Here is My Question:
I was diagnosed with MS a few years ago. I was planning on getting a recreational card for migraines and anxiety, however, does marijuana affect the MS in any negative way?

Answer:
There is some data that indicates neuropathic pain and spasticity in MS could be helped with marijuana.  However, there is also data that it can affect cognitive performance as well.  For neuropathic pain and spasticity, there are legally (Federal) prescribes medicines that can address those specific symptoms.  You can refer to the symptoms section of this site to explore those potential options:  https://www.healthcarejourney.com/symptoms.html

For more on MS and cannibis:  https://www.healthcarejourney.com/q--a-for-virtual-ms-center/medical-marijuana-and-its-impact-on-multiple-sclerosis
Regarding cognition and MS, you can refer to our website as well:  https://www.healthcarejourney.com/cognitive-dysfunction.html 

A. Scott Nielsen MD MMSc
Neurologist and MS Specialist at Kaiser Permanente

Here is My Question:
I’m asking this question out of frustration of results from overpriced medications Ampyra and Copaxone. SARMS and peptides seem to have some benefits for people with MS. Has the medical community looked at this opportunity?

​Answer:
SARMS, also known as Selective Androgen Receptor Modulators, are not approved by the FDA and are under investigation for a number of conditions including MS. My understanding is that the unregulated product people buy on line is often not what they promise it to be. Whether these drugs will be of any benefit is unknown at present. Not sure what “peptide” therapies you are referring to in your question.

Revere (Rip) Kinkel MD
Professor of Clinical Neurosciences
Director of the Multiple Sclerosis Program
Clinical Neurosciences Director
University of California San Diego

Here is My Question:
My understanding is that live vaccinations are contradicted in patients being treated with Ocrevus. I have read different opinions on being around people who receive live vaccines. My question is about pets who receive live vaccinations - particularly the kennel cough vaccine - Bordetella-.B. bronchiseptica. Would giving this live vaccine to dogs be a problem for an owner with a compromised immune system due to Ocrevus treatment?

​Answer:
I see little reason to be concerned about exposure to people or pets who have received live vaccines

Revere (Rip) Kinkel MD
Professor of Clinical Neurosciences
Director of the Multiple Sclerosis Program
Clinical Neurosciences Director
University of California San Diego

Here is My Question:
Is it safe to do breastfeed while on Avonex?

Answer:
There was a study several years ago of interferon concentration in the breast milk of mothers taking regular weekly doses of Avonex. They measures the concentrations out to 7 days and found very small amounts of interferon in the breast milk at all time points. None of the infants displayed any side effects or abnormal behavior

Revere (Rip) Kinkel MD
Professor of Clinical Neurosciences
Director of the Multiple Sclerosis Program
Clinical Neurosciences Director
University of California San Diego

Question:
I have night sweats with Tecfidera. What can I do about it?

Answer:
Night sweats with Tecfidera are not that uncommon in my experience. Some people benefit from an aspirin at bedtime. Try a baby aspirin first (81 mg) and increase to 325 mg or even 650 mg as needed. As always ask your doctor if it is advisable for you to take aspirin on a regular basis.

Revere (Rip) Kinkel MD
Professor of Clinical Neurosciences
Director of the Multiple Sclerosis Program
Clinical Neurosciences Director
University of California San Diego

​PLEASE NOTE:  The information/opinions on this site should be used as an information resource only.  This information does not create any patient-HCP relationship, and should not be used as a substitute for professional diagnosis and treatment.  Please consult your health care provider before making any healthcare decisions or for guidance about a specific medical condition.

Here is My Question: 
I am 37 and will be starting Ocrevus soon but a bunch of vaccines were ordered before I start it. My doctor wants me to get the Hep A, HPV, HIB, Pneumococcal, shingles, tdap. I got the tdap and pneumococcal today. HIB, HPV, and shingles were denied because of age and hep A for unknown reasons. 

1. Do I need the HPV vaccine at 37 if I’ve had HPV in the past and am now completely negative since I had my daughter in 2010 and I’m also in a monogamous relationship? 

2. Should I get the shingles vaccine this early? I did have chickenpox as a child. 

3. Are the HIB and Hep A usually recommenced? 

Also, should I get the breast cancer gene test if I am unsure of family history or beast cancer? 

Answer:
The vaccines you mention are all appropriate but not all will be covered.

1.  The FDA only recommends the HPV vaccine to age 26. it will not hurt you to get it after age 26 but it’s also not likely to be required given your monogamous relationship. If you plan on more sexual partners or think your partner may be having more sexual partners then it may be a good idea. No matter the circumstances you would need to pay for it yourself.

