Here is My Question:
I want to get a lip piercing but not sure if my skin will be able to handle it.

Answer:
I wish I could help you answer this question. I can tell you that MS will not affect the ability of your skin to repair itself after trauma, surgery, or piercing. However, certain treatments like recent or current corticosteroids or immunosuppressants can affect healing.

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

Here is My Question:
Hello, I just turned sixty and have had MS for 35 years or so took Avenox and stopped it for extreme flu like symptoms, then took Tecfidera for 8 months or so then stopped it for fear of PML. Just had an MRI that showed little activity (inflamation) is what one neurologist calls it. He wants to repeat MRI in 6 months and perhaps treat then if needed while another neurologist. I see occasionally says I should treat! My question is : How should one make a decision on either or? Thank you in advance for any input you may have have on this subject .

Answer:
Your decision hinges on what is being referred to as, "a little activity", on your MRI and over what time interval this "activity" occurred. MRI activity decreases with each decade, particularly in those with stable MS without progressive disease by the age of 60. 

You need to have an expert independently review your MRI scans to determine if there is really any ongoing MS activity. If there is doubt, then staying off treatment and repeating your MRI in 6 months is reasonable, particularly at the age of 60. 
​
You also need to have a full discussion of your concerns with your neurologist since they are the only ones capable of providing a fully informed opinion based on your history and examination. For instance, we have no information about your disease course, level of disability, risk factors for disease progression or other medical conditions. All these factors are important to treatment decisions. 

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

​#multiplesclerosis

Here is My Question:
What do you know about the EMBOLD A188 trial and it’s promise of demyelination? How far off might we be? Any chance to be included in the phase 3?

Answer:
EMBOLD is currently recruiting patients for the phase 2 portion of the study. UCSD is a clinical trial site for this study. Follow the link pasted below to learn more about the study and to contact Atara Biotherapeutics about a study site near your residence. If you live in San Diego County, UCSD is one of the study sites for the EMBOLD study. You need an appointment with either me or Dr Jennifer Graves to be evaluated for this study. The main entry criterion is progressive multiple sclerosis and age less than 61.

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

Here is My Question:
I'm seeking financial resources that could help with cost of building an entry ramp in BAY Area, CA​

Answer:
I would reach out to the National Multiple Sclerosis Society patient assistance program for starters. If you see an MS