Question:
I have 2 questions after receiving results of my yearly MRI's and my first Dexa Scan. 

Question #1 Is it often seen that MS patients develop pretty severe Osteoporosis? I recently had the first Dexa Scan I've done and the findings show Lumbar Spine T-Score -1.9 and 0.0838 gm/cm Bone mineral density, and Left Femoral Neck T-Score of -3.4 and 0.473 gm/cm Bone Mineral Density results showing Osteoporosis which I was given Fosamax to treat. 

Question #2 Are hemangioma and meningioma the same issues?  Are they considered "not a concern, an incidental finding?" When would they be a concern?  Is this something that neurology follows?  In the MRI Cervical Spine w/without contrast they found:Enhancing Hemangioma @ T1 Vertebral Body and Broad Based Protrusion at C6-C7. In the brain MRI findings: small area of developmental venous anomaly or capillary telangiectasia. I have often been told I have a Meningioma in the R Front Lobe that is very small and appears calcified. 

Answer:
Osteoporosis is seen in MS and may be related to several indirect causes of the disease.  Bone strength and density is responsive to stress (ie, weight bearing) as well as adequate calcium intake and vitamin D.  MS can lead to less physical activity (ie, less weight bearing) and spending more time indoors and out of the sunlight (resulting in deficient vitamin D).  Moreover, some medications used
for symptomatic treatment of MS can also lead to thinning of the bones.  Simple ways to help mitigate those possible effects is to supplement with vitamin D3, calcium, and exercise (under your
physician's supervision).  

Fosamax, as you have been treated with, can also be used in the right circumstances.  Of course, there are other medical reasons for osteoporosis, and this is best investigated/treated by your primary care physician.

For your second question, vertebral body hemangiomas are benign and not uncommonly seen on imaging for MS.  Also, a develop venous anomaly is an incidental congenital finding.  Meningiomas are most commonly benign growths of the meninges (or covering of the brain).  Small meningiomas are typically asymptomatic and are monitored over time using MRI.  Most of the time, nothing needs to be done about them.

Your neurologist can monitor this (if it is even necessary based on your circumstances).
Hope this helps.

A. Scott Nielsen MD MMSc
Virginia Mason Multiple Sclerosis Center

Question: I'm feeling really down and am on my 5th week on Cymbalta (60mg). I think it is changing my mood but it is not helping my pain. I feel no one cares or wants to listen and even i notice my husband is sick of it. I try my best but with leg pain, headaches and feeling drained it is hard to be happy. I am just surprised how downhill my MS is going and wonder is it my meds or because my meds are not working??

--------------------------------------------------

Answer: Thank you very much for your question.  The first thing to keep in mind to help frame how you approach this is to recognize that mood symptoms, and depression and anxiety in particular, are very commonly experienced in MS and are much more prevalent than in the general population.  The second thing to keep in mind is that they are very treatable using medications counseling, and/or behavioral medicine (non medication approaches that can have a medication like effect) treatments.  Sometimes these symptoms represent a form a depressive or anxiety disorder, and other times they are secondary to other things, like adjusting to a new MS diagnosis, a new life event (positive or negative), other symptoms (like pain, headaches, cognitive problems, or new MS symptoms, etc.).  In your case it sounds like you are dealing with pain, headaches and fatigue in addition to the mood symptoms and that the medication you are currently taking, duloxetine (cymbalta) 60mg daily, is not helping after 5 weeks on treatment.  I have a few recommendations which I hope will help and give you some additional options to think about.

