Clinic Note Template for Multiple Sclerosis
Interim: ***
- Any relapse since last clinic visit: ***
- Symptoms related to DMT: ***
- Symptoms related to chronic MS: *** spasticity, gait impairment, numbness, tingling, fatigue, depression, memory impairment
HPI:
Initial Diangnosis:
- Age:
- Symptom:
- Workup:
Relapses:
- Year: Presentation, Treatment
- ***: ***
Last Workup:
- MRI brain: ***
- MRI Spine: ***
- CSF: ***
Routine workup for DMT: ***
| Medication (Generic / Brand) | Initial Workup | Follow-Up Monitoring |
|---|---|---|
| Fingolimod (Gilenya) | CBC, EKG, VZV IgG, ophthalmology (macular edema screen) | CBC, LFT every 6 months |
| Siponimod (Mayzent) | CYP2C9 genotype, CBC, LFT, ophthalmology | LFTs, eye exam, CBC periodically |
| Ozanimod (Zeposia) | CBC, LFT, ophthalmology | CBC, LFT periodically |
| Ponesimod (Ponvory) | CBC, LFT, pulmonary function tests | CBC, LFT periodically |
| Dimethyl Fumarate (Tecfidera) | CBC (lymphs >1000), JC virus Ab | CBC every 6 months |
| Diroximel Fumarate (Vumerity) | CBC | CBC every 6 months |
| Teriflunomide (Aubagio) | LFT, pregnancy test | LFT monthly, BP each visit |
| Cladribine (Mavenclad) | CBC, pregnancy test, malignancy screen | CBC before each yearly course |
| Interferon beta-1a/1b (Avonex, Rebif, Betaseron) | CBC, LFT, depression screen | CBC, LFT periodically |
| Peginterferon beta-1a (Plegridy) | CBC, LFT | CBC, LFT periodically |
| Glatiramer acetate (Copaxone) | None | Minimal or none |
| Natalizumab (Tysabri) | JC virus Ab with index | JC virus Ab every 6 months, monitor for PML |
| Ocrelizumab (Ocrevus) | CBC, Hepatitis B/C, infections screen | CBC, infections screen every 6 months |
| Rituximab (off-label) | CBC, Hep B/C, infections screen | CBC, infection screening every 6 months |
| Alemtuzumab (Lemtrada) | CBC, CK, TSH, urinalysis, VZV status, skin exam | CBC, CK, urinalysis monthly; TSH every 3 months |
| Mitoxantrone (rare use) | Cardiac echo, CBC | LVEF before each dose, CBC |
| Ublituximab-xiiy (Briumvi) | CBC, infections screen | CBC, infections screen every 6 months |