MCQ Quiz: Multiple Sclerosis

Multiple Sclerosis (MS) is a chronic, immune-mediated disease of the central nervous system characterized by inflammation, demyelination, and neurodegeneration. Its management has been revolutionized by the development of numerous disease-modifying therapies (DMTs). Pharmacists play a vital role in managing these complex medication regimens, counseling on administration and side effects, and helping to improve a patient’s quality of life. This quiz will test your knowledge on the pathophysiology, clinical presentation, and pharmacologic management of Multiple Sclerosis.

1. The underlying pathophysiology of Multiple Sclerosis involves the immune system attacking what structure in the central nervous system?

• a. The neuronal cell body
• b. The myelin sheath surrounding axons
• c. The neuromuscular junction
• d. The blood-brain barrier itself

Answer: b. The myelin sheath surrounding axons

2. What is the most common clinical course of Multiple Sclerosis at the time of diagnosis?

• a. Primary Progressive MS (PPMS)
• b. Secondary Progressive MS (SPMS)
• c. Progressive Relapsing MS (PRMS)
• d. Relapsing-Remitting MS (RRMS)

Answer: d. Relapsing-Remitting MS (RRMS)

3. What is the first-line treatment for an acute MS relapse or exacerbation?

• a. A long-acting interferon
• b. A short course of high-dose corticosteroids
• c. Glatiramer acetate
• d. An oral disease-modifying therapy

Answer: b. A short course of high-dose corticosteroids

4. The primary goal of a disease-modifying therapy (DMT) in MS is to:

• a. Cure the disease.
• b. Only treat the symptoms of an acute relapse.
• c. Reduce the frequency and severity of relapses and slow the accumulation of disability.
• d. Regenerate lost myelin.

Answer: c. Reduce the frequency and severity of relapses and slow the accumulation of disability.

5. Interferon-beta preparations are a long-standing injectable DMT for MS. What is a very common side effect that patients should be counseled on?

• a. Severe nausea and vomiting
• b. Weight gain
• c. Flu-like symptoms (fever, chills, myalgias)
• d. Hair loss

Answer: c. Flu-like symptoms (fever, chills, myalgias)

6. Glatiramer acetate (Copaxone) is an injectable DMT that is thought to work by:

• a. Acting as a decoy for the immune system, mimicking myelin basic protein.
• b. Blocking the S1P receptor.
• c. Inhibiting pyrimidine synthesis.
• d. Depleting B-cells.

Answer: a. Acting as a decoy for the immune system, mimicking myelin basic protein.

7. Fingolimod (Gilenya) is an oral DMT that requires first-dose observation for at least 6 hours to monitor for what adverse effect?

• a. Hypertension
• b. Tachycardia
• c. Bradycardia
• d. Anaphylaxis

Answer: c. Bradycardia

8. Natalizumab (Tysabri) is a highly effective monoclonal antibody for MS, but its use is restricted due to a black box warning for:

• a. Severe liver injury
• b. Progressive Multifocal Leukoencephalopathy (PML)
• c. Cardiotoxicity
• d. Agranulocytosis

Answer: b. Progressive Multifocal Leukoencephalopathy (PML)

9. Which of the following is an oral DMT that works by activating the Nrf2 antioxidant response pathway?

• a. Teriflunomide
• b. Fingolimod
• c. Dimethyl fumarate
• d. Cladribine

Answer: c. Dimethyl fumarate

10. A common and bothersome side effect of dimethyl fumarate upon initiation is:

• a. Drowsiness
• b. Flushing and gastrointestinal upset
• c. Bradycardia
• d. Hair loss

Answer: b. Flushing and gastrointestinal upset

11. Ocrelizumab (Ocrevus) is a monoclonal antibody that targets which type of immune cell, making it effective for both relapsing and primary progressive MS?

• a. T-cells
• b. Neutrophils
• c. CD20-positive B-cells
• d. Macrophages

Answer: c. CD20-positive B-cells

12. Before initiating many DMTs for MS, patients must be screened for:

• a. High cholesterol
• b. Diabetes
• c. Latent tuberculosis and viral hepatitis.
• d. Gout

Answer: c. Latent tuberculosis and viral hepatitis.

13. A patient on an immunosuppressive DMT for MS should be counseled against receiving which type of vaccine?

• a. Inactivated influenza vaccine
• b. Tetanus toxoid vaccine
• c. Live attenuated vaccines (e.g., MMR, varicella)
• d. Pneumococcal polysaccharide vaccine

Answer: c. Live attenuated vaccines (e.g., MMR, varicella)

14. A pharmacist’s role in the management of MS includes:

• a. Counseling on proper injection technique for injectable DMTs.
• b. Managing the side effects of medications.
• c. Screening for drug interactions.
• d. All of the above.

Answer: d. All of the above.

