{"id":643,"date":"2020-02-17T20:42:08","date_gmt":"2020-02-17T15:12:08","guid":{"rendered":"https:\/\/medicineplexus.com\/?p=643"},"modified":"2020-02-17T20:42:08","modified_gmt":"2020-02-17T15:12:08","slug":"multiple-sclerosis","status":"publish","type":"post","link":"https:\/\/medicineplexus.com\/multiple-sclerosis\/","title":{"rendered":"Multiple Sclerosis"},"content":{"rendered":"\n<p><strong>Multiple Sclerosis<\/strong><\/p>\n\n\n\n<ul><li>Autoimmune disease, <strong>mediated by myelin-specific CD4 T cells<\/strong><\/li><li>Characterized by:<ul><li>Inflammation<\/li><\/ul><ul><li>Demyelination<\/li><\/ul><ul><li>Gliosis (scarring)<\/li><\/ul><ul><li>Neuronal loss<\/li><\/ul><\/li><li>Twenty&nbsp; years after diagnosis:<ul><li>&gt; 80% patients <strong>functional limitations.<\/strong><\/li><\/ul><ul><li><strong>50-60% require assistance to walk.<\/strong> (EDSS&gt;6)<\/li><\/ul><ul><li>70% are limited in ability to perform major activities.<\/li><\/ul><\/li><\/ul>\n\n\n\n<ul><li>Cause\u00a0 unknown, but believed to be multi-factorial.<\/li><li>Develops between the 20-40 year<\/li><li>Prevalence \u00e0 3\/100,000 for India<\/li><li>Types of MS:<ul><li><strong>RRMS- Relapsing-Remitting MS\u00a0 &#8211; most common 85%<\/strong><\/li><li>PPMS &#8211; Primary-Progressive MS<\/li><li>SPMS &#8211; Secondary-Progressive MS<\/li><li>PRMS &#8211; Progressive-Relapsing MS<\/li><\/ul><\/li><\/ul>\n\n\n\n<figure class=\"wp-block-image size-large\"><img loading=\"lazy\" decoding=\"async\" width=\"428\" height=\"318\" src=\"https:\/\/medicineplexus.com\/wp-content\/uploads\/2020\/02\/image-243.png?w=428\" alt=\"\" class=\"wp-image-680\" srcset=\"https:\/\/medicineplexus.com\/wp-content\/uploads\/2020\/02\/image-243.png 428w, https:\/\/medicineplexus.com\/wp-content\/uploads\/2020\/02\/image-243-300x223.png 300w\" sizes=\"(max-width: 428px) 100vw, 428px\" \/><\/figure>\n\n\n\n<p><strong>Pathophysiology<\/strong><\/p>\n\n\n\n<ul><li>initial important event in MS occurs when autoreactive CD4+ T helper cells are activated in the periphery.<\/li><li>they secrete cytokines that damage the oligodendroglial cells. Inside the brain, T cells and accompanying macrophages and microglial cells release osteopontin (OPN), interleukin-23 (IL-23), IFN-&nbsp;and tumour-necrosis factor (TNF), all of which damage the myelin sheath.<\/li><li>Concomitantly, B cells (plasma cells) produce myelin-specific antibodies<\/li><li>Lymphocytes recognize myelin as foreign and attack.<\/li><li>Triggers inflammatory processes<\/li><li>Remyelination<\/li><li><strong>Newly-formed myelin sheaths are thinner and often not as effective as the original ones.<\/strong><\/li><li><strong>Repeated attacks lead to scar-like plaque up around the damaged axons<\/strong><\/li><li>Axons&nbsp; are damaged by the attacks<\/li><li>the brain is unable to compensate, due to neuroplasticity.<\/li><\/ul>\n\n\n\n<p><strong>Clinical features<\/strong><\/p>\n\n\n\n<ul><li>Spasticity<\/li><li>Ataxia \/ tremors<\/li><li>Cognitive decline<\/li><li>Sensory loss (tingling, numbness)<\/li><li>Fatigue, Pain, Bowel \/Bladder dysfunction, Depression<\/li><\/ul>\n\n\n\n<p><strong>Diagnostic Tools:<\/strong><\/p>\n\n\n\n<ul><li>-McDonald criteria<\/li><li>-MRI<\/li><li>-CSF \u2013 Oligoclonal bands<\/li><\/ul>\n\n\n\n<p><strong>Goal of Treatment<\/strong><\/p>\n\n\n\n<ul><li>No known definitive cure for multiple sclerosis.<\/li><li>Treatment is aimed at-<\/li><li>&nbsp;&nbsp;&nbsp;-Returning function after an attack,<\/li><li>&nbsp;&nbsp;&nbsp;-Preventing new attacks,<\/li><li>&nbsp;&nbsp;&nbsp;-Preventing disability.