Wednesday, January 31, 2018

Staying With Rituxan Rather Than Switching to Ocrevus

The latest disease-modifying therapy, called Ocrevus (ocrelizumab), was approved in March 2017 for relapsing and primary progressive forms of MS. Ocrelizumab works differently than other DMTs for MS in that it selectively depletes B-cells. B-cells are a type of white blood cell that develops antibodies in response to specific antigens, a process which helps the immune system to fight invaders. However, abnormal B-cells may mistakenly produce autoantibodies that contribute to autoimmune diseases such as multiple sclerosis, rheumatoid arthritis (RA), lupus, or scleroderma.

Ocrevus is very closely related to the drug Rituxan (rituximab) which is used to treat certain autoimmune diseases, such as rheumatoid arthritis and myasthenia gravis, as well as cancers like non-Hodgkin’s lymphoma and chronic lymphocytic leukemia. Both therapies work in the same way to alter the immune system. Rituxan is also commonly used off-label to treat MS, and I have personally used it since 2009.

Ocrelizumab specifically targets and destroys CD20+ B-cells in a way that serves to lower the immune system. Studies of ocrelizumab demonstrated that it could reduce relapses by 46 to 47 percent in people with relapsing MS compared to treatment with subcutaneous interferon beta-1a. People with primary progressive MS (PPMS) who received ocrelizumab were 24 percent less likely to experience disability progression than those who received placebo in a clinical study.

Ocrelizumab is an intravenous infusion therapy which is delivered twice a year in an infusion center or doctor’s office. The first dose is divided in half and given as two separate infusions, two weeks apart. Pre-medications, such as corticosteroids and an antihistamine, are given in advance to reduce the risk of infusion-related reactions that may include itchy skin, hives, coughing or wheezing, throat irritation, flushing, shortness of breath, dizziness, or fatigue. Since ocrelizumab weakens the immune system, patients are at greater risk of developing infections. Additional risks include reactivation of the hepatitis B virus and progressive multifocal leukoencephalopathy.

The decision to switch treatment or not

The MS community has received ocrelizumab with excitement and open arms. I personally know several people who have either switched to Ocrevus already or are considering it. Several factors come into play when making treatment decisions, including comparing efficacy, side effects, impact on lifestyle, and insurance coverage. Twelve years ago, MS patients would choose a treatment and stick with it, even if their disease remained active. Now, patients have options and may switch DMTs when their disease fails to reach NEDA (no evidence of disease activity).

Like many people living with multiple sclerosis, I am determined to do all I can to slow down the disease. Although I might not always exercise as much as I should or I might indulge in rich food on occasion, I still try to focus on healthy lifestyle habits and reduce stress. An important part of fighting this disease for me is to consistently use a disease-modifying therapy.

Read this post in its entirety:

Why I Am Not Considering Ocrevus?

Wednesday, January 24, 2018

Is CIS the same as MS?

When someone experiences a single demyelinating or inflammatory attack of the central nervous system that causes neurological symptoms resembling MS, it is called clinically isolated syndrome, or CIS. Here are some common questions about CIS and how it is distinguished from other forms of MS.

Is CIS the same as MS?

According to updated recommendations redefining the phenotypes of MS made in 2014, CIS is considered an official form of MS. However, not everybody who experiences an episode of CIS will go on to develop full-blown multiple sclerosis.

How does CIS resemble other forms of MS?

An episode of CIS includes neurological symptoms that last for 24 hours or longer and are caused by inflammation or demyelination within the central nervous system (CNS). Myelin is the fatty substance that surrounds and protects nerves. Myelin helps to speed messages along nerves, and a loss of myelin serves to slow down the messages or keep them from getting through in the first place. A place where inflammation has attacked the myelin is called a lesion. The effects of demyelination are the same for each form of MS.
An attack of CIS can be monofocal — involving a single symptom related to a single lesion — or multifocal — involving more than one symptom caused by lesions in different locations in the CNS. The CNS includes the brain, spinal cord, and optic nerves. An episode of CIS is often followed by complete or partial recovery.

How is CIS diagnosed?

Similar to other diseases of the central nervous system, diagnosis of CIS may include laboratory tests to eliminate other potential causes of symptoms, a complete neurological exam to access function of the nerves, a thorough medical history, and magnetic resonance imaging (MRI) to look for evidence of inflammation or demyelination within the CNS. Depending upon symptoms, the recommended MRI given at this stage of diagnosis may only include the brain and not the spinal cord.

Read this post in its entirety:

What Is Clinically Isolated Syndrome?

Wednesday, January 17, 2018

Focus On Yourself At Least Once Every Day

Each New Year brings hope and a sense of optimism amidst a potentially gloomy season with brittle cold weather and often gray skies. It is a time to begin with a proverbial clean slate. A time to start fresh and improve something about your life — eat better, exercise more, spend less money, read more books, learn a new skill — practically any goal can become a New Year’s resolution.

But there’s something about resolutions — they’re hard to keep. Each January, many people make an effort to do something different and end up disappointing themselves when a month later their resolve has fizzled into the gray sky. It can be total resolution evaporation.

My suggestion to prevent the evaporation? Make only one resolution: Focus on yourself once every day.

Life presented many challenges to me in the past 9 months. It was a really tough year. As a result, I did not take care of myself as I should. I stopped exercising. I stopped going out and having a blast on my bike. I stopped caring what I ate. I focused simply on surviving and taking care of others.

Maybe you can relate. At some time in your life, perhaps you have fallen victim to ignoring your own needs too. It’s an all too common situation, no matter what the details of the circumstances are. What you and I need to do now is to find a way to begin to take care of ourselves without a total resolution meltdown.