2. Shingles is probably not required at your age if you have good immunity to varicella ( a blood test will tell).

3. Hep A is a good idea if you live in certain areas like San Diego or the southwest where we have had frequent outbreaks.

4. By HIB you are referring to the haemophilis influenza type B vaccine. This is usually given to children and probably not necessary for you, especially since your daughter is 8 or 9 and probably received this vaccine before the age of 2.

5. Ask your doctor about getting BRCA 1 or 2 gene testing. This is usually only recommended for people with family medical histories of breast cancer or several other types of invasive cancer (pancreatic and prostate) especially in people with an ashkenazi jewish background. We usually do recommend pap smears and mammograms before starting Ocrevus if not done recently.

Good luck
Revere (Rip) Kinkel MD
Professor of Clinical Neurosciences
Director of the Multiple Sclerosis Program
Clinical Neurosciences Director
University of California San Diego

Here is My Question: 
I was diagnosed with MS last year. Not sure which type but no clear cut relapse or remission just symptoms that don’t go away. My walking is mostly not affected other than from vertigo so my neurologist isn’t taking me very seriously. I have multiple hyperintense T2 lesions of the periventricular area, a positive LP, at least one major incident we think was the beginning of this back in 2015 when I had Parvo virus. Also VERY BAD “MS hug" but no obvious lesions on the spine but my recent MRI interpretation says there may be 2 subtle areas of signal abnormalities likely representing demyelination. My neurologist wasn’t sure if he could see them and they were only visible on the axial images. 

I also have some T1 hypointensities on the MRI of the brain. I read that the 2D images are better at preventing over interpretation of these and I do have them in the T1 2D but they are dark but not as black as the CSF. I was on Copaxone prior to these possible spinal lesions and I have decided to switch to Ocrevus. I was worried mine might be more of the slow progressing type. My main issues are cognitive, MS hug (girdling), muscle spasms, neuropathies, vertigo, and more. 

My main questions are, does this sound like progressive type? Do you have t1 hypointensities in Relapsing remitting? Does this sound like definite MS? My neuro diagnosed me but always down plays my concerns about progression and wanting to be on a more aggressive drug than Copaxone so sometimes I just feel like it’s all in my head (pun intended). 

I was tested for everything under the sun and it was all negative so its either MS or some other unknown problem no one can figure out. Is it too aggressive to try Ocrevus or is it better to just be proactive and take care of it now? I’m just afraid to play it slow and possibly end up with worse damage. Do the darker T1 areas mean more progressive or more intense disease? 

Answer:
I am not able to determine if you carry a diagnosis of MS based on the information provided. I also do not know your age, which is important. Let’s assume your first attack was in 2015, as you suggest, and you’ve been on Copaxone for a year. It is not clear from your description whether any new problems have developed over the past year, but you may have developed new MRI abnormalities over the past year.

Based on this information let me answer your specific questions:
​
1. T1 hypointensities occur in all types of MS including relapsing MS but become more numerous and darker with disease duration. They are one of many risk factors for disease progression but this depends on your age.
2. As I said I can not determine if you should be characterized as definite MS based on the information provided
3. Progressive disease is always defined in retrospect and requires objective changes in neurological function on examination. From your description, your disease does not sound like progressive in type, at least not yet
4. There are many great options for treatment between copaxone on one end of the spectrum and Ocrevus on the other end of the spectrum. A lot depends on your age, other medical problems and your possible desire to have children in the near future. 

You should talk to your neurologist about oral treatment options to start. Tecfidera, Gilenya and Siponimod (just approved by the FDA) may be more effective than Copaxone and are well tolerated. 
Good luck

Revere (Rip) Kinkel MD
Professor of Clinical Neurosciences
Director of the Multiple Sclerosis Program
Clinical Neurosciences Director
University of California San Diego

Question:
What are the differential diagnoses for a brain MRI that shows both juxtacortical and periventricular lesions?

Answer:
There are a wide variety of vascular and inflammatory diseases that are associated with juxtacortical and periventricular “lesions” or, to use a more accurate label, T2 hyperintensities.
It is important to correctly define these lesions or T2 hyperintensities as follows:

1. A periventricular lesion must abut the ventricular surface. This means there can not be even a small gap between the lesion edge and the ventricular surface. The ventricule is the space in the middle of the brain where spinal fluid is formed and circulates.
2. The most specific juxtacortical lesion is a leukocortical lesion with a U or hook shape that follows the contour of a cortical gyrus. Leukocortical means that the lesion involves both the cortex and the underlying white matter. To be truly juxtacortical the lesion must be immediately adjacent to (touching) or involving the cortex. Otherwise the lesion is better referred to as a subcortical white matter lesion. Subcortical white matter lesions are not very specific for any disorder.

