Here is My Question:
What is the carryover risk of PML when transitioning a patient from Tysabri to Rituximab? Does that change how you transition?

For example, can you stop Tysabri and then start Rituximab in less than 30days (in an attempt to prevent or reduce likelihood of rebound?) OR because of lingering PML risk do you wait a certain number of days? THANKS (A neuro pharmacist)

Answer:
First, this is great that specialists treating people with MS are starting to ask questions on this site.  We want this to be a learning forum for all of us to share and learn, so there is no reason for only those with MS to ask questions here, so thanks for your question! 

To answer your question, there is really no single answer for every case. It depends on the individual's risk of a relapse after stopping Tysabri, their JCV antibody index, their prior history of immunosuppression and their duration of Tysabri therapy.

I personally do not wait more than 60 days to treat with Rituximab so as to minimize the risk of relapse after stopping Tysabri, but this wait is often dictated by insurance authorization delays more than anything else. Most relapses after stopping Tysabri occur between 3 and 6 months following the last dose, so treating with Rituximab within 60 days is prudent. You may wait up to 3 months in a person with a lower risk of relapse and a higher risk of PML. You will definitely wait longer if there is any  concern of early pre symptomatic PML at the time of stopping Tysabri. I think it is important to repeat another MRI and possibly check CSF before starting Rituximab to make sure there is no new activity suspicious for PML.

These are of course just my thoughts on the matter. Many others in the field wait far longer than 3 months in all cases before using Rituximab after stopping Tysabri.

If you search this site for PML, you will find a lot of information about it. http://www.healthcarejourney.com/apps/search?q=PML

-Rip Kinkel, MD

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.

Answer:
Tysabri is a humanized monoclonal antibody that binds to an adhesion molecule on immune cells and prevents the cells from gaining entry into the brain.

Anti-Lingo-1 is a humanized monoclonal antibody developed by Biogen Idec that binds to Lingo-1, a molecule expressed on the surface of oligodendrocyte precursor cells (cells that make myelin) that prevents oligodendrocytes from remyelinating axons (it is negative regulator of myelination). In animal models Anti-Lingo-1 promotes remyelination and is being tested in phase II studies of MS patients.

Although both drugs are monoclonal antibodies they have totally different effects on the body and nervous system.

-Rip Kinkel, MD

Here is My Question:
I have recently changed my medication from Copaxone 20 mg to 40 mg. I have 36 days worth of Copaxone 20 mg. I would like to give this to someone but not having luck yet. My doctors office said they wouldn't take it as it has to be refrigerated. Each one is sealed so fear of tampering should not be an issue.

Answer:
This is an excellent question; some MS specialists will take the left-over drug from patients to give to other patients in need, but I general advise against this practice, particularly with drugs that need to be refrigerated or kept out of the light. My institution also has a rule against this practice. You should never give any drugs to even a friend or family member since this is against the law. The bigger problem is getting rid of needles and syringes with or without unused drug. These should always be disposed of in a Sharps container (they have smaller sizes for travel purposes) and these are supplied by the manufacturer or distributor of the drug to your home. Contact your community waste/trash center to learn how you should get rid of the filled Sharps containers. Some clinics will allow you to drop off filled Sharps Containers to be disposed of with the rest of their medical waste. You should ask in advance if this is permissible.

-Rip Kinkel, MD

Here is My Question:
Hi! I have been on the medication Tysabri for almost a year now and I wanted to know if it is safe for me to get plastic surgery. I don't know if the being on the medication Tysabri and anesthesia for the surgery is ok... Please let me know! Thanks!

Answer:
There is no evidence that Tysabri inhibits wound healing after surgery or increases the risk of infection after surgery. I recommend that my patients continue on Tysabri without interruption if they plan to undergo surgery including plastic surgery, but as always, please discuss with your physician.

Good luck

Rip Kinkel, MD

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:
Is there a possibility of problems taking echinacea in a mixture for allergies?

Answer:
Please see the attached posting on warnings regarding the use of Echinacea. http://www.mayoclinic.org/drugs-supplements/echinacea/safety/hrb-20059246

This warning aside, Echinacea, an extract from the root of the native american plant commonly called the Purple Coneflower, has a long history in herbal medicine as a natural stimulator of innate immune responses against viruses and possibly cancers. There is evidence that it may shorten the consequences of the flu virus and may be effective in other conditions.

Most advice for or against the use of echinacea extracts in patients with immune mediated disorders is based on the overly simplistic notion that anything that activates any part of the immune system is potentially harmful. To my knowledge this has never been demonstrated except in one case report that suggested a role of echinacea in either the development or worsening of immune mediated skin disorders such as pemphigus vulgaris and dermatomyositis.

Echinacea does stimulate the production of Natural Killer (NK) cells, an important regulator of innate and adoptive immune responses, but I am not aware of any studies characterizing the specific subtype of NK cells that are enriched in the peripheral blood or tissues of patients taking this extract. This is important since certain NK cell subpopulations may enhance cytotoxicity and injury and other NK cell populations may regulate and control immune responses in a beneficial manner. For instance, in MS there is a known enrichment of CD56bright natural killer (NK) cells in spinal fluid that may be associated with disease remissions.

A new MS therapy that may be approved by the FDA in the future called, Daclizumab, may actually work by increasing the numbers of CD56bright natural killer (NK) cells. Therefore, it will be important to learn exactly how echinacea affects NK cell subpopulations and function, and whether this effect is either beneficial or harmful in different immune mediated diseases.

Since the verdict is still out on this subject, it is probably best to avoid echinacea until we have a better understanding of the biologic and clinical effects of this phytochemical extract on immune medicated diseases.

-Rip Kinkel, MD