<\/li><\/ul>\n\n\n\n<p><strong>Treatment of acute attack<\/strong><\/p>\n\n\n\n<p><strong><u>Glucocorticoids:<\/u><\/strong><strong><\/strong><\/p>\n\n\n\n<ul><li>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;-reduces severity of attack<\/li><li>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&#8211; reduces duration of attack<\/li><li>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&#8211; long term benefits?<\/li><li>Dose: 500-1000mg\/d for 3-5 days methyl prednisolone, taper with 60-80 mg\/d oral dose over 2wks<\/li><li>ADR: fluid retention, K+ loss, wt gain, acne, emotional liability gastric disturbances<\/li><\/ul>\n\n\n\n<p><strong><u>Plasma exchange: <\/u><\/strong><strong><\/strong><\/p>\n\n\n\n<ul><li>&nbsp;&nbsp;&nbsp;&#8211; benefits patients with fulminant attacks<\/li><li>&nbsp;&nbsp;&nbsp;-pts not responding to steroids<\/li><li>&nbsp;&nbsp;&nbsp;&#8211; high cost<\/li><li>Dose: 7 exchanges<\/li><\/ul>\n\n\n\n<p><strong>Disease modifying agents<\/strong><\/p>\n\n\n\n<figure class=\"wp-block-image size-large\"><img loading=\"lazy\" decoding=\"async\" width=\"505\" height=\"335\" src=\"https:\/\/medicineplexus.com\/wp-content\/uploads\/2020\/02\/image-244.png?w=505\" alt=\"\" class=\"wp-image-681\" srcset=\"https:\/\/medicineplexus.com\/wp-content\/uploads\/2020\/02\/image-244.png 505w, https:\/\/medicineplexus.com\/wp-content\/uploads\/2020\/02\/image-244-300x199.png 300w\" sizes=\"(max-width: 505px) 100vw, 505px\" \/><\/figure>\n\n\n\n<p><strong>Interferons<\/strong><strong><\/strong><\/p>\n\n\n\n<ul><li>Derived from human cytokines<\/li><li>Interferon \u03b2 1a, Interferon \u03b2 1b:<\/li><li>First FDA approved for relapsing forms of secondary progressive MS.<\/li><\/ul>\n\n\n\n<figure class=\"wp-block-image size-large\"><img loading=\"lazy\" decoding=\"async\" width=\"223\" height=\"317\" src=\"https:\/\/medicineplexus.com\/wp-content\/uploads\/2020\/02\/image-245.png?w=223\" alt=\"\" class=\"wp-image-682\" srcset=\"https:\/\/medicineplexus.com\/wp-content\/uploads\/2020\/02\/image-245.png 223w, https:\/\/medicineplexus.com\/wp-content\/uploads\/2020\/02\/image-245-211x300.png 211w\" sizes=\"(max-width: 223px) 100vw, 223px\" \/><\/figure>\n\n\n\n<figure class=\"wp-block-image size-large\"><img loading=\"lazy\" decoding=\"async\" width=\"285\" height=\"296\" src=\"https:\/\/medicineplexus.com\/wp-content\/uploads\/2020\/02\/image-246.png?w=285\" alt=\"\" class=\"wp-image-683\" \/><\/figure>\n\n\n\n<figure class=\"wp-block-table\"><table><tbody><tr><td>Periphery: Prevents upregulation of MHC II on APCInhibits clonal expansion of TH1 Apoptosis of T cellsDown regulation of co-stimulatory (CD40) &nbsp;&nbsp;&nbsp; &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; molecules Down regulation of adhesion molecules &nbsp;<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<figure class=\"wp-block-table\"><table><tbody><tr><td><strong>BBB:<\/strong> conversion of cell-associated VCAM-1 into soluble VCAM-1Reduced chemokine &amp; CCR5 receptor expressionReduced T cell migration by inhibition of T cell MMPs &nbsp;<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<p><strong>&nbsp;<\/strong><\/p>\n\n\n\n<p><strong>Effects and Efficacy<\/strong><\/p>\n\n\n\n<ul><li>Reduce severity of relapses &amp; their frequency by about 1\/3rd.<\/li><li>Fewer lesions on MRI.<\/li><li>May reduce the chance of disability in people with relapsing-remitting MS.<\/li><li>May help slow the progression of cognitive impairment.