1 Multiple Sclerosis: An Overview for Pharmacists

2 What does MS look like? Julia—a 35yo white married mother of 3 who is exhausted all the time and can’t drive because of vision problems and numbness in her feet Jackson—a 25yo African-American man who stopped working because he can’t control his bladder or remember what he read in the morning paper Maria—a 10yo Hispanic girl who falls down a lot and whose parents just told her she has MS Loretta—a 47yo white single woman who moved into a nursing home because she can no longer care for herself There are many different faces of MS. The disease is so variable from one person to another that no two people experience it in exactly the same way.

3 What else does MS look like?Sam—a 45yo divorced white man who has looked and felt fine since he was diagnosed seven years ago Karen—a 24yo single white woman who is severely depressed and worried about losing her job because of her diagnosis of MS Sandra—a 30yo single mother of two who experiences severe burning pain in her legs and feet Richard—who was found on autopsy at age 76 to have MS but never knew it Jeannette—whose tremors are so severe that she cannot feed herself

4 1396: Earliest Recorded Case of MSSister Lidwina van Schiedam is thought by many to be the earliest recorded case of MS. She was healthy and active as a child and teenager, but fell while ice skating in 1396 and subsequently developed numerous symptoms characteristic of MS.

5 From Sister Lidwina to the present…1868—Jean-Martin Charcot describes the disease and finds MS plaques (scars) on autopsy. 1878—Louis Ranvier describes the myelin sheath (the primary target of MS in the central nervous system). “Multiple sclerosis is often one of the most difficult problems in clinical medicine.” (Charcot, 1894) “When more is known of the causes and…pathology of the disease… more rational methods may brighten the therapeutic prospect.” (Gowers, 1898) 1981—1st MRI image of MS is published.

6 From Sister Lidwina to the present, cont’d1993—The first disease-modifying agent for MS—Betaseron—is approved in the U.S. 1998—Bruce Trapp confirms that the nerve fibers themselves are irreversibly damaged early in the disease course (probably accounting for the permanent disability that can occur). 2009—Today, there are seven medications approved in the U.S. for the treatment of MS and more in the pipeline. Today there are 400,000 people with MS in the U.S and 2.5 million worldwide.

7 What MS Is: MS is considered an immune-mediated disease —perhaps autoimmune. The immune system attacks the myelin coating around the nerves in the central nervous system (CNS—brain, spinal cord, and optic nerves) and the nerve fibers themselves. Its name comes from the scarring caused by inflammatory attacks at multiple sites in the central nervous system. The primary site of the attack in MS is the myelin coating that surrounds the nerve fibers in the central nervous system. The expert consensus is that MS is an immune-mediated disease. It is now known at this time whether MS is autoimmune or a different immune-mediated disease process.

8 What MS Is Not: MS is not: Contagious Directly inheritedAlways severely disabling Fatal—except in fairly rare instances Being diagnosed with MS is not a reason to: Stop working Stop doing things that one enjoys Not have children People with MS have very close to a normal life expectancy. There are some individuals in whom a very rapid and severe disease course leads to death, and there are some in whom the complications of the disease become so debilitating that death eventually results. In addition, the suicide rate in people with MS is significantly higher than in the general population, with depression being the single greatest risk factor. Death certificate-based reviews indicate that suicide may be the cause of death for MS clinic attendees in as many as 15% of all cases (Sadovnick et al 1991). While people with MS used to be encouraged to give up most of their work and family dreams, they are now encouraged to keep their lives as full, productive, and busy as they are able and interested in having them be.

9 What Causes MS? Genetic Predisposition Environmental TriggerImmune Attack This diagram illustrates that when a person who is genetically susceptible encounters the (as yet unknown) environmental trigger, the immune-mediated response is initiated, causing damage in the central nervous system. Loss of myelin & nerve fiber

10 What happens in MS? ...cross the blood-brain barrier…“Activated” T cells... ...cross the blood-brain barrier… …launch attack on myelin & nerve fibers... Although scientists are still working out the details of the immune attack in MS, the basic steps involved appear to be as follows: Misguided immune cells—called T cells—cross the blood-brain barrier (BBB) into the CNS. The BBB, which is thought to consist of walls of capillaries in the CNS, usually prevents or slows the passage of undesirable substances (e.g., disease-causing organisms) from the blood into the CNS. These T cells release chemicals that rally other immune system forces that attack the myelin coating around the nerve cells, as well as the cells that manufacture myelin. This attack causes inflammation and then destruction. The nerve fibers themselves also come under attack. Once the myelin and nerve fibers have been damaged, nerve signals are slowed or stopped. MS lesions (damaged areas as seen on MRI) form, with hardened scars or plaques that may impair normal myelin repair processes. …to obstruct nerve signals myelinated nerve fiber

