Gilenya may show the most promise for modification of the disease, but the studies have only been proven for children over the age of 16, which still leaves another demographic that needs reliable treatment. Corticosteroids like prednisone can relieve issues of inflammation, but close monitoring by the child's pediatrician is suggested. The invitation of specialty pharmacy services may also be advantageous. Treatment with methylprednisolone is not recommended, but if therapies are enacted they should be closely monitored and should not be taken under lengthy periods of time. Dexamethasone, like prednisone, is indication-specific and as with other corticosteroids needs close monitoring. As pharmacy continues to evolve so must the pharmacy technician. Understanding disease states like multiple sclerosis and the treatments required to control the disease advance the career of the pharmacy technician as well as perpetuate the well-being of the patient. References: Avenox, http://www.avenox.org, January 2013, accessed 12 February 2013 Betaseron, http://www.betaseron.org, January 12,2013 accessed 13 February 2013 Copaxone, http://www.copaxone.com, January 2013, accessed 12 February 2013 MedWatch Safety Alerts, May 2012: MS Drug Investigation Continues The Food and Drug Administration. 2012 http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm307217.htm#5 Accessed 26 July 2012 MedWatch: The FDA Safety Information and Adverse Event Reporting Program The Food and Drug Administration. 2012. http://www.fda.gov/Safety/MedWatch/default.htm Accessed 21 July 2012 Multiple Sclerosis Association of America, http://www.mymsaa.org ,January 31 2013, accessed 13 February 2013 Multiple Sclerosis Foundation, http://www.msfocus.org , January 2013, accessed 13 February 2013 Multiple Sclerosis, http://www.multiplesclerosis.com , January 31,2013, accessed 14 February 2013 National Multiple Sclerosis Society, http://www.nationalmssociety.org ,January 2013, accessed 14 February 2013 New Drug Could Treat Alzheimer's, Multiple Sclerosis and Brian Injury Science Daily. July 2012. http://www.sciencedaily.com/releases/2012/7/2012147/1302.htm Accessed 26 July 2012 Pharmacist Prescribing Better Care U.S. Department of Health and Human Services Health Resource and Services Administration. April 2009. http://www.hrsa.gov. Accessed 22 July 2012. Pharmacist's Role in Meeting National Patient Safety Goals Health Care Associated Infection and Prevention. Volume 44:pp: 404-411.May 2009. Polman, C Reingold, S.Banwell, B. Clanet, M. Cohen, Massimo J., F.Kazuo, F.Havardarvo, E. Hutchinson, M. Kappos, L. Lublin, F. Montilban, O'Conner, P.Wolheilm-Sandburg, M Thompson, A. Waubant, E. Weinshker, B.and Wolinsky, J. Diagnostic Criteria for Multiple Sclerosis: 2010 Revision to McDonald Criteria. Annals of Neurology. February 2011. Volume 69:pp292-302. Preventing Medication Errors pp: 26-32. To Err is Human: Building a Safer Health System. November 1999. Institutes of Medicine. http://nap.edu/catalog/11623.html. Accessed 21 July 2012. What is Paresthesia? National Institute of Neurological Disorders and Strokes. May 2010. http://www.ninds.nih.gov/disorders/paresthesia/paresthesia.htm Accessed 26 July Author Bio: Sandy Andrews lives in Chambersburg, Pennsylvania with her husband of 17 years, Rob and her two teenage sons, Joshua and Caleb. She will be completing her BA in English from Arizona State University in July and will be moving on to complete her Masters Degree in English from Northern Arizona University. Sandy has over 20 years of experience as a Certified Pharmacy Technician, primarily in institutional pharmacy. Recently, Sandy has had a career change and is writing educational material for pharmacists and pharmacy technicians. Sandy is hoping to continue the growth of this new career choice. Idea in Brief: Multiple sclerosis is a progressive neurodegenerative disease that results in compromised function of the central nervous system. While there is no cure for the disease, science continues to make strides toward a better understanding of MS. This program will interpret some of the mysteries associated with multiple sclerosis as well as give greater insight to the treatments used to control the disease. Idea in Practice: As the role of the pharmacy technician continues to evolve, understanding disease states, such as multiple sclerosis, becomes a required part of the pharmacy technician's skill set. Treatments associated with the management of multiple sclerosis will also continue to develop. It is necessary for the pharmacy profession to be informed of available treatments in order to better serve the patient. Pharmacy technicians are essential to the practice of medication management. Patients who are afflicted with multiple sclerosis will require the skills of a qualified pharmacy team and central to this team will be the certified pharmacy technician.