1) Duloxetine (cymbalta): Antidepressants reach full effect within 4-6 weeks of starting treatment.  Lack of effect at 5 weeks is a good signal to congtact your prescriber and discuss options.  It could be that further adjustment of the dose is needed (higher doses of duloxetine are often used in psychiatry and also for headache and pain management even though the usual maximum dose is 60mg daily), or that a different antidepressant is needed (it is not uncommon to need to try 2 or more antidepressant trials to find the "right" one).  It will also be helpful (I think) for you to further assess the type of headaches and pain that is present.  Duloxetine can help with certain types of pain (especially neurogenic pain) but less so with others and often needs to be supplemented (or replaced) with other treatments.  Same thing with the headaches. Duloxetine helps more with certain types of headaches and less so with others, and may also need to be supplemented (or replaced) with other treatments.  Finally, ruling out that your treatment resistant symptoms are due to a MS exacerbation is also important.  All of these considerations suggest that you talk with your providers for further assessment, guidance, and treatment planning at this time.  Depending on your situation, referrals to a pain specialist, a headache specialist, or both may be needed (but not always, often can be managed by your PCP and neurology specialists).

2) Effects of Fatigue: Fatigue can be a product of pain and also of MS, and can likewise reduce the pain threshold (how much pain you can tolerate) and worsen mood symptoms.  In the warmer summer months, heat (if you are heat sensitive) can exacerbate fatigue as well.  Practicing energy conservation and heat management techniques (including using cooling equipment when outdoors if needed) can help you keep the energy you have in the tank and to use it most effectively.  Doing so can minimize the effect fatigue has on other symptoms.  Self-monitor a bit to see if you notice worsening of pain and headaches and mood symptoms when you are more tired and if there is a daily pattern of this.  If so, there may be a fatigue effect involved.  A review of your medication list with your provider can also help to see if other medications you are on may be contributing to fatigue, headaches, or both (duloxetine is not know to commonly cause either).

3) Self-Monitoring for Depression: Feeling down is never much fun but it could be worse, and it is important to watch for signs that it may be worsening.  Losing interest in things you used to like to do (decreased motivation), decreased ability to enjoy pleasurable activities (anhedonia), increased isolation, decreased appetite for food or intimacy, difficulty with concentration (more than usual), difficulty sleeping, and thoughts of self-harm are all indicators that depressive symptoms are worsening and suggest that you should contact your provider for follow up immediately.  From your message I cannot tell if you are experiencing any of these things or just feeling down.  That being said, in mental health care, as well as in general health care, prevention and early treatment is often better than waiting for things to get worse.  Best to try and get your current symptoms better treated so they will not worsen.  But while you are working on that, keep these other things in mind to watch for as they can indicate worsening.

4) Non-medication options: Medicines are just one of many options that can help with treating mood symptoms and pain.  Non-medication options can often be used instead of medicines and are commonly used in combination with medicines for mental health and pain management.  Counseling can be very effective (especially if working with a counselor with experience helping people with chronic illness, I recommend cognitive-behavioral-therapy or CBT based approaches), especially in situations where difficult life situations are involved, relationships are involved, and/or if you are wrestling with difficult decisions or trying hard to adapt to a chronic health condition (like MS).  Oftentimes, counseling can have a faster onset of action than medication, especially if you have weekly counseling sessions.  Behavioral medicine approaches such as meditation, yoga, tai chi, progressive muscle relaxation, guided imagery, exercise (yes, general exercise), sleep hygiene, and others can also help.  A basic exercise plan (even getting outdoors and walking daily is a good start) will do wonders.  Add a daily pleasurable activity such as a hobby, etc. (even if just for 30 minutes) can also have a good effect (do it even if you don't feel like it, over time it will have a countering effect to the depressive symptoms).  Talk about these options with your providers to see which ones might be best for you.  Sometimes there can be a wait to start counseling (if you choose that option), but the good news is that there are many self-help options available that are actually quite effective and can be combined with traditional counseling approaches.  Two sources that have been really helpful for the people I have treated as a MS mental health specialist include The Relaxation and Stress Reduction Workbook and The Stress and Mood Management Program for Individuals With Multiple Sclerosis: Workbook.  Both of them are very user friendly, less than $20, and do not take a pile of reading to get results.  

