Here is My Question:
Hello, Is it at all possible to have MS with a normal brain MRI? I’ve been dealing with progressive symptoms for almost a year now and I am just feeling completely hopeless on what to do. I’ve had numerous appointments with my PCP, I’ve been to the ER, had a ton of tests completed labs drawn with my OB and I had my very first appointment with a neurologist today that felt extremely unproductive. I have been dealing with numbness, tingling, intense burning bone pain in my legs, thigh and knee swelling, upper arm pain, balance issues, perimenopause, shaking and random hand tremors, excruciating rib pain and so much more. I also have a family history of MS and Guillian-Barre Syndrome. I have been joining virtual MS groups and told that it’s important to get a full head, neck and spinal MRI…but since my brain MRI was normal (which I got a few months ago) it’s being ruled out. I just feel like something isn’t right nor adding up and would be grateful for any support or advice you could offer.

Answer:
Diagnostic evaluations are highly dependent on a detailed history and examination. This can only be accomplished with an in person visit.

Revere P (Rip) Kinkel, MDProfessor of Neurosciences
Director of the Multiple Sclerosis Program
University of California San Diego
#multiplesclerosis

Here is My Question:
Which DMT is best for me and safe for my fetus if I am going for IVF treatment?

Answer:
This is a difficult question to answer because of the many steps involved with in vitro fertilization. Generally, you do not want exposure of the egg after fertilization. Since each disease therapy is associated with definite pharmacological duration (Multiple the half life of the drug by 5 to be safe), it is relatively easy to determine the potential duration of exposure after last dose. Your neurologist should be able to help with his decision. If they are not familiar with the detailed pharmacokinetic or pregnancy recommendations for any DMT, they can always consult with a medical science liason from the drug company or ask for consultation from an MS specialist.
Hope this helps.

Revere P (Rip) Kinkel, MDProfessor of Neurosciences
Director of the Multiple Sclerosis Program
University of California San Diego
#multiplesclerosis

Here is My Question:
Can I get my JVC test done at any hospital?

Answer:
You can get the JCV Index done at any lab as long as they know where to send the blood sample for analysis

Revere P (Rip) Kinkel, MDProfessor of Neurosciences
Director of the Multiple Sclerosis Program
University of California San Diego
#MS #multiplesclerosis

Here is My Question:
My sister has relapsing/remitting form of MS and is currently under treatment with Ocrevus. She is doing quite well and other than fatigue and depression ( under treatment with antidepressants) she is a highly functional individual. Our concern is the increased risk of breast cancer that comes as a warning with Ocrevus - especially since our mum died from breast cancer at the age of 53. Would that be meaningful for my sister to switch over to the newly approved Briumvi when it becomes available? How real is the breast cancer risk with Ocrevus? Thank you a lot in advance.

Answer:
There are continuing reasons to be cautious about the risk of Breast cancer and other malignancies in people with MS treated with immunosuppressive therapies, including the B cell depleting therapies. Current B cell depleting therapies include Rituximab, Ocrevus, Briumvi and Kesimpta.

Remember the risk of malignancy increases with age. Therefore, the most relevant clinical data sets will be those that include older people with MS. Ocrelizumab was studied in 2 separate trials involving younger relapsing patients and older primary progressive patients.

The median age of patients participating in the Ocrevus primary progressive trial was 46, whereas patients participating in the relapsing trial were approximately 10 years younger on average.

In the primary progressive MS clinical trial called Oratorio there were 11 cases of malignancy (4 cases of breast cancer) among 488 patients (2.25 %) treated with Ocrevus versus 2 cases of malignancy (no cases of breast cancer) among 244 patients (0.82 %) treated with placebo.

As expected, rates of cancer in the younger patients participating in the Opera clinical trials for relapsing remitting MS were lower; there were 4 cases of cancer (2 breast cancer) among 827 people (0.48 %) treated with Ocrevus and 2 cases of cancer (no case of breast cancer) among 829 patients (0.24 %) treated with Interferon Beta-1a (Rebif).

While these rates of cancer are still relatively low, it is also important to realize that they occurred within 3 years of onset of treatment- a relatively short period of time- and there was no formal screening of participants for cancer or cancer risk prior to onset of treatment. It is certainly possible that cancer was already developing in some of these patients prior to starting therapy and the expression of the cancer was accelerated by treatment.

How do we use this information to help minimize risk of cancer on treatment? The most important step is to perform cancer screening prior to initiation of immunosuppressive MS therapy. The screening should be individualized for age, past medical history and family history but should, at a minimum, include baseline followed by annual mammograms in woman.