15. Dalfampridine is a potassium channel blocker used in MS to:

• a. Reduce the number of relapses.
• b. Improve walking ability.
• c. Treat depression associated with MS.
• d. Slow disease progression.

Answer: b. Improve walking ability.

16. Which of the following is a common symptom of MS?

• a. Fatigue
• b. Numbness or tingling
• c. Spasticity
• d. All of the above

Answer: d. All of the above.

17. Teriflunomide is an oral DMT that carries a black box warning for:

• a. Cardiotoxicity
• b. Hepatotoxicity and teratogenicity
• c. PML
• d. Severe rash

Answer: b. Hepatotoxicity and teratogenicity

18. What is the mechanism of action for sphingosine 1-phosphate (S1P) receptor modulators like fingolimod and siponimod?

• a. They deplete B-cells from the circulation.
• b. They sequester lymphocytes in the lymph nodes, preventing their entry into the CNS.
• c. They inhibit pyrimidine synthesis.
• d. They block potassium channels.

Answer: b. They sequester lymphocytes in the lymph nodes, preventing their entry into the CNS.

19. Which oral DMT requires pharmacogenomic testing for the CYP2C9 genotype before initiation?

• a. Fingolimod
• b. Siponimod
• c. Teriflunomide
• d. Dimethyl fumarate

Answer: b. Siponimod

20. A key counseling point for a patient starting an interferon-beta product is to:

• a. Take it with food to reduce GI upset.
• b. Pre-treat with an analgesic/antipyretic like ibuprofen to reduce flu-like symptoms.
• c. Expect immediate improvement in symptoms.
• d. Apply a heating pad to the injection site.

Answer: b. Pre-treat with an analgesic/antipyretic like ibuprofen to reduce flu-like symptoms.

21. Alemtuzumab is a high-efficacy infusion therapy for MS that can cause what significant long-term risk?

• a. The development of secondary autoimmune disorders.
• b. Chronic kidney disease.
• c. Severe weight gain.
• d. Permanent hair loss.

Answer: a. The development of secondary autoimmune disorders.

22. The choice of a specific DMT for a patient with MS is based on:

• a. Disease activity and severity.
• b. The medication’s side effect profile.
• c. Patient preference and lifestyle.
• d. All of the above.

Answer: d. All of the above.

23. A patient taking teriflunomide who wishes to become pregnant must undergo what procedure?

• a. A washout period with plasmapheresis.
• b. An accelerated drug elimination procedure with cholestyramine or activated charcoal.
• c. A 2-year waiting period after stopping the drug.
• d. No special procedure is needed.

Answer: b. An accelerated drug elimination procedure with cholestyramine or activated charcoal.

24. The management of MS requires a multidisciplinary approach.

• a. True
• b. False

Answer: a. True

25. A pharmacist counseling on a self-injectable DMT should always demonstrate proper injection technique and discuss:

• a. Site rotation to prevent injection site reactions.
• b. Proper disposal of needles and syringes.
• c. Both a and b.
• d. Neither a nor b.

Answer: c. Both a and b.

26. Which of the following is NOT a disease-modifying therapy for MS?

• a. Natalizumab
• b. Ocrelizumab
• c. Glatiramer acetate
• d. Baclofen

Answer: d. Baclofen

27. Baclofen and tizanidine are medications used in MS to manage:

• a. Fatigue
• b. Depression
• c. Spasticity
• d. Neuropathic pain

Answer: c. Spasticity

28. The term “demyelination” refers to the destruction of:

• a. The axon of a neuron.
• b. The cell body of a neuron.
• c. The myelin sheath that insulates a neuron.
• d. The synapse between two neurons.

Answer: c. The myelin sheath that insulates a neuron.

29. Ofatumumab and ublituximab are newer monoclonal antibodies for MS that target CD20 and are administered via which route?

• a. Oral
• b. Intravenous
• c. Subcutaneous
• d. Intramuscular

Answer: c. Subcutaneous

30. The overall goal of MS pharmacotherapy is to:

• a. Manage symptoms and modify the disease course to improve long-term outcomes.
• b. Cure the disease within 5 years.
• c. Use the most potent immunosuppressant for every patient.
• d. Avoid all medications due to their side effects.

Answer: a. Manage symptoms and modify the disease course to improve long-term outcomes.

31. A patient on dimethyl fumarate should have which lab parameter monitored regularly?

• a. Serum creatinine
• b. Liver function tests
• c. Complete blood count (CBC) for lymphopenia.
• d. Serum potassium

Answer: c. Complete blood count (CBC) for lymphopenia.

32. A patient experiences Lhermitte’s sign. This is an electrical shock-like sensation that runs down the back and limbs upon flexion of the neck, and it is a symptom of:

• a. Parkinson’s disease
• b. Multiple Sclerosis
• c. Alzheimer’s disease
• d. ALS

Answer: b. Multiple Sclerosis

33. The management of MS involves treating both relapses and the underlying disease progression, as well as managing symptoms.

