Here is My Question:
Do Kegel devises work?

Answer:
Kegel exercises to strengthen the pelvic floor muscles can help lower urinary tract symptoms related to weak muscles from MS. Presumably, the devices that encourage the kegel exercises could help.

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

Here is My Question:
How long does Avonex stay in the body?

Answer:
Following a 30 mcg intramuscular injection, peak levels are reached in 15 hours (in some as early as 6 hours) and then decline thereafter with an elimination half life of 19 hours. We typical consider a drug fully eliminated after 5 half lives or, in this case within 4 to 5 days after the injection. However, the biological effects of the drug can persist much longer than the drug itself.

Hope that 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 have RRMS and am taking Ocrevus. When seeing my PCP for unrelated issues, she tested my TSH and after T4. My TSH has always been normal but now my free T4 is low. I'm in the medical field and I’m familiar with the thyroid function and pituitary involvement etc. My question is, is this something I should have investigated with thyroid antibody testing etc. or check more info pituitary involvement? If I have some corpus collosum atrophy (according to my MS specialist) would this possibly cause this issue and is there any way to really know the cause? Would levothyroxine be effective if it is caused by a pituitary problem? Can Ocrevus cause this type of issue? Just want to know what to look for when I follow up with my PCP.

Answer:
Most patients with low free T4 and normal TSH levels actually have normal thyroid function. The low free T4 is simply caused by altered Thyroid hormone binding proteins, which does not effect thyroid function. An endocrinologist can figure this out for you, if necessary. 

• If your TSH level is high and your free T4 is low then you have primary hypothyroidism
• If your TSH level is low and your free T4 is low then there is a problem with your pituitary or hypothalamus causing secondary hypothyroidism

Two other things to remember about thyroid function tests

1. If you are taking Biotin supplements your thyroid test results will be inaccurate. You need to stop all Biotin supplement for a week before getting thyroid tests.
2. If you are taking estrogen (such as in birth control) this can effect total T4 levels

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 have a posterior bulging disc, facet atrophy most severe at L4 and L5, and peroneal compression. My toes on one foot have been constantly numb for 6 months and I have constant lower back pain. Are any of these possible indicators of MS or Lou Gehrig's disease as there is a family history of both along with Parkinson’s?

Answer
We are not able to provide medical opinions on this site for several very good reasons. The purpose of this site is provide information that will help you and your doctor reach an appropriate decision.  In that context let me make a few comments about your question

First, it appears that you've already undergone an evaluation, hopefully by a neurologist, that led to an MRI scan of your lumbar spine. The question to ask at this point is a simple one: is it possible that the findings on the MRI scan are sufficient to explain both your pain and the unilateral numbness in one foot ? This can only be answered by an experienced neurologist after a detailed history and examination with review of your imaging studies. If the answer is unclear after this evaluation, then the neurologist may need to obtain electrodiagnostic studies (Nerve Conduction studies with EMG) to clarify the underlying issues.

Based on the information provided there is no reason for you to be considering MS or Lou Gehrig's disease. 

It is always best in medicine to take everything one step at a time. Go see a good neurologist and get some answers

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 the first physician blog of 2020! Happy New Year! Click on the link below to read the blog.

GILENYA FOR KIDS WITH MS

Here is My Question:
I just found out my free T4 is low but TSH is mid-low normal. No thyroid antibodies. Can MS affect the hypothalamic-pituitary axis and cause secondary hypothyroidism? Would this still be treated with synthroid or the like? If I’m also on Trileptal and if it is the cause of the issue, do you still treat the low free T4 if the Trileptal is the only thing that has been effective for my pain?

Answer:
The labs likely reflect early hypothyroidism. This can be seen in association with MS (whether or not you have the TPO antibodies). However, to our knowledge, it is not a cause and effect relationship. Speaking with your internist/PCP to monitor the thyroid and determine if/when to initiate synthroid is appropriate. Trileptal isn’t associated and I would not factor that into the equation.

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

Here is My Question:
I have RRMS and I’m taking Ocrevus. My dog just had the live bordetella intranasal vaccine for Kennel Cough and I read later that it should be avoided when the owner is on an immunocompromising medication. I was in the room and even kissed the puppies face and definitely was exposed to the vaccine. Should I be worried or take precautions? I read conflicting data but some highly regarded sites indicated it may not be safe. I can’t get in touch with my MS provider. 

Answer:
There are very rare reports of human cross contamination from intranasal bordetella vaccine sprays given to dogs.  Your risk of a serious infection would depend on your extent of immunosuppression, which, in turn, is likely related to your duration of treatment with Ocrevus. If you develop signs of infection or a respiratory illness within 2-4 weeks of exposure, inform your health care provider of your potential exposure, so that appropriate testing can be done. Bordetella is a gram negative coccobacillus that responds  to treatment with common antibiotics.

It is probably best to contact your primary care provider for this issue.

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 going to be 3 weeks without being on Tecfidera, due to insurance issues. Can I restart it at the higher dose?

Answer:
Yes.