<\/li><li>Long term efficacy unknown<\/li><li>Higher doses of INF\u03b21b have shown good results but chances of neutralising antibodies<\/li><\/ul>\n\n\n\n<p><strong>ADR<\/strong><\/p>\n\n\n\n<ul><li>Injection site reactions<\/li><li>Flu-like symptom complex<\/li><li>Elevated liver enzymes, alteration in blood count, hypersensitivity reactions, neutralising antibodies<\/li><\/ul>\n\n\n\n<p><strong>Glatiramer acetate<\/strong><\/p>\n\n\n\n<ul><li>Polypeptides with the amino acids glutamate, lysine, alanine tyrosine<\/li><\/ul>\n\n\n\n<p>Action<\/p>\n\n\n\n<ul><li>&nbsp;-Affects antigen presentation<\/li><li>&nbsp;-Th1 to Th2 Shift<\/li><li>&nbsp;-Induces neurotropic factors like brain derived neurotropic factor (BDNF)<\/li><li>&nbsp;&#8211; Displaces MBP by binding to MHC molecule<\/li><\/ul>\n\n\n\n<p>S\/E<\/p>\n\n\n\n<ul><li>-Well tolerated<\/li><li><strong>-Lipoatrophy permanent and is perhaps most severe S\/E<\/strong><\/li><li>s.c. injections of 20 mg OD<\/li><li>JAN 2014 Higher dose &amp; lower frequency regimen approved &#8212; <strong>40 mg sc 3 times\/week GA at 12 months<\/strong><\/li><\/ul>\n\n\n\n<p><strong>Mitoxantrone<\/strong><\/p>\n\n\n\n<ul><li>Potent inhibitor of topoisomerase II<\/li><li>Approved for SPMS, PRMS, &amp; worsening RRMS \u00e0 <strong>broadest indication in MS but not used as 1<sup>st<\/sup> line because of cardiotoxicity. <\/strong><strong><\/strong><\/li><li>Action<\/li><li>&nbsp;&nbsp;-intercalates into DNA through hydrogen bonding, crosslinks and strand breaks.<\/li><li>&nbsp;&#8211;<strong>Induces apoptosis of active immune cells<\/strong><\/li><li>&nbsp;<strong>-Inhibits activation of several pro-inflammatory cells and macrophages.<\/strong><\/li><li>S\/E<\/li><li>-Rare but possibility of treatment related leukemia<\/li><li>&#8211;<strong>Dose-dependent cardiotoxicity<\/strong><strong><\/strong><\/li><\/ul>\n\n\n\n<p><strong>Natalizumab<\/strong><\/p>\n\n\n\n<ul><li>Approved for RRMS as monotherapy in 2006<\/li><li>Action<\/li><li>-Selective adhesion molecule inhibitor (SAM)<\/li><li>-Binds to and Blocks \u03b14\u03b21 integrin (VLA4)<\/li><li>-Prevents transendothelial migration of activated&nbsp;&nbsp; leukocytes from small venules into CNS<\/li><li>Dose &#8211; 300 mg infused i.v. over one hour, every four weeks.<\/li><li>S\/E<\/li><li>&nbsp;&nbsp;<strong>progressive multifocal leukoencephalopathy (PML) if<\/strong><strong><\/strong><\/li><li><strong>&nbsp;&nbsp;&nbsp;&nbsp;&#8211; &gt; 2 years treatment<\/strong><\/li><li>&nbsp;&nbsp;&nbsp;&#8211;&nbsp; Prior treatment with an immunosuppressant<\/li><li>&nbsp;&nbsp;&nbsp;&#8211;&nbsp; The presence of anti-JCV antibodies<\/li><li>withdrawal from the market in 2005; however, it was reapproved in 2006 by the&nbsp;FDA for commercialization under a special restricted distribution program<\/li><\/ul>\n\n\n\n<ul><li><strong>Fingolimod<\/strong><\/li><li><strong>First orally administered, disease-modifying drug approved by the FDA 2010<\/strong><\/li><li>Sphingosine 1-phosphate receptor (<strong>S1PR) modulator<\/strong><\/li><li>Dose -0.5 mg OD<\/li><li>oral sphingosine 1-phosphate receptor (S1PR) modulator that subsequent to its phosphorylation binds with high affinity to S1PR<\/li><li>leads to an internalization and degradation of the receptor in different tissues and cell types, including lymphocytes.<\/li><li>As a consequence, fingolimod inhibits the ability of autoreactive lymphocytes to regress from the lymph nodes towards the CNS.<\/li><li><strong>Bradycardia-<\/strong>observed for 6 hours after the first dose.<\/li><li><strong>all patients started on fingolimod must be monitored for at least 6 hours following the first dose.<\/strong><\/li><li>Increase the risk of infection (Influenza), and macular oedema can occur with or without visual symptoms<\/li><\/ul>\n\n\n\n<p><strong>Teriflunomide<\/strong><\/p>\n\n\n\n<ul><li>Active metabolite of Leflunomide, Immunomodulating drug.<\/li><li>Approved by FDA 2012<\/li><li>Exerts a cytostatic effect on proliferating B and T.<\/li><\/ul>\n\n\n\n<ul><li>reversibly inhibits the de novo synthesis of pyrimidine by blocking the mitochondrial enzyme dihydro-orotate dehydrogenase (DHODH).