• a. True
• b. False

Answer: a. True

34. Which of the following is a common symptom managed in MS?

• a. Fatigue
• b. Bladder dysfunction
• c. Neuropathic pain
• d. All of the above

Answer: d. All of the above

35. A pharmacist is a key resource for patients with MS due to:

• a. The complexity of the medication regimens.
• b. The high cost of DMTs and the need for assistance with access.
• c. The need for ongoing counseling and adherence support.
• d. All of the above.

Answer: d. All of the above.

36. A key part of the diagnostic criteria for MS is the demonstration of dissemination of lesions in:

• a. Time and space.
• b. The peripheral nervous system only.
• c. The liver and kidneys.
• d. The bloodstream.

Answer: a. Time and space.

37. Cladribine is an oral DMT for MS with a unique dosing schedule that involves:

• a. Daily administration for life.
• b. Two short treatment courses over two years.
• c. A once-weekly injection.
• d. A monthly infusion.

Answer: b. Two short treatment courses over two years.

38. The “first-line” DMTs for MS traditionally included which agents due to their long-term safety data?

• a. Natalizumab and Alemtuzumab
• b. Interferons and Glatiramer acetate
• c. Fingolimod and Teriflunomide
• d. Ocrelizumab and Rituximab

Answer: b. Interferons and Glatiramer acetate

39. A patient taking glatiramer acetate should be counseled about the possibility of what post-injection reaction?

• a. Flu-like symptoms
• b. A transient reaction of flushing, chest tightness, and anxiety that is self-limiting.
• c. Severe nausea and vomiting.
• d. Bradycardia.

Answer: b. A transient reaction of flushing, chest tightness, and anxiety that is self-limiting.

40. A key counseling point for any patient on a potent immunosuppressive DMT is:

• a. To report any signs or symptoms of an infection immediately.
• b. That they can stop the medication at any time.
• c. That they no longer need to worry about relapses.
• d. To get all of their live vaccines.

Answer: a. To report any signs or symptoms of an infection immediately.

41. The treatment of MS has shifted towards:

• a. Using less effective therapies first.
• b. A more personalized approach, considering early use of higher-efficacy therapies for patients with more active disease.
• c. Using only injectable medications.
• d. Using only oral medications.

Answer: b. A more personalized approach, considering early use of higher-efficacy therapies for patients with more active disease.

42. Which of the following is NOT a primary goal of MS management?

• a. To reduce relapse frequency.
• b. To slow disability progression.
• c. To manage symptoms.
• d. To completely regenerate damaged myelin.

Answer: d. To completely regenerate damaged myelin.

43. A pharmacist’s role includes helping patients manage the financial toxicity of expensive MS medications by connecting them with assistance programs.

• a. True
• b. False

Answer: a. True

44. The presence of oligoclonal bands in the cerebrospinal fluid (CSF) is a finding that supports a diagnosis of:

• a. Parkinson’s disease
• b. Alzheimer’s disease
• c. Multiple Sclerosis
• d. ALS

Answer: c. Multiple Sclerosis

45. Which of the following is a common challenge in MS care?

• a. Adherence to long-term injectable therapies.
• b. Managing the invisible symptom of fatigue.
• c. The high cost of medications.
• d. All of the above.

Answer: d. All of the above.

46. “Shared decision-making” between the patient and provider is critical when choosing a DMT for MS.

• a. True
• b. False

Answer: a. True

47. A patient with MS reports worsening symptoms when they have a fever from a minor infection. This phenomenon is known as:

• a. A true MS relapse.
• b. Uhthoff’s phenomenon.
• c. Lhermitte’s sign.
• d. A dyskinesia.

Answer: b. Uhthoff’s phenomenon.

48. The management of MS requires a holistic approach that addresses:

• a. The disease process.
• b. Symptom management.
• c. The patient’s mental and emotional well-being.
• d. All of the above.

Answer: d. All of the above.

49. The overall landscape of MS treatment has:

• a. Remained unchanged for the past 30 years.
• b. Evolved dramatically with the introduction of numerous oral and high-efficacy infusion therapies.
• c. Shifted to using only corticosteroids.
• d. Become less complex over time.

Answer: b. Evolved dramatically with the introduction of numerous oral and high-efficacy infusion therapies.

50. The ultimate goal of a pharmacist learning about Multiple Sclerosis is to:

• a. Be a knowledgeable and compassionate member of the healthcare team who can help patients navigate complex therapies to improve their quality of life.
• b. Memorize every available DMT.
• c. Pass the neurology exam.
• d. Be able to diagnose MS.

Answer: a. Be a knowledgeable and compassionate member of the healthcare team who can help patients navigate complex therapies to improve their quality of life.