11 What happens to the myelin and nerve fibers?This drawing shows the steps involved in the damage to the myelin and axons. The yellow segments represent the myelin coating. One area of myelin has been damaged. The immune attack becomes directed toward the axon itself. The axon is severed. Myelin has some ability to repair itself, and the potential of myelin repair is an area of intensive research at this time. Once the axons are damaged, however, they cannot be repaired. Because axonal damage can occur even in the earliest stages of the disease, early treatment with a disease-modifying medication should be considered by anyone with a confirmed diagnosis of MS.

12 What are possible symptoms?MS symptoms vary between individuals and are unpredictable Fatigue (most common) Decreased visual acuity, diplopia Bladder and/or bowel dysfunction Sexual dysfunction Paresthesias (tingling, (numbness, burning) Emotional disturbances (depression, mood swings) Cognitive difficulties (memory, attention, processing) Pain (neurogenic) Heat sensitivity Spasticity Gait, balance, and coordination problems Speech/swallowing problems Tremor Any or all of these symptoms are possible in MS, depending on where in the CNS the lesions form. Only the symptoms that appear in orange are readily visible—which means that what you see when you look at a person with MS is probably only the “tip of the iceberg.” Some people develop only one or two of these symptoms over the course of the disease, while other people may develop several. Fatigue is the most common symptom of MS. In addition to “primary MS fatigue,” which results from impaired nerve transmission, there can be added fatigue caused by depression, disturbed sleep (e.g., by pain, nocturia, PLMs), impaired mobility, and some medications.

13 How is MS diagnosed? MS is a clinical diagnosis: Signs and symptomsMedical history Laboratory tests Requires dissemination in time and space: Space: Evidence of scarring (plaques) in at least two separate areas of the CNS (space) Time: Evidence that the plaques occurred at different points in time There must be no other explanation There is no single test that can determine if a person has MS. The current criteria for the diagnosis of MS require evidence of plaques that occurred in different places in the CNS at different points in time. This is why it can sometimes take months or even years to confirm the diagnosis. Until evidence of a second attack can be found, the current criteria for the diagnosis of MS have not been met.

14 What tests may be used to help confirm the diagnosis?Magnetic resonance imaging (MRI) Visual evoked potentials (VEP) Lumbar puncture MRI makes it possible to visualize and count lesions in the white matter of the brain and spinal cord. Evoked potentials are recordings of the nervous system’s electrical responses to the stimulation of specific sensory pathways. Since damage to myelin results in a slowing of response times, EPs can identify areas of damage along specific nerve pathways whether or not the person is experiencing any symptoms. VEPs are considered the most useful for diagnostic purposes. Lumbar puncture is used to examine CSF for changes that are characteristic of MS.

15 What is a clinically-isolated syndrome (CIS)?First neurologic episode caused by demyelination in the CNS May be monofocal or multifocal May or may not go on to become MS CIS accompanied by MS-like lesions on MRI is more likely to become MS than CIS without lesions on MRI Interferon medications delay second episode Avonex, Betaseron, Extavia, Copaxone approved for this use Rebif has demonstrated its effectiveness

16 Who gets MS? Usually diagnosed between 20 and 50Occasionally diagnosed in young children and older adults More common in women than men (3:1) Most common in those of Northern European ancestry More common in Caucasians than Hispanics or African Americans; rare among Asians More common in temperate areas (further from the equator) Note: Because MS is thought of primarily as a disease of young white women, individuals in other groups may find it harder to: get a diagnosis adjust to the diagnosis

17 What is the genetic factor?The risk of getting MS is approximately: 1/750 for the general population (0.1%) 1/40 for person with a close relative with MS (3%) 1/4 for an identical twin (25%) 20% of people with MS have a blood relative with MS The risk is higher in any family in which there are several family members with the disease (aka multiplex families) MS is not directly inherited like hair or eye color. If heredity were the only factor, the risk for an identical twin would be 1/1 instead of 1/4. A close – or first degree – relative is a parent, child, or sibling.