I hope that this is helpful.  I think you are right on target to be concerned about your current symptoms and that your instinct is good to want to think about other options.  I hope the above is helpful for you as you think on your options and also for your discussions with your providers.  Best wishes :)

-----------------------------------------------

    
BRANT J. OLIVER, PhD, MS, MPH, APRN-BC

Assistant Professor, School of Nursing, MGH Institute of Health Professions, Boston, MA
Adjunct Assistant Professor, The Dartmouth Institute and Departments of Community & Family Medicine and Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, NH
Faculty Senior Scholar, Dept. of Veterans Affairs National Quality Scholars (VAQS) Fellowship Program, White River Junction, VT
Faculty Nurse Scientist, Yvonne L. Munn Center for Nursing Research, Massachusetts General Hospital, Boston, MA
Neurobehavioral Specialist, Multiple Sclerosis Specialty Care Program, Concord Hospital, Concord, NH
Board Certified Nurse Practitioner (APRN-BC): Family Practice (FNP-BC) and Psychiatry (PMHNP-BC)

It is a new age...and research methods are starting to transform.  HealthCare Journey is interested in promoting this change and so we are encouraging new and innovative ways to conduct research. The study below can be conducted from where you are right now...yup, right in front of your computer. No need to travel anywhere.  Just 30 minutes and you will be involved in an important research study, so please participate if you can and pass this along to anyone you know who might be interested!
  
Here is what the study is about...


Do you want to help prevent people with MS from falling?   

Dr. Laura Rice, from the University of Illinois at Urbana-Champaign, is leading a study with colleagues Dr. Jacob Sosnoff, also from the University of Illinois Urbana-Champaign, and Dr. Deborah Backus, from the Shepherd Center in Atlanta, Georgia, to see why people with Multiple Sclerosis (MS) who do not walk outside of their home fall.  

How long will it take? This online survey will take about 30 minutes of your time to complete.

How do you qualify? To qualify for this study, you must: 
1.     Have MS diagnosed by a neurologist
2.     Be older than 18 years of age
3.     Be unable to ambulate outside of the home
4.     Be able to do at least 25% of the work of the transfer
5.     Have access to a device to complete an online survey

What do you need to do?

1.     If you are interested, please go to this link:
https://survey.co1.qualtrics.com/SE/?SID=SV_24caaDnBKBb3YdT

      OR contact Dr. Laura Rice at [email protected]   

Question:
I smoke cigarettes but don't drink. Is it safe to be on Ampyra if I'm a smoker?

Answer:
There are no contraindications or warnings regarding smoking and Ampyra. In the absence of data, we suggest you speak with your physician about your situation.

As you probably already know, smoking is bad for MS, and while it is difficult to quit it is highly recommended to do so.  Here is a previous blog about smoking and MS.

http://www.healthcarejourney.com/q--a-for-virtual-ms-center/smoking-and-multiple-sclerosis  

Revere (Rip) Kinkel MD
Director of the Multiple Sclerosis Program

Question:
Here is your answer to my question about comparing the sides effects of Avonex versus Plegridy: 

"This has positive and negative effects; on the positive side you can take the drug less often and with more consistent and prolonged biological effects. There also seems to be less neutralizing antibody formation; on the negative side, side effects tend to be more prolonged and sometimes delayed in onset. I have had patients report flu like side effects lasting up to 4 days after injection, which can be managed by prolonging the use of ibuprofen or acetaminophen. This problem decreases over time, much like the flu like side effects decrease over time with Avonex. Titration of the dose over the first 4 weeks is also helpful. In my experience the injection site reactions are a little more problematic. These are often delayed in onset, beginning a day after injection, and then can worsen over several days. This requires icing and steroid creams until this improves over time." 

My question is...Knowing this and having no problems with my intramuscular injections every week (AVONEX) would I be able to continue with Avonex instead of starting Plegridy or will Avonex not be available anymore? Thank you.

Answer:
There are no reports that Biogen plans to stop production of Avonex.  Avonex or a biosimilar drug should be available for a long time.

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

Question:
What is Fampyra?

Answer:

Fampyra is the European name for ampyra; they are the same drug.

Please refer to my prior comments on Ampyra by using the search button on the web site

Briefly, Ampyra is a potassium channel blocker approved by the FDA to increase walking time in people with MS. The improvement in walking time has been associated with improvements self reported walking quality and performance.