<\/li><li>By inhibiting DHODH and reducing DNA synthesis, teriflunomide exerts a cytostatic effect on proliferating B and T cells.<\/li><li>induce Th-2-mediated anti-inflammatory cytokine activation.<\/li><li><strong>black box warning for the risks of hepatotoxicity and teratogenicity<\/strong><\/li><\/ul>\n\n\n\n<figure class=\"wp-block-image size-large\"><img loading=\"lazy\" decoding=\"async\" width=\"444\" height=\"150\" src=\"https:\/\/medicineplexus.com\/wp-content\/uploads\/2020\/02\/image-247.png?w=444\" alt=\"\" class=\"wp-image-684\" srcset=\"https:\/\/medicineplexus.com\/wp-content\/uploads\/2020\/02\/image-247.png 444w, https:\/\/medicineplexus.com\/wp-content\/uploads\/2020\/02\/image-247-300x101.png 300w\" sizes=\"(max-width: 444px) 100vw, 444px\" \/><\/figure>\n\n\n\n<p><strong>Dimethyl Fumarate<\/strong><\/p>\n\n\n\n<ul><li>Orally administered immune modulator<\/li><li>Approved in 2013 in US for RRMS<\/li><li>Mechanism of action<\/li><li>&nbsp;&nbsp;-Shift of proinflammatory immune reaction to a Th2-like&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<br>&nbsp;&nbsp; -Promote apoptosis of CD4 &amp; CD8 T cells.<\/li><li>S\/E \u00e0 flushing, abdominal pain, diarrhea, and nausea.<\/li><li><strong>Like Natalizumab, also a\/w PML<\/strong><\/li><\/ul>\n\n\n\n<p><strong>Alemtuzumab<\/strong><\/p>\n\n\n\n<ul><li>Humanized monoclonal <strong>antibody targeting CD52,<\/strong> a broadly expressed cell\u2013surface molecule on immune cells.<\/li><li><strong>Rapid, long-lasting removal of lymphocyte populations from the circulation.<\/strong><\/li><li>Conferred neuroprotective effects.<\/li><li>Approved in 2014<\/li><li>Dose : IV infusion<\/li><li>&nbsp;-1<sup>st<\/sup>&nbsp; course: 12 mg\/day on 5 consecutive days.<\/li><li>&nbsp;-2<sup>nd<\/sup>&nbsp; course: 12 mg\/day on 3 consecutive days 12 months after first&nbsp; treatment course<\/li><li>Infusion-related reactions (headache, rash, nausea, fever, itching, insomnia, and fatigue).<\/li><li>Infections (i.e., upper respiratory and urinary tract infections, sinusitis, and herpes simplex infections).<\/li><\/ul>\n\n\n\n<p><strong>Daclizumab<\/strong><\/p>\n\n\n\n<ul><li>Humanized monoclonal antibody <strong>binds to the high-affinity interleukin-2 (IL-2) receptor subunit (CD25). <\/strong><strong><\/strong><\/li><li>Approved by FDA IN 2016 for RRMS<\/li><li>Reserved for inadequate response to two or more drugs indicated for the treatment of MS<\/li><li>Dose -150 mg once monthly s.c.<\/li><li>S\/E&nbsp;&nbsp;&nbsp; -Hypersensitivity Reactions, Infections<\/li><li>&nbsp;&nbsp;&nbsp;&nbsp;-Depression and Suicide<\/li><li>C\/I- Pre-existing hepatic disease or hepatic impairment<\/li><\/ul>\n\n\n\n<p><strong>Ocrelizumab<\/strong><\/p>\n\n\n\n<ul><li><strong>Humanized anti-CD20 monoclonal antibody.<\/strong><\/li><li>Approval march 2017 in US<\/li><li>Treatment of relapsing MS or PPMS<\/li><li>Mechanism of action<\/li><li>&nbsp;&nbsp;&nbsp;-Kills B cells by causing antibody-dependent cell-mediated cytotoxicity<\/li><li>Dose -Given as parental infusion 600 mg every 6 months<\/li><li>Infusion reactions including itchy skin, rash, flushing, throat and mouth irritation, fever, fatigue<\/li><li>Increased risk of infections including respiratory tract infection and herpes infection<\/li><\/ul>\n\n\n\n<p><strong>Dalfampridine<\/strong><\/p>\n\n\n\n<ul><li><strong>First drug approved by FDA- improve walking in patients.<\/strong><\/li><li>Tablets sustained-release formulation of 4-aminopyridine.<\/li><li>Mechanism of action<\/li><li><strong>-Blocks K+ channels on the surface of nerve fibers<\/strong>.<\/li><li>-Improve the conduction of nerve signals in nerve fibers whose insulating&nbsp; myelin coating damaged by MS.<\/li><li>Maximum recommended dosage is one 10-mg tablet twice daily, with or without food.