18 What is the prognosis? One hallmark of MS is its unpredictability.Approximately 1/3 will have a very mild course Approximately 1/3 will have a moderate course Approximately 1/3 will become more disabled Certain characteristics predict a better outcome: Female Onset before age 35 Sensory symptoms Monofocal rather than multifocal episodes Complete recovery following a relapse It’s important to remember that the majority of people with MS do not become severely physically disabled. Most will remain able to walk, although they may need an assistive device—such as a cane or walker—to do so. That being said, people who remain fully ambulatory may still be unable to work or function comfortably at home because of cognitive changes or other symptoms that interfere with everyday activities. Some people have a “benign” course of MS that remains mild throughout their lifetime. The challenge is that it is impossible to determine at the outset who will do fine and who will experience disabling symptoms 5, 10, or 20 years down the road. Therefore, most MS specialists recommend early treatment, as we’ll talk about in a few minutes.

19 What are the different patterns (courses) of MS?Clinically Isolated Syndrome (CIS) Relapsing-Remitting MS (RRMS) Secondary Progressive MS (SPMS) Primary Progressive MS (PPMS) Four disease courses have been identified in MS. These will be described in more detail in the next few slides

20 What happens in MS over time?Relapsing-remitting Secondary Progressive Disability Disability Time Time Disability Disability Time Time Disability Time Primary Progressive Relapsing course can be: -active or inactive -worsening or not worsening Progressive courses can be: -active with or w/o progression -not active with or without progression Lublin, et al. Neurology 2013 .

21 An Overview of Treatment Strategies

22 Who is on the MS “Treatment Team”?Neurologist Urologist Nurse Physiatrist Physical therapist Occupational therapist Speech/language pathologist Psychiatrist Psychotherapist Neuropsychologist Social worker/Care manager Pharmacist No single practitioner can address all of the problems potentially created by MS. The ideal treatment team, whether located in a single center, or spread out in the community, should include a variety of specialties. While most people with MS are treated by a neurologist, most do not have ready access to this kind of comprehensive care team. A major challenge for patients and families in today’s healthcare system is coordinating the care provided by these specialists.

23 What are the treatment strategies?Gone are the “Diagnose and Adios” days of MS care Management of MS falls into five general categories: Treatment of relapses (aka exacerbations, flare-ups, attacks—that last at least 24 hours) Symptom management Disease modification Rehabilitation (maintain/improve function) Psychosocial support The days of “diagnose and adios” in MS care (so labeled by Dr. Labe Scheinberg whom many consider to be the father of the comprehensive care model in MS) are long gone. While we do not have a cure for MS, we have a variety of treatment and management strategies to minimize the impact of MS on everyday life.

24 How are relapses treated?Not all relapses require treatment Mild, sensory sx are allowed to resolve on their own. Sx that interfere with function (e.g., visual or walking problems) are usually treated 3-5 day course of IV methylprednisolone—with/without an oral taper of prednisone High-dose oral steroids used by some neurologists Rehabilitation to restore/maintain function Psychosocial support While corticosteroids reduce inflammation, they are not thought to have any long-term effect on the disease. They are used primarily in exacerbations that are significantly impacting a person’s ability to function. Chronic, long-term use of steroid medications poses significant health risks (osteoporosis, glaucoma, gastrointestinal problems, etc.). Steroids can cause significant emotional upheaval in some people—including feelings of being “high” or manic while on the medication, followed by strong feelings of let-down or depression when coming off the medication. Some people may require a medication such as Depakote® to handle these severe swings. People may react differently to the medication at different times.