Even though this MRI criteria is more specific, it is not diagnositc. The diagnosis is only assured in the correct clinical setting.

Hope this helps
Revere (Rip) Kinkel MD
Professor of Clinical Neurosciences
Director of the Multiple Sclerosis Program
Clinical Neurosciences Director
University of California San Diego

Here is my question:
I am being put under general anesthesia tomorrow to remove my wisdom teeth but am unsure if I should take my Extavia shot tonight or wait until after the surgery.

Answer:
It makes little difference if you take the Extavia tonight or wait until after you recover. If a person experiences side effects with interferon injections, I usually suggest that they hold their injection until after they recover from surgery. Check with your physician and I suspect he or she will agree. Good luck.

Revere (Rip) Kinkel MD
Professor of Clinical Neurosciences
Director of the Multiple Sclerosis Program
Clinical Neurosciences Director
University of California San Diego

Here is My Question:
There is a device called the Biocharger; https://biocharger.com/persona/alternative-therapies/

Could this help manage MS symptoms?

Answer #1:
There is no real scientific evidence that this biocharger helps with disease or symptoms of disease.  In fact, the disclaimer on the website states it does not diagnose or mitigate any disease. The research presented on the website is hypotheses (over 100 years old) without any practical data to support its use in the management of disease. They do reference recipes to be used but it remains unclear to me if these incorporate herbs.  This device is being marketed as a product that emits electromagnetic energy within a radius of ~3-5 feet and that somehow treats people for a myriad of different (and unrelated) diseases. I would recommend a “buyers beware” caution to anyone with MS thinking about shelling out $14,000 for this.

A. Scott Nielsen MD MMSc
Neurologist and MS Specialist at Kaiser Permanente

Answer #2:
Thanks for the question. I checked out the website thoroughly. There are comments about “proven benefits” and even “testimonials” (whatever they are worth), but the company provides no peer reviewed references and I can find no references on the BioCharger in PubMed or any other search engine; this and the cost, which is $14,000, should make anyone pause and move on. Unless you are a millionaire with money free to throw around, do not even think twice.

Revere (Rip) Kinkel MD
Professor of Clinical Neurosciences
Director of the Multiple Sclerosis Program
Clinical Neurosciences Director
University of California San Diego

Here is My Question:
Does spasticity hurt? Can the pain in my hamstrings be due to spasticity?

Answer:
Patients tend to report painful spasticity but there are exceptions.  Spasticity can present in any muscle or muscle group, but also tend to follow other signs of central nervous system involvement that your neurologist can confirm on the neurological exam.  If spasticity is the cause of symptoms, various medicines could be used, but I typically recommend deep stretching of the affected muscles frequently first as this can be helpful while avoiding medication side effects.  

A. Scott Nielsen MD MMSc
​Neurologist and MS Specialist at Kaiser Permanente

Here is My Question:
I think my SPMS is being made more uncomfortable by arthritic changes and I'm wondering what meds will help?

Answer:
This is a really good question. MS never exists in a vacuum; instead it co-exists with everything else life throws at you, including old age and arthritis. In most cases your joint problems are a result of osteoarthritis, especially if the pain involves knees, hips, shoulders and/or spine. You can think of this as a form of wear and tear arthritis that can be accelerated by the muscle weakness and sensory alterations associated with Multiple Sclerosis.

There is no single treatment for osteoarthritis . You need to take an integrated approach that involves exercise (especially Tai Chi and Yoga), mindfulness/meditation and relief of pain with non-steroidal anti-inflammatory medications (think motrin). Additional approaches may include corticosteroid injections in several different types of joints for short term relief of pain and injections of the knee joint with hyaluronic acid for more long term pain reduction. Glucosamine and chondroitin sulfate may also be beneficial for knee pain in some people. More recently, platelet rich plasma injections have been used to treat joint, tendon and ligament injuries.