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

Here is My Question:
How do you test to see if the Ocrevus is working? 

Answer:
There is no test that tells us directly if any disease modifying therapy is working. For some therapies it is very easy to determine if the drug is doing what it is supposed to  do, but this doesn’t mean that it is helping any particular person control their MS.
 
For instance, Ocrevus is a monoclonal antibody that binds to and destroys any B cell in your bloodstream expressing a protein on the cell surface called CD20. We can take a blood sample from a person after they are given Ocrevus and it will tell us if the ocrevus did what it is supposed to do; that is, destroy these identified cells. However, this doesn’t mean that the drug is benefiting a particular person with MS. We need to evaluate (by examinations, clinical outcome measures, self- report and MRI) how you are doing over a reasonable period of time after starting Ocrevus, usually 2 to 3 years, to determine if it is able to control your MS.

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 have been ordered to take Vitamin D (1x), iron (1x), and alpha lipoic acid (2x) daily. How should these be taken for optimal absorption with regard to taking them at the same time and with or without food?

Answer:
Alpha lipoic acid and vitamin D can be taken with or without food. Iron supplements should be taken one hour before or two hours after meals usually with water. All can be taken together.

​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 a person on Avonex take Vascepa safely? Can it cause increased risk of liver and pancreas problems?

Answer:
Vascepa is essentially highly concentrated fish oil, used to lower triglyceride levels
There should be no interaction or problems using this medication if you are also taking an interferon such as Avonex, Plegridy, Betaseron, Extavia or Rebif.

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:
This question has been really been driving me nuts. I know there is research pointing to a possible like between MS and EBV but have you ever heard of or is it possible that human parvovirus B19 could trigger MS in the same way? I have RRMS diagnosed last year around May 2018. In 2015, I started having a bunch of crazy symptoms like muscle pain, difficulty walking, burning, dizziness, and a bunch of other weird things.

My smart PCP asked if my daughter recently had fifth disease and low and behold she had it the week before. It was severe and I ended up with a positive ANA and anti-RNP antibodies, liver inflammation and a ton other stuff. Had to see Rheumatologist to rule out mixed connective tissue disease etc. Eventually the ANA and anti-RNP became normal and we just left things at that. I wish I had an MRI around that time but didn’t. I kept getting weird symptoms for years and finally got a diagnosis of MS last year and have brain and spinal cord lesions and brain atrophy. I’m 38 :(.

I’ve just always been so curious as to whether it is possible for the parvo to trigger this but most of my MDs have never seen an adult with parvo.

Thanks!!!!

Answer:
I am aware of adults with Parvovirus B19 infections, but there is as yet no link between this virus and the development of  MS reported in the literature.

​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 a SPMS patient and have had MS for 40 years. I am interested in starting Mayzent which is a new medicine for the SPMS patients. I would like to find out how patients have started on Matzent, How they are doing on the Mayzent...any reactions or anything else? Thank You.

Answer:
Mayzent (generic name Siponimod) is the newest SIP1 receptor modulator. The oldest, and currently the only other available, SIP1 receptor modulator is Gilenya (generic name Fingolimod). Mayzent is called a selective SIP1 receptor modulator because it only binds to the type 1 and type 5 receptors, whereas Gilenya binds to all SIP1 receptors. For practical purposes this has little effect on the side effect profile of these drugs.

The most common side effects are headache, elevated blood pressure and elevated liver enzymes. Less common or rare side effects include macular edema (usually beginning in the first 4 months of treatment), shortness of breath, cardiac arrhythmias (abnormal heart beat), various infections including shingles and a condition called posterior reversible encephalopathy syndrome. Physicians monitor regularly for these conditions, all of which are reversible with prompt identification and treatment

I am not aware of any other unexpected problems emerging since the drug was approved and released by the FDA.

​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 my neurologist sign a letter for an emotional support animal?

​Answer:
Any licensed health care provider can provide you with a letter of justification for an emotional support animal. The letter must state that the person applying has a physical or mental impairment (no need to mention the actual diagnosis) that substantially limits one or more major life activities and  their is a disability-related need for an assistance animal.  Specifically, in the case of an emotion support animal, the animal provides emotional support that alleviates one or more of the identified symptoms or effects of a person's existing disability.

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 have RRMS and I’m on Ocrevus. I have had a lot of problems lately with symptoms. I had my second full dose of Ocrevus a week ago. My recent blood work showed a generally normal CBC with a WBC at the low edge but my monocytes % was elevated but only 11. Would this possibly have anything to do with my recent Ocrevus infusion? MS in general? Or is it something I should get looked into for other causes? I looked my labs over the last few years and my monocytes % have steadily increased and have been between 9-11 for a few years. I know it’s mild so I was wondering if I should have any concern outside of MS.

Answer:
Relative percentages of lymphocytes will change when using immunotherapy.  The absolute numbers are more important.  Mild elevations are not likely to be clinically meaningful.  Keep in mind that symptomatic therapy is a different discussion than disease modifying therapy (ie, Ocrevus).

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