Real-time sonography is a relatively simple and inexpensive method of accurately measuring muscle thickness as long as the operator adheres to a strict imaging protocol and avoids excessive pressure with the transducer.

58C M E C h o i c e w w w . c c n s . o r g Multiple sclerosis (MS) is a chronic inflammatory demyelinating disease of the central nervous system. The most common form of the disease is relapsing-remitting MS (RRMS) where patients experience multiple exacerbations, or "relapses" over time. There are a number of proven treatments available for RRMS, one of them being glatiramer acetate. Given on a daily basis by subcutaneous injection, it has shown to reduce annualized relapse rate by 32%. 1 Despite its claimed excellent adverse event profile 1 there is increasing concern with skin reactions and the occurrence of lipoatrophy with the use of glatiramer acetate. 2 As described in the 1995 pivotal trial, "The most commonly recognized adverse event was a localized ABSTRACT: Background: Patients with relapsing remitting multiple sclerosis on the disease modifying therapy of glatiramer acetate may be experiencing an adverse reaction of lipoatrophy at the sites of their subcutaneous injections. The purpose of this study was to complete a full examination of the injection site areas for users of glatiramer acetate, and to examine the relationship between lipoatrophy and patient characteristics. Methods: Glatiramer acetate users were identified by means of chart review. Over six months, during regular clinic appointments, assessment included a full examination of injection site areas including visual inspection and manual palpation. Additional patient and clinical characteristics were obtained by means of chart review and patient questioning. Results: Seventy-six patients had been or were current users of glatiramer acetate. Of these, 34 (45%) had evidence of lipoatrophy in at least one injection site area. All were female, and five had severe, nine had moderate and 20 had mild lipoatrophy. In some cases, lipoatrophy occurred within months of therapy initiation. Case reviews are included for five of the 34 patients, along with photographs of the lipoatrophy, a magnetic resonance image and comments on skin biopsies. Conclusions: Prevalence of lipoatrophy was much higher than expected. Possible reasons for this adverse reaction are explored and suggested treatment recommendations are reviewed. Lipoatrophy can be very disfiguring and is thought to be permanent, and the psychological impact can be significant. It is, therefore, important that patients be aware of the possibility of lipoatrophy, be able to identify it and discontinue injecting in areas where it is identified. RÉSUMÉ: La lipoatrophie chez les patients atteints de sclérose en plaques traités par l'acétate de glatiramère. Introduction: Les patients atteints de la forme rémittente de sclérose en plaques qui prennent de l'acétate de glatiramère, peuvent avoir de la lipoatrophie aux points d'injections souscutanées comme effet secondaire du médicament. Le but de cette étude était de procéder à un examen complet des points d'injections chez les utilisateurs d'acétate de glatiramère et d'examiner la relation entre la lipoatrophie et les caractéristiques des patients. ...

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