Remember, these therapies are wonderfully effective, particularly in younger individuals with relapsing MS. Their effectiveness diminishes with age (> 50) and with progressive disease, while risk of cancer increases with age. Because of the differential risks of cancer and infections by age group and disease type, the decision on when to initiate or stop therapy must be made individually. 

Revere P (Rip) Kinkel, MDProfessor of Neurosciences
Director of the Multiple Sclerosis Program
University of California San Diego
#MS #multiplesclerosis #Ocrevus #cancer #Briumvi

Here is My Question:
BECAUSE I HAVE KIDNEY DISEASE, CAN I GET AN MRI WITHOUT THE EXTRA CONTRAST ADDED BECAUSE IT MAKES THE KIDNEY DISEASE WORSE?

Answer:
MRIs without contrast provide valuable information in people with known or suspected MS ; in fact, contrast is usually avoided in people with impaired kidney function.  
It is important to understand why we use contrast in clinical practice. Here are the most common reasons:

1. We define MS disease activity as new or significantly enlarged MRI "lesions" without contrastand/or a documented relapse. It is both the presence of this disease activity and its subsequent elimination that formed the basis for the approval of almost all disease modifying therapies (DMTs). We can confidently determine the presence of new or enlarging MS T2 hyperintensities (the so-called white spots observed without any contrast) without contrast, as long as the background amount of T2 hyperintensities, called the lesion burden, is not too large and images from different time points are collected in a similar manner. When the lesion burden is large, visually observing relatively small new lesions can be akin to finding a needle in a haystack.  Contrast helps us understand if the new or enlarging MS lesions are relatively new or arising within a previous region of T2 hyperintensity, a piece of information that is harder to determine without contrast.
2. Contrast tells us if there is breakdown of the blood brain barrier (BBB). In the case of MS breakdown of the BBB is usually caused by acute inflammation. This contrast enhancement is far more common in people under the age of 45 than people over 45 even off of treatment.
3. The hallmark of most modern DMTs is the elimination of contrast enhancing lesions. Once we determine that a therapy is working as desired by MRI and clinical criteria, it is often possible to forgo using contrast on further monitoring MRIs

When is contrast useful? Diagnostically, it is very hard to observe certain disease features suggesting another diagnosis such as a vascular malformation, leptomeningeal enhancement, diffuse subependymal enhancement or a brain tumor. For this reason, contrast scans are often obtained if the initial non-contrast scan does not answer the clinical question being asked

Revere P (Rip) Kinkel, MDProfessor of Neurosciences
Director of the Multiple Sclerosis Program
University of California San Diego
#MRI #MS #multiplesclerosis #DMTs

Here is My Question:
Can I fill with hyaluronic acid and use polydioxanone threads?

Answer:
There is literally no information available on the outcomes in people with MS or autoimmune disease who receive hyaluronic acid injections with or without polydioxanone threads. 

Revere P (Rip) Kinkel, MDProfessor of Neurosciences
Director of the Multiple Sclerosis Program
University of California San Diego
#hyaluronicacid #polydioxanonethreads #MS #multiplesclerosis

Here is My Question:
Hello, I am 31 and has been successfully (EDDS 0) treated since 2017 (2 years of Tecfidera, in 2019 switched to Natalizumab, in 2020 switched to Cladribine due to high level of anti JVC antibodies). 
In 2022, 12 months after completing the second course of Cladribine, I got pregnant and on the 23.06.2023 delivered a healthy boy. I am breastfeeding.
I feel well, completely asymptomatic, Still EDDS - 0
3 weeks ago, I had my routine check-up MRI which revealed two new lesions (1 of which is 6 mm GD (+).
My questions are:
1. Should I have the 3rd course of Cladribine
2. If yes, can I stop breastfeeding for 14 days, then resume or:
3. Should I stop breastfeeding and be started a new medication (I have been offered options Cladribine od Ocrevus)
I’d love to carry on with breastfeeding but I’m scared of the risk of the disease worsening

I would appreciate your advice!
Many thanks!

Answer:
Great question. The safest option- among those you mention- while breast feeding would be a single dose of Ocrevus. You could even receive a single lower dose of Ocrevus (300 mg x 1 dose). This would provide protection against recurrent MS activity for 6 months or more. Ocrevus is an IgG monoclonal antibody, and very little if any of the drug passes into breast milk. Most of the antibodies passed from the mother to child in breast milk are IgA type antibodies. We also now have several studies showing the safety of Ocrevus in breast feeding mothers. 

Remember, we pre-medicate people prior to the Ocrevus infusion with a dose of steroids and often Benadryl and Tylenol to prevent infusion reactions. Because the pre-medications may enter breast milk we recommend, pumping and dumping breast milk for at least 24 to 48  hours after the infusion.

​PLEASE NOTE: This information/opinions on this site should be used as an information source 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.

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