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

Question:
Upon waking in the morning I have tingling all over my body reminding I have MS, what is this?

Answer:
Tingling is a very common symptom in people with MS. While it does not typically involve the entire body, this is certainly possible. This can occur with certain medications (most commonly topiramate used to treat seizures or migraine headaches), other medical conditions (hyperparathyroidism), anxiety or hyperventilating. I would talk to your doctor about this symptom and see if he or she has an alternative explanation.

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

Here is My Question:
My doctor is great; the staff is horrible. I can't get through to ask a question. No one ever calls me back. My neuro made a llist of things (wrote them out himself) he wants me to have done, ie: rheumatologist, sleep study, go to Mellen Center in Cleveland Ohio and get an MRI on my head and back. Only thing done is the MRI, but I have heard nothing about results. No follow up appt was made or anything. I signed up for their portal but the password did not work. I've left message 3 tiimes about that as I hoped I could communicate better that way. I don't know what to do. I have been in tears, as it seems there is no one who cares. Sorry if that sounds like "poor me" but I am truly frustrated and don't know what to do. 

I'm ready to find a new neurologist but concerned will they not be able to see results of my MRI since they are also Promedica? It seems the "staff" is as important as the doctor! You know the neuro I go to and I really do like him. He told me he knows you! He agreed with everything you had said to me before. I'm sure you don't remember me. (I'm referring to Dr. Kinkel here). Please help. What do I do? Am I wrong in thinking of finding another neuro? As I said, I do like him, but his people do nothing! Today I am feeling so exhausted, it is hard to function. Depression has been bad and now it is much worse! I'm feeling very much alone here and I thought of you. Perhaps you can "make a suggestion"? I would give the neuro's name but don't feel I probably should. He spoke highly of you, Dr. Kinkel. Thank you for allowing me take up more of your time! 

Answer:
I wish I could say that dealing with other health systems is better but if you are having difficulty navigating the Cleveland Clinic System, which is better and more customer friendly than almost every other large health system, I think we are all in trouble. Most good health systems have an ombudsman who’s sole responsibility is resolving these communication issues and making recommendations for improvements. I would carefully write out the sequence of problems you’ve encountered and call this ombudsman for help. No one is offended by this approach and it may actually help to solve a correctable problem. You can also ask to speak directly to the administrative manager of the Mellen Center for help in resolving the issue. Again, it is best to state only the facts and avoid highly emotional or angry appeals.

Good luck

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

Here is My Question:
I'm thinking of stopping Copaxone. I'm considering not doing anything, quite frankly. Is it always necessary to treat MS? I'm just quite tired of the lack of caring on the doctor's part and taking the injections. My issues are mostly cognitive. I'm so depressed, I just want to quit. Maybe if I could stop thinking about the whole thing, I would feel better! Again, does one ALWAYS have to go on a DMD? I can't take Rebif, Gilenya and I hate the bumps from Copaxone.

Answer:
You have a lot of company when it comes to being tired of giving yourself injections and wondering whether you need to be on a disease modifying therapy at all. The most common reason for stopping long term injectable DMTs is  "injection fatigue” combined with depression.  Nothing is more important that treating your depression. In order to effectively manage your MS using DMTs (assuming they are warranted in your case) your doctors must help you with your depression and your outlook. Let me also be clear that this is a group effort; your doctors may or may not be able to prescribe effective anti-depressants and help you find a good therapist (both important); you must also take responsibility for improving your mental health and outlook. This may involve exercising more regularly, eating better, stopping smoking or using unnecessary drugs, reengaging in activities of interest to you and reconnecting with people in and outside of your family. 

To answer your question more directly, not everyone needs to be on a disease modifying therapy, although I have no idea if this statement applies to you. What I do know is that everyone needs to work on enhancing their own innate  "self efficacy" (see prior Blogs) so they have the tools to deal with MS over time or any vicissitude of life.