25 How is the disease course treated?Thirteen disease-modifying therapies are FDA-approved for relapsing forms of MS: glatiramer acetate (Copaxone®; Glatopa™ - generic equivalent) [inj.] interferon beta-1a (Avonex®, Plegridy™, Rebif®) [inj.] interferon beta-1b (Betaseron® and Extavia®) [inj.] dimethyl fumarate (Tecfidera®) [oral] fingolimod (Gilenya®) [oral] teriflunomide (Aubagio®) [oral] alemtuzumab (Lemtrada®) [inf] mitoxantrone [inf] natalizumab (Tysabri®) [inf] These medications differ somewhat in their mode of action, dosage levels, route of delivery, frequency of injection/infusion, and side effect profile. The injectable medications (in orange) are given on a schedule ranging from once per week to QD. Avonex is given IM; the others are SQ. Many people self-inject; others need someone else to assist them. All of the injectable medications are approved as first-line therapies. The oral medications are in blue. Although these are approved by the FDA as first-line treatments, physicians differ in their willingness to use them as first-line medications because of their more significant side effects. The infused medications are in gray; they are generally reserved for those patients who have not received sufficient benefit from one or more of the first-line medications. Mitoxantrone is the only FDA-approved medication for secondary-progressive MS. Patients work with their neurologist to determine which medication would be most suitable. Taking both the disease course and the patient’s lifestyle into account will enhance the likelihood of treatment adherence. Not all insurance formularies include all of these (expensive) medications; each of the pharmaceutical companies does have a patient assistance program to help people obtain their medication. Tysabri is for people with relapsing forms of MS. It is approved as a monotherapy and is generally recommended for those people who have not gotten sufficient benefit from the injectables or can’t tolerate the side effects. Associated risk of PML, a serious infection that is generally fatal. Tysabri may be used as a first-line therapy for someone with very active disease. Novantrone is also reserved for those patients in whom the disease is progressing in spite of treatment with the disease-modifying medications. Associated cardiac risk as well as increased incidence of leukemia.

26 What do the disease-modifying drugs do?All reduce attack frequency and severity, reduce scarring on MRI, and probably slow disease progression. These medications do not: Cure the disease Make people feel better Alleviate symptoms Unlike antibiotic medications we take for an acute condition like strep throat or bronchitis, or the symptom management medications we take for a headache or cold, these disease-modifying medications are designed for long-term use. These medications will not cure MS or make it feel better. They are designed to reduce the number and severity of attacks and alter the course of the disease. It is virtually impossible for a person to know if the drug is “working” at any given time.

27 How important is early treatment?The Society’s National Medical Advisory Committee recommends that treatment be considered as soon as a dx of relapsing MS has been confirmed. Irreversible damage to axons occurs even in the earliest stages of the illness. Tx is most effective during early, inflammatory phase Tx is least effective during later, neurodegenerative phase No treatment has been approved for primary-progressive MS. Approximately 60% of PwMS are on Tx The MS Coalition’s Consensus Paper on The Use of Disease-Modifying Therapies in Multiple Sclerosis is available on the Society’s website. Since irreversible axonal damage can occur very early in the disease course, a major goal of early treatment is to try and prevent that from happening.

28 What factors affect treatment adherence?Patient readiness is key Factors affecting readiness include: Lack of knowledge about MS Denial of illness Unrealistic expectations of treatment outcomes Side effects Cultural factors Lack of support (medical team, family) Distrust of medical community and/or prescription medications People vary significantly in their readiness to initiate treatment as well as their ability to adhere to a treatment regimen. Patients seen at MS specialty centers are more likely to initiate and continue treatment because they have a better understanding of the rationale for treatment, more realistic expectations, more assistance with side effect management, and more on-going support in the treatment process.

29 Treatment Challenges in MS ResearchCurrent therapies—primarily anti-inflammatory Future therapies Design selective therapies that target very specific components of the immune system Utilize combination of strategies: Anti-inflammatory Neural repair Neuroprotection Our current therapies primarily treat the early, inflammatory phase of MS. To date, we do not have effective treatments for the later, more progressive/degenerative phases. The goal is to design therapies that suppress or alter very targeted parts of the immune system while leaving the rest of the immune system intact. Research is focusing on three primary areas—reducing inflammation, and repair and protection of neurons.

30 New Treatments on HorizonEnhancement of Existing Therapies Potential Therapies Oral estrogens/testosterone laquinimod Parenteral rituximab (Rituxan) declizumab (Zenapax) dirucotide

31 Managing MS Symptoms Symptom management begins on Day 1 and continues throughout the disease course. Symptom management is an art. Virtually every medication used to treat MS symptoms is used off-label. Effective symptom management involves medication, rehabilitation strategies, emotional support—and good coordination of care.