<\/li><li><strong>ADEs<\/strong><\/li><li>Higher dose cause seizures<\/li><li>Urinary tract infections.<\/li><li>Insomnia, dizziness, headache, nausea, weakness<\/li><li>Back pain, balance disorders, swelling in the nose or throat.<\/li><li>Tingling, or itching of the skin.<\/li><\/ul>\n\n\n\n<p><strong>Treatment algorithm<\/strong><\/p>\n\n\n\n<figure class=\"wp-block-image size-large\"><img loading=\"lazy\" decoding=\"async\" width=\"602\" height=\"255\" src=\"https:\/\/medicineplexus.com\/wp-content\/uploads\/2020\/02\/image-248.png?w=602\" alt=\"\" class=\"wp-image-685\" srcset=\"https:\/\/medicineplexus.com\/wp-content\/uploads\/2020\/02\/image-248.png 602w, https:\/\/medicineplexus.com\/wp-content\/uploads\/2020\/02\/image-248-300x127.png 300w\" sizes=\"(max-width: 602px) 100vw, 602px\" \/><\/figure>\n\n\n\n<p><strong>Cladribine \u2013 approved in March 2019<\/strong><\/p>\n\n\n\n<ul><li>purine antimetabolite.<\/li><\/ul>\n\n\n\n<ul><li>mechanism &#8211; not been fully elucidated but is thought to involve cytotoxic effects on B and T lymphocytes through impairment of DNA synthesis, resulting in depletion of lymphocytes.<\/li><\/ul>\n\n\n\n<ul><li><strong>indicated for the treatment of relapsing forms of multiple sclerosis (MS), to include relapsing-remitting disease and active secondary progressive disease, in adults.<\/strong><\/li><\/ul>\n\n\n\n<ul><li>Because of its safety profile \u00e0 generally recommended for patients who have had an inadequate response to, or are unable to tolerate, an alternate drug indicated for the treatment of MS.<\/li><\/ul>\n\n\n\n<p><strong>Black Box Warning:<\/strong><\/p>\n\n\n\n<ul><li>may increase the <strong>risk of malignancy.<\/strong><\/li><li>contraindicated in patients with current malignancy; evaluate the benefits and risks on an individual basis for patients with prior or increased risk of malignancy.<\/li><li><strong>Risk of Teratogenicity:<\/strong> contraindicated for use in pregnant women and in women and men of reproductive potential who do not plan to use effective contraception because of the risk of fetal harm.<\/li><\/ul>\n\n\n\n<p><strong>Siponimod<\/strong><\/p>\n\n\n\n<ul><li><strong>Approved March 2019<\/strong><\/li><li>sphingosine1-phosphate receptor modulator.<\/li><li>specifically indicated for the treatment of relapsing forms of multiple sclerosis (MS), to include clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease, in adults.<\/li><\/ul>\n","protected":false},"excerpt":{"rendered":"<p>Multiple Sclerosis Autoimmune disease, mediated by myelin-specific CD4 T cells Characterized by: Inflammation Demyelination Gliosis (scarring) Neuronal loss Twenty&nbsp; years after diagnosis: &gt; 80% patients functional limitations. 50-60% require assistance to walk. (EDSS&gt;6) 70% are limited in ability to perform major activities. Cause\u00a0 unknown, but believed to be multi-factorial. Develops between the 20-40 year Prevalence[&#8230;]\n","protected":false},"author":3,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_seopress_robots_primary_cat":"","_seopress_titles_title":"","_seopress_titles_desc":"","_seopress_robots_index":"","footnotes":""},"categories":[3],"tags":[],"_links":{"self":[{"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/posts\/643"}],"collection":[{"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/comments?post=643"}],"version-history":[{"count":0,"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/posts\/643\/revisions"}],"wp:attachment":[{"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/media?parent=643"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/categories?post=643"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/tags?post=643"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}