Good luck to you

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

Here is My Question:
I started to get tension headaches at the age of 14 yrs old and from the age of 17 yrs I had one every day to this day. Around 14/15 yrs of age I got glandular fever. At age 13 I had a head on collision car accident and broke my upper leg and thumb and spent 2 months in hospital. After that time I struggled with my health, especially my headaches. When I was diagnosed with MS 3 yrs ago it sort of solved the puzzle. I had my first attack 3 yrs ago with my eye. I am 43 yrs old now. My question is can you have MS for years without having an attack???? My neurologist said I have had MS for years. I think I've had it since around 17 yrs of age but I never had a attack, unless my headaches were a MS attack??

Answer:
It is widely recognized now that MS usually exists for years if not decades before a person develops identifiable symptoms. There is even a new descriptive category for patients identified by random MRI scanning for other reasons (often headaches) during the asymptomatic stage, called a 'radiologically isolate syndrome' or RIS.  Most recent studies suggest that about 1/3 of people with RIS will go on to develop clinically evident multiple sclerosis within relatively short follow-up periods. It is quite possible that the percentage of people with RIS who develop MS will increase as they are followed for more than a decade.

An MS diagnosis is frequently predated by unusual though non specific symptoms including headaches, tingling sensations, mental fogginess and fatigue. However, these symptoms are so common in otherwise healthy individuals as to render them of limited diagnostic utility in isolation.

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

Here is My Question:
Lyrica and Neurontin......Lyrica gave me all the side effects and more pain. As Neurontin is the same family as Lyrica, will I get the same side effects if I try Neurontin?? Or does Neurotin work different somehow?

Answer:
Gabapentin (Brand name Neurontin) and Pregabalin (Lyrica) are very similar in terms of mechanism of action, but there are major differences between the drugs:

1. Pregabalin is absorbed rapidly and completely with peak effects within one hour of taking a dose, whereas gabapentin has poor bioavailability with a less consistent relationship between dosing and clinical effect
2. Pregabalin has linear kinetics meaning as you increase the dose there is a proportional increase in the drug level available in your body, whereas gabapentin has non linear kinetics requiring increasingly higher dose to get more drug available. 

The issues of poor bioavailability and non linear kinetics are why some people respond dramatically to gabapentin at a total dose of 300 mg in a day (a very low dose) and other people require 3600 mg in a day. Because pregabalin is much more potent and bioavailable, much lower doses are required (75 to 300 mg a day) with a more consistent relationship between dose and benefits.

Side effects are similar between the two drugs when you compare groups of patient but side effects often differ in the same patient: i.e. one person may tolerate gabapentin poorly at a dose associated with limited benefits and have side effects with pregabalin at a dose that is markedly effective. The opposite can occur as well.

Lastly, studies in people with neuropathic pain show that those who do not respond to gabapentin may respond to pregabalin. This is what doctors have observed in clinical practice for years.

Most insurance companies request a trial of gabapentin before trying pregabalin because gabapentin works well in many people AND pregabalin is more expensive. Pregabalin is a also a schedule V drug that the FDA and DEA states may have some temporary (i.e. non sustaining or addictive) psychic effects that warrants an extra level of control in prescribing. For practical purposes this means doctors have to write out the prescription instead of sending it to the pharmacy electronically (which is much easier). I have not observed these psychic effects in my patients nor have they reported these effects to me during clinic visits.

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

Here is My Question:
I have a very difficult decision to make. I have MS, and my husband has MS in his family. He also has an autoimmune condition, so he probably got some of the bad genes too. So the question is, if we have a baby, what's his/her risk of having MS? Or, the worst case scenario: what's the risk of developing MS if both parents have MS? Thanks!