32 Managing MS Fatigue > 80% of people with MS experience fatigue; many identify it as their most disabling Along with cognitive dysfunction, fatigue is the most common cause of early departure from the workforce MS fatigue is easily misunderstood by family members and employers as laziness or disinterest MS fatigue is multi-faceted

33 Managing MS Fatigue, cont’dIdentify/address contributory factors Disrupted sleep; muscle fatigue; disability-related fatigue; depression; medications Develop comprehensive treatment plan Medications: amantadine; modafinil Energy management: planning/prioritizing; mobility aids Exercise regimen In addition to “primary MS fatigue” or lassitude, which results from impaired nerve transmission, there can be fatigue caused by disturbed sleep (e.g., by pain, nocturia, PLMs), depression, impaired mobility, muscle weakness, and some medications. The first step in treating fatigue is to identify and address all contributory factors. MS lassitude often responds well to medication, exercise, and cooling strategies.

34 Managing Bladder Dysfunction> 75% of people with MS will experience bladder problems. Bladder dysfunction is a major cause of morbidity, embarrassment, and social isolation.

35 Managing Bladder DysfunctionStorage dysfunction Small, spastic bladder in which small quantity of urine triggers the urge to void Sx include: urgency, frequency, incontinence, nocturia Tx includes: anticiholinergic/antimuscarinic medication Emptying dysfunction Bladder fails to empty  risk of UTI Sx include: urgency, frequency, nocturia, incontinence Tx includes: ISC and anticholinergic/antimuscarinic medications

36 Managing Bowel ProblemsExperienced by 50% of people with MS Constipation—most common “Diarrhea” (related to impaction) Bowel incontinence—least common Managed best with regular bowel routine Adequate fluid/fiber intake Exercise OTC products as needed Anticholinergic medications added to manage incontinence

37 Managing Spasticity (increased muscle tone)Experienced by 40-60% of people with MS (more common in the lower extremities) Management strategies: Stretching Oral medication (baclofen, tizanidine, clonazapam, gabapentin, cyproheptidine, dantrolene, dopaminergic agonists Baclofen pump Botox injections; nerve blocks; surgery Some spasticity is useful to counteract weakness Pain anywhere in the body will increase spasticity. Thus bladder infections will increase spasticity. Spasticity as a symptom needs treatment only if it gets in the way of function or comfort. Its presence, by itself, is not a singular reason to treat. After removing noxious stimuli, the management of spasticity begins with a good exercise program emphasizing stretching and range of motion. Baclofen is the most commonly prescribed medication. If the oral medications are not sufficient—or the doses required produce too many side effects—there are procedures that may help. Botox and ITB (intrathecal baclofen) have generally replaced surgical procedures.

38 Managing Primary Sexual Dysfunction40-80% of men and women with MS Reduced libido (behavioral/environmental strategies) Sensory disturbances (anticonvulsant medications) Anorgasmia (body-mapping exercises) Women Reduced lubrication (gels) Men Erectile dysfunction (pharmacotherapy; implants)

39 Managing Secondary/Tertiary Sexual DysfunctionSecondary dysfunction (other contributory factors) Managing MS symptoms that interfere with sexual activity/pleasure (fatigue, spasticity, etc.) Managing medications to promote sexual comfort and responsiveness (anticholinergics; antidepressants, fatigue and spasticity meds) Tertiary dysfunction (feeling; attitudes) Education; counseling

40 Managing Cognitive DysfunctionOccurs in 50-60% of people with MS Ranges from relatively mild to quite severe Correlates with number of lesions and lesion area on MRI, as well as brain atrophy Can occur at any time but is more common later in the disease Can occur with any disease course, but is slightly more likely in progressive MS. Being in an exacerbation is a risk factor for cognitive dysfunction. Most common problems: memory; attention/concentration; information processing Treatments: Disease-modifying therapy to prevent relapses Cognitive rehabilitation: primarily compensatory

41 Managing Depression Depression is one of the most common symptoms of MS (resulting from immune system changes, neurologic changes and psychosocial factors) >50% of people with MS will experience a major depressive episode. Suicide in MS is 7x higher than in the general population. Greatest risk factor for suicide in MS is depression. Depression is under-recognized, under- diagnosed and under-treated in MS Recommended tx = psychotherapy + medication + exercise Depression in people with MS is believed to be part of the disease process itself, as well as a reaction to it. Information about the high prevalence of depression in MS and its possible relationship to the disease process itself is very helpful for patients and their families. Many are more comfortable acknowledging their depression and getting help for it when they understand its relationship to MS. Fatigue, impaired attention and concentration, motor slowing, feelings of worthlessness and guilt, impaired sleep can all be part of the MS picture, making it difficult to distinguish clinical depression. In addition to psychotherapy and antidepressant medication, aerobic exercise, tailored to the abilities of the individual, has been shown to enhance mood in people with MS.

