Ask the Doctor: Treatment Questions and Diagnostic Issues
By Dr. Jack Burks
MSAA’s Chief Medical Consultant
Q: If someone has lesions on his or her spine, can Tysabri possibly help with relapsing-remitting MS? I have read that Tysabri only helps to combat brain inflammation. Please let me know your opinion.
A: Fortunately, this information you read is not accurate. Tysabri® (natalizumab) works well throughout the brain and spine to help reduce inflammation. Its mechanism of action is to reduce the ability of destructive (pro-inflammatory) lymphocytes from crossing the blood-brain barrier into the brain and spinal cord, where they become misdirected and attack healthy myelin and nerves. Lymphocytes are a type of white blood cell found in the immune system, whose job is usually to help fight diseases. However, in MS and other autoimmune diseases, they may cause damage.
Tysabri is one of several approved disease-modifying therapies (DMTs). Having an in-depth discussion with your neurologist or MS specialist about DMTs and their benefits and risks will help you to decide what option might be the best treatment for you. For information on all of the approved DMTs, please visit MSAA’s website at mymsaa.org and select “Treatments” under “MS Information.”
Q: I have had relapsing-remitting MS for nine years now. I’ve tried a few of the DMTs and am doing well. In addition to MS, I have had type 1 diabetes for 51 years. Although I’d like my blood sugar to be lower, I am doing okay and I walk daily. My questions are: (1) do many people with MS also have diabetes, and (2), do you have any special recommendations for people such as me who have both conditions?
A: The chance for type I diabetes is increased three-times in individuals with MS, according to a recent Danish study. Both illnesses are related to lymphocytes in the immune system targeting an individual’s own body – specifically the pancreas and the brain, in this case. My recommendations for you are to keep up with a good diet, exercise regularly, and continue the efforts you are making to lower your blood sugar. Good health strategies help both diseases.
As you have experienced, DMTs can be very helpful for your MS. While older individuals with MS may be more inclined to have type II diabetes, many younger, type I diabetic patients are now living long lives with MS. An area of future research is to better understand the incidence as well as the most effective combined treatments for both conditions.
Q: If my spinal tap is normal, does that mean I don’t have MS?
A: Some individuals with MS may have a normal spinal tap. In those situations, neurologists usually rely on the neurological history and examination as well as the MRI and other tests. For example, one test (evoked potentials) measures the speed of myelin function in the eye, brain, and spinal cord. If doubts remain, going to an MS center for a second opinion is an option.
Q: I was diagnosed in 1998 with relapsing-remitting MS. I was prescribed double-dose Betaseron and have been on this medication for 20 years. Now I’m 66-years old and my doctor wants me to discontinue my treatment. Reason: I have not had any relapses in the past 10 years, although my MRI does show some new lesions. He feels it’s not doing anything for me now and claims there is a greater possibility of my getting cancer at my age. I feel it’s doing what it was supposed to do! I welcome your opinion or thoughts.
A: I am so pleased that you have had no MS relapses for more than 10 years while on Betaseron® (interferon beta-1b). More good news is the fact that studies of patients on Betaseron for more than 20 years have not shown an increased risk of cancer. Nonetheless, some neurologists believe that having no relapses for several years indicates that the treatment (to quote your question) “is not doing anything.”
The risk of stopping Betaseron is that your MS may get more severe. New MRI lesions may indicate that you continue to experience some ongoing MS damage. You need to compare the potential risks of stopping your therapy versus the risk of cancer. The research does not demonstrate an increased cancer risk with Betaseron, but everyone must face the risk of cancer as we age, even if we take no medications.
In general, I encourage everyone to get the recommended testing for cancer as they age, but as noted, Betaseron has not been shown to increase one’s risk of cancer. In addition, I personally do not recommend discontinuing MS disease-modifying therapy, especially if there is MRI evidence of new MS activity. However, the final decision is between you and your neurologist.
Q: I am 64-years old. My doctor recently changed my medication from Gilenya to Ocrevus. I have heard that the trials for Ocrevus indicated reduced efficacy in patients older than 55 years of age. Is this true?
A: The clinical trials with Ocrevus™ (ocrelizumab) did not include patients older than 55. Therefore, no data are available to know if someone 64 years of age would respond better or worse than the studied patients who were 55 or younger.
Your neurologist likely reviewed your specific risk and benefit profile before switching from Gilenya® (fingolimod) to Ocrevus. The FDA prescribing information says Ocrevus is “indicated for treatment of adult patients with relapsing or primary-progressive MS.” Since no data are available on patients older than 55, beware of rumors. Ask specific questions to your neurologist. If still concerned, consider a second opinion
at an MS center.
Q: I was interested in the question that you received regarding sudden falls published in the Summer/Fall 2017 issue of The Motivator. I have had that experience and discovered that falls were likely to occur when I wasn’t paying attention. If I become distracted from paying attention to walking, I seem to lose contact with my position in space, similar to closing my eyes during a balance test.
A: Thank you for sharing your personal experiences. I agree – paying attention and not getting distracted while walking, especially at night, is critical for individuals with MS and for those who have experienced falls or losing their “position in space.” Good lighting and removing obstacles in the house that may inadvertently cause someone to trip is critically needed. Individuals with MS and their families should “fall-proof” their home as much as possible.
Please Submit Your Questions To:
MSAA
Questions for Ask the Doctor
c/o Dr. Jack Burks
375 Kings Highway North
Cherry Hill, New Jersey 08034
Questions may also be emailed to askdr@mymsaa.org. Please be sure to include “Ask the Doctor” in the subject line.
Jack Burks, MD is the chief medical consultant for MSAA. He is an international MS neurologist, writer, lecturer, and researcher, who assists with the development of new MS therapies as well as new MS centers. He also advises patients, families, MS organizations, and healthcare groups. Dr. Burks is an adjunct professor at Nova Southeastern University and clinical professor of neurology at Florida International University. In addition, he has authored numerous textbooks, chapters, and articles on MS.