Answer:
Please see Dr. Kinkel's answer to this question posed by another patient:
http://www.healthcarejourney.com/q--a-for-virtual-ms-center/what-is-the-risk-of-passing-ms-to-a-child

A. Scott Nielsen MD MMSc
Virginia Mason Multiple Sclerosis Center

Here is My Question:
I have been on Gilenya for 3yrs. Several months ago I was diagnosed with breast cancer. My neurologist took me off Gilenya while I was going through treatments for cancer (lumpectomy and radiation). I'm now cancer free. My neurologist said I shouldn't go back on Gilenya because of my previous cancer diagnosis. He put me on another drug but the side effects bothered me so he took me off it. He now wants to put me back on Gilenya. I also tested positive for JC virus. I just read about the concern of Gilenya and the possibility of causing PML. Should I be concerned about going on Gilenya since I've had cancer and tested JC virus positive? 

Answer:
The incidence of PML in MS patients receiving Gilenya since its approval in 2010 is extremely low. There is no evidence that JC virus antibody studies predict the risk of PML on Gilenya or any therapy other than Tysabri. There is also no clinical evidence from post marketing studies that Gilenya interferes with the ability of your immune system to provide adequate surveillance against the recurrence of cancer, although this remains a theoretical concern with this treatment. 

Risks are always relative and must be interpreted in the context of what makes you comfortable or uncomfortable.  Although I know nothing about your MS, it is quite likely that your risk of  MS worsening without effective treatment is much higher than your risk of  developing PML or experiencing a recurrence of cancer as a result of treatment with Gilenya. You and your doctors have a better idea of the following information that is needed to help you with this decision:

1. What is the severity of your MS and your risk of becoming significantly disabled in the near term (i.e. next 5 to 10 years)?  The higher the near term risk the greater the importance of initiating treatment with a highly effective treatment now. However, if you are already significantly disabled with problems walking and classified as either secondary or primary progressive MS, there is little evidence that Gilenya will be beneficial. In this situation the risk:benefit ratio may be reversed. A good way to think about this is to consider the last time you experienced your age, the last time you experienced a typical relapse and the manner in which MS has worsened over time; generally, if you are over 50, have not experienced a typical relapse in more than 2 years and have noticed slow worsening of you condition over a period in excess of 6 months, you have either secondary or primary progressive MS. 

2. How effective was Gilenya during your prior three years of treatment with this drug? If it was only partially effective, perhaps another therapy is more appropriate at this time

3. What is your risk of cancer recurrence? If it is considered a very small risk based on cancer type, stage and treatment then there is less concern?

Hope this helps 

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

Here is My Question:
Why does my vision get blurry when I get hot? It happens a lot in the summer and it is so annoying! Is there anything I can do about it?

Answer:
Blurry vision is a very common symptom in patients with multiple sclerosis.  Blurry vision that is triggered by heat typically occurs in the eyes of patients who have had a prior episode of optic neuritis.  This phenomenon was first described an ophthalmologist in the 19th century and is called Uhtoff's phenomenon, in his honor.

Typically patients who have had optic neuritis will have very good recovery of visual acuity in the affected eye.  However, if the body gets overheated (for example after vigorous exercise or in the summer heat) the vision in the previously affected eye will temporarily get blurry.  Once the body cools off (air conditioning, or drinking an ice cold beverage) the blurry vision resolves rapidly.

Uhtoff's phenomenon is not  considered an MS relapse but is a reminder that the optic nerve has suffered prior injury from the multiple sclerosis.  If both eyes have had optic neuritis in the past then both eyes may become blurry in the heat. 

The best way to prevent Uhtoff's phenomenon is to stay cool and well hydrated. Some patients with MS are so sensitive to the heat that they wear ice pack vests (these are vests with pockets which can be stuffed with ice packs) when going outdoors in the summer.  

If you do notice that your vision becomes blurry but does not return back to normal after your body has cooled off, you should consider contacting your neurologist or ophthalmologist (in particular if the blurry vision lasts > 24 hours).