42 Managing Pain 75% of people with MS experience painNeuropathic (central) pain Paroxysmal pain (trigeminal neuralgia; headache) Anticonvulsants Continuous pain (dysesthesias) Tricicyclics; anticonvulsants Nociceptive (secondary) pain Musculskeletal pain Physical therapy; NSAIDs Spasticity—As described previously

43 Managing Ataxia/TremorIncidence is unknown Potentially severely disabling No effective treatments at this time Medications that may be tried: propranolol; primidone; acetazolamide; buspirone; clonazepam Occupational therapy Weighting; assistive devices Thalamic surgery for tremor (generally poor results)

44 Serious ComplicationsUrosepsis Aspiration pneumonia Pulmonary dysfunction Skin breakdown Untreated depression Osteoporosis These secondary complications are the primary factors affecting the life-span of people with MS. In the absence of these complications, the life expectancy for people with MS is very close to normal.

45 What can people do to feel their best?Balance activity with rest. Talk with their doctor about the right type/amount of exercise for them. Eat a balanced low-fat, high-fiber diet. Avoid heat if they are heat-sensitive. Drink plenty of fluids to maintain bladder health and avoid constipation. Follow the standard preventive health measures recommended for their age group

46 What else can people do to feel their best?Reach out to their support system; no one needs to be alone in coping with MS. Stay connected with others; avoid isolation. Become an educated consumer. Make thoughtful decisions regarding: Disclosure Choice of physician Employment choices Financial planning Be aware of common emotional reactions.

47 The Allure of CAM

48 Understanding CAM’s AllureMS treatments are only partially effective. Personal testamonials are extremely powerful. Many people believe “Safe…natural…healthy…effective…” and distrust the effects of mainstream medicine. It feels good to “take charge” of a chronic, unpredictable disease.

49 The Use of Complementary and Alternative Medicine (CAM) in MSUsed by 50-88% of people with MS, generally in conjunction with conventional treatments Practitioners optimize the placebo effect Recommendations to patients from Allen Bowling, MD, PhD Consider conventional medicine first Learn about effectiveness, safety, cost Discuss it with your physician Use caution (“buyer beware”) Remember: MS involves excessive immune activity; no need to “boost” immune system” Bowling AC. Optimal Health with Multiple Sclerosis . New York: Demos Health, 2014

50 Possibly Beneficial CAM InterventionsDiet low in saturated fat and enriched in polyunsaturated fatty acids (may suppress immune system) Acupuncture: anxiety, bladder; depression; pain; sleep Massage: anxiety, pain, depression; pain; spasticity Meditation: anxiety, pain, depression, pain Exercise (T’ai chi; yoga): fatigue; anxiety, depression; weakness; walking Cooling: fatigue; spasticity; walking Biofeedback: anxiety; pain; sleep; bladder Bowling AC. Optimal Health With Multiple Sclerosis. New York: Demos Health, 2014

51 Dietary Supplements to be AvoidedSupplements that may stimulate the immune system: Oligomeric proanthocyanidins Pycnogenol Saw palmetto Selenium Stinging nettle Vitamin A Zinc Alfalfa Ashwagandha Astragalus Cat’s claw Garlic Licorice Melatonin Bowling AC. Complementary and Alternative Medicine in Multiple Sclerosis (2nd ed.). New York: Demos Medical Publishing, 2007

52 So what do we know about MS?MS is a chronic, unpredictable disease The cause is still unknown MS affects each person differently; symptoms vary widely MS is not fatal, contagious, directly inherited, or always disabling Early diagnosis and treatment are important Significant, irreversible damage can occur early on Available treatments reduce the number of relapses and may slow progression Treatment includes: attack management, symptom management, disease modification, rehab, emotional support

53 NMSS Resources for Patients and FamiliesNationwide network of chapters around the country Web site (www.nationalmssociety.org) Access to information, referrals, support ( ) Educational programs (in-person, online) Support programs (self-help groups, peer and professional counseling, friendly visitors) Consultation (legal, employment, insurance, long-term care) Financial assistance

54 Society Resources for ProfessionalsProfessional Resource Center Website: Comprehensive MS library/literature search services Clinical consultations with MS specialists Professional publications Professional education programs (medical, rehab, nursing, mental health) Consultation on insurance and long-term care issues