For patients with more advanced osteoarthritis involving the hip and knee and, in some cases, the shoulder, your doctor may recommend total joint replacement surgery even if you have more advanced progressive disease. This type of surgery done in the right hands in well selected patients can dramatically improve function and quality of life

In my experience it is best to be evaluated by specialists in sports medicine and pain medicine  for relief of joint, bursa (the lining around the joint), ligament and tendon pain. The correct diagnosis is of utmost importance. They will refer you to an orthopedic surgeon if they believe surgery is a good option

Good luck

Revere (Rip) Kinkel MD
Professor of Clinical Neurosciences
Director of the Multiple Sclerosis Program
Clinical Neurosciences Director
University of California San Diego

Here is My Question:
Can MS cause a low grade fever? My doctor can’t seem to find a reason for why I keep having one.

Answer:
Fever is not a known issue in MS, in fact, on average patients can have a slightly lower body temperature

Benjamin M. Greenberg, MD, MHS
Vice Chair of Translational Research and Strategic Initiatives
Cain Denius Scholar of Mobility Disorders
Distinguished Teaching Professor
Department of Neurology and Neurotherapeutics
Department of Pediatrics
UT Southwestern Medical Center
Dallas, Texas

Here is My Question:
As my MS advances, (RRMS 17 years-on glatopa daily shots) my gut seems to get worse. Especially since I had C-Diff a couple of years ago. I have had 2 short courses of flagyl for tooth abcesses recently. It was really awful then. But now it won't go away even when not on antibiotics. Is nausea and vomiting now an MS symptom that will not go away?

Answer:
In general those symptoms are usually not due to MS inflammation, although we do see constipation that can cause symptoms.

Benjamin M. Greenberg, MD, MHS
Vice Chair of Translational Research and Strategic Initiatives
Cain Denius Scholar of Mobility Disorders
Distinguished Teaching Professor
Department of Neurology and Neurotherapeutics
Department of Pediatrics
UT Southwestern Medical Center
Dallas, Texas

Here is My Question:
Has Siponimod been FDA approved?

Answer:
Siponimod has not been approved by the FDA yet but they are supposed to announce their decision sometime this month (March 2019)

Revere (Rip) Kinkel MD
Professor of Clinical Neurosciences
Director of the Multiple Sclerosis Program
Clinical Neurosciences Director
University of California San Diego

Here is My Question:
Can Copaxone be used to treat PPMS?

Answer:
Copaxone has been FDA approved for RRMS and does not for PPMS (no evidence for effectiveness in PPMS).  The b-cell biologicals do have data to support use in PPMS.

A. Scott Nielsen MD MMSc
Neurologist and MS Specialist at Kaiser Permanente

Here is My Question:
Is SPMS worse than PPMS? I’m feeling I’m better off with PPMS because I have sudden things occur.

Answer:
The general course of PPMS and SPMS are very similar and the rate of progressive disability are also similar.  SPMS is different in that it is preceded by a relapsing-remitting course while PPMS does not.  The individual’s experience with MS can vary.

A. Scott Nielsen MD MMSc
Neurologist and MS Specialist at Kaiser Permanente

Here is My Question:
I was recently diagnosed with relapsing-remitting MS my doctor gave me the choice of medicine and I decided to go with Ocrevus. Being JC virus positive should I be concerned about PML?

Answer:
Risk of PML has been observed in MS patients on b-cell biological when there is combined or overlapping immunotherapy (ie, coming off Tysabri and onto Ocrevus or Rituximab for instance).  Since you were recently diagnosed I assume you are not on another therapy but this would be your first exposure to an immunotherapy.

A. Scott Nielsen MD MMSc
Neurologist and MS Specialist at Kaiser Permanente

​PLEASE NOTE:  The information/opinions on this site should be used as an information resource only.  This information does not create any patient-HCP relationship, and should not be used as a substitute for professional diagnosis and treatment.  Please consult your health care provider before making any healthcare decisions or for guidance about a specific medical condition.

Here is My Question:
I have a paralyzed right diaphragm with resulting atelectasis of the right lower lobe and part of middle lobe. My last MRI in 8/18 didn't show any disease C3-5. I have been off Aubagio since 7/18 due to side effects (abnormal low WBC) and will be restarting it this month. Will be repeating MRI to assess for new disease. How often does MS cause phrenic nerve damage?

Answer:
Unilateral paralysis of a diaphragm is relatively rare in MS, although studies performed years ago suggested subclinical involvement of diaphragm function in a larger number of patients. This paralysis does not require involvement of the cord segments with the anterior horn cells supplying innervation to the diaphragm through the phrenic nerve (C3,4 and 5). This can also be the result of involvement of central motor pathways above this level in the brainstem.

Good luck

Revere (Rip) Kinkel MD
Professor of Clinical Neurosciences
Director of the Multiple Sclerosis Program
Clinical Neurosciences Director
University of California San Diego