Sincerely,

Benjamin Osborne, MD
Associate Professor
Departments of Neurology and Ophthalmology
Georgetown University Hospital

#blurryvision #Uhtoffs #multiplesclerosis

 My Question:
I know that Avonex and Plegridy are exactly the same drug and so they both have same side effects, but I am wondering if those effects last 1 day only as Avonex or do they last more? Thank you

Answer:
Plegridy is a re-engineered form of interferon beta 1a, the same molecule in both Avonex and Rebif, with a polyethylene glycol residue attached. This increases the effective mass or size of the molecule and decreases the clearance of the drug from your body. This has positive and negative effects; on the positive side you can take the drug less often and with more consistent and prolonged biological effects. There also seems to be less neutralizing antibody formation; on the negative side, side effects tend to be more prolonged and sometimes delayed in onset. I have had patients report flu like side effects lasting up to 4 days after injection, which can be managed by prolonging the use of ibuprofen or acetaminophen. This problem decreases over time, much like the flu like side effects decrease over time with Avonex. Titration of the dose over the first 4 weeks is also helpful. In my experience the injection site reactions are a little more problematic. These are often delayed in onset, beginning a day after injection, and then can worsen over several days. This requires icing and steroid creams until this improves over time.

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


#Plegridy

Question:
How much turmeric is needed to be effective?

Answer:
We do not as yet know the ideal dose of Turmeric acid, since we do not know if it is an effective treatment for MS. It has been studied in a number of human inflammatory conditions, such as arthritis and inflammatory bowel disease, and reported to have some positive effects. Most authorities recommend 400 to 600 mg capsules or tablets three times a day. It is usually mixed with black pepper or piperine to enhance absorption, so make sure one of these components are listed in the ingredients on the supplement bottle. 

Turmeric is generally well tolerated although some people report mild nausea. There are potential drug interactions so make sure you tell your doctor if you are planning to take this supplement. These interactions include but are not limited to the following:

1. Turmeric acid may cause an increased risk of bleeding especially if taken in combination with anticoagulants (e.g. warfarin or heparin) or anti platelet agents (aspirin or ibuprofen). Most authorities recommend that you stop taking Turmeric supplements at least 2 weeks before major surgery
2. Turmeric acid may interfere with some anti cancer drugs  including cyclophosphamide and Doxorubicin
3. Turmeric acid  may slow the elimination of several common drugs leading to an increase in the amount in your system on any given dose; some of these drugs include verapamil, phenytoin, propranolol and theophylline

Hope this information helps.

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

Question:
Prior to being diagnosed with MS, I always loved the summer and the sun. However, the impact of the heat is too much and I find myself never wanting to go outside in the summer. Why does the heat make my MS worse?

Answer:
Read our page on heat sensitivity to learn about why heat impacts MS and what you can do to enjoy the summer. http://www.healthcarejourney.com/heat-sensitivity.html

Hope this helps.

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

Here is My Question:
I would like to stop with my Cymbalta as after 1 week 30 mg and 3 weeks 60 mg, and it is not helping at all for my neuropathic pain. I would like to see my neurologist but unfortunately he is not very good as he does not specialize in MS. My doctor cannot see me for 2 weeks and I cannot wait this long. I don't think taking them longer will help my pain and my question is how do I stop with Cymbalta as it is an antidepressant and know I cannot stop suddenly. Thank you in advance.

Answer:
This must be discussed with your prescribing physician. 

I realize that access to your doctor is hard right now, but please understand that chronic pain can be difficult to treat and may require different approaches.  Cymbalta (ie, duloxetine) takes time to work.  A few weeks is not enough time to consider it a failure for neuropathic pain.  The 60mg you are taking is a good dose, but appropriate time on that dose is essential to label it as "effective" or a "failure".  I'm concerned when a patient makes up their mind about a therapy prematurely and ends up "throwing the baby out with the bathwater" which sets the time table backwards in getting you to a better place with your pain.  This is most likely to happen when physicians don't take the time to set realistic expectations about a therapeutic.

If you are not having major side effects to Cymbalta, then I would recommend continuing it through the next couple weeks and make sure you schedule to see your doctor to discuss next steps.  There very well may be other approaches to help you, but that needs to be worked out with a physician that knows your situation and has examined you.  

A. Scott Nielsen MD MMSc
Virginia Mason Multiple Sclerosis Center