Once I realize what I really need — to show myself kindness and love — I can find ways to do just that. It’s not an easy task, honestly, because I’m so programmed to take care of everybody and everything else first. But there’s always going to be something else to do.
Since my neglected needs are primarily physical, I have chosen a physical solution. Your needs may be emotional, social, recreational, or financial, thus your solution should match the corresponding need.

Here are the questions I asked myself in order to identify what I need to do to show myself kindness and love within my current circumstances.

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The Only Resolution You Need to Make

Wednesday, January 10, 2018

Shingrix versus Zostavax for People with MS

People with MS may be at higher risk of getting shingles because of reduced immune system function due to disease-modifying treatments. High-dose steroids, often used during relapses, may also increase the risk of a shingles outbreak.

One of the biggest differences between these two shingles vaccines is the fact that Zostavax contains a live-attenuated (weakened) virus to stimulate the immune system, while Shingrix is a non-live, subunit vaccine that works by introducing only a small part of the actual microbe. Those of us living with multiple sclerosis or many other chronic diseases take medications that reduce the effectiveness of our immune systems. Because of this we can’t receive vaccines that contain live virus, which would put us as even greater risk of developing the very disease we’re trying to protect ourselves from.

Since Shingrix does not contain live virus, it should be much safer for people with lowered immune systems. My doctor was very happy to inform me of this during our routine medical visit. I was thrilled to learn the news. ACIP should issue recommendations on the use of Shingrix in people with compromised immunity in February 2018.

Even if you've already had shingles, it is still a good idea to be vaccinated. An episode of shingles might provide a few years of protection from recurrence, but that protection fades away. People who have already had the Zostavax vaccine can also receive the Shingrix vaccine. In fact, the ACIP recommends it.

My experience with shingles

In August 2005, I was still in the process of being diagnosed with multiple sclerosis and was prescribed a five-day course of intravenous solumedrol (IVSM), followed by an oral steroid taper, to reduce inflammation. It was an extraordinarily stressful time because the steroids temporarily reduced my immune system. By the time September rolled around, I began to develop small, itchy blisters on one side of my face and neck. I recognized the outbreak as shingles because a family member had recently contracted the virus.

Several antiviral medications — acyclovir, valacyclovir, and famciclovir — may be used to reduce the severity of shingles and shorten its duration. But these medications need to be taken as soon as possible after the shingles rash appears in order to be effective. Since I recognized my own case of shingles, I went to the ER for assessment and treatment. It’s a good thing I did because my rash was very close to my eye. The ER doctor had an ophthalmologist examine my eye carefully to make sure that the virus had not entered it. Thankfully, it was fine.

Read this post in its entirety:

The New Shingles Vaccine is Good News for People with MS

Wednesday, January 3, 2018

Using Disease-Modifying Therapies to Slow Down Multiple Sclerosis

Currently available disease-modifying therapies (DMTs) are primarily used in relapsing forms of the disease, including relapsing-remitting MS (RRMS), secondary-progressive MS (SPMS) in patients still having relapses, and progressive-relapsing MS (PRMS). Some DMTs are also approved for delaying a second exacerbation in people who have been diagnosed with clinically isolated syndrome (CIS). One DMT has been approved for primary progressive MS (PPMS).

Disease-modifying therapies (DMTs) can be grouped together in a variety of ways. They can be categorized as oral drugs, self-injectables, or infusible medications; or they may be identified by their mechanism of action (MOA, or how they work). DMTs can also be divided into so-called first-line agents, which are common initial treatment choices for people diagnosed with MS, or second-line agents, which are typically reserved for patients who have not responded adequately or are unable to tolerate first-line drugs.

Self-injectable DMTs

Self-injectable disease-modifying therapies considered to be first-line options include Avonex (interferon beta-1a), Rebif (interferon beta-1a), Betaseron (interferon beta-1b), Extavia (interferon beta-1b), Copaxone (glatiramer acetate), and Glatopa (glatiramer acetate). Interferon beta drugs are FDA- approved to treat all relapsing forms of MS. With the exception of Rebif, interferon beta drugs are also approved for use in CIS. Copaxone is a synthetic polypeptide agent which is approved for RRMS and CIS. An additional injectable medication includes Plegridy (pegylated interferon beta-1a).

Oral DMTs

Since 2010, three oral therapies, each with different mechanisms of action, have been approved by the FDA for treatment of relapsing forms of MS. Gilenya (fingolimod) is the first in a new class of oral MS medications, called sphingosine 1-phosphate receptor modulators, which suppress lymphocyte circulation in the immune system. Two other agents in this class are currently in clinical trials. Aubagio (teriflunomide) is also the first in a new class of oral MS medications called pyrimidine synthesis inhibitors which have anti-inflammatory and immunoregulatory properties that have been used to treat rheumatoid arthritis and psoriatic arthritis. Tecfidera (dimethyl fumarate) is in a class of drugs called Nrf2 activators believed to have anti-inflammatory and cytoprotective properties.

Intravenous DMTs

Intravenous therapies include Tysabri (natalizumab), Ocrevus (ocrelizumab), Lemtrada (alemtuzumab), and Novatrone (mitoxantrone) which are typically reserved as second-line treatment choices. Tysabri, a humanized monoclonal antibody that binds to alpha-4 integrin and inhibits T-cells from crossing the blood-brain-barrier, is administered every 4 weeks by specially trained healthcare providers. Tysabri is approved for relapsing forms of MS and is highly effective, but carries the risk of a serious brain infection called progressive multifocal leukoencephalopathy (PML). Ocrevus, a humanized monoclonal antibody that binds to and depletes CD20+ B-cells, is administered twice a year with the first dose split into two infusions. Ocrevus is associated with infusion-related reactions and increased risk of breast cancer.

Read this post in its entirety:

Slowing Down Long-Term Progression of Multiple Sclerosis With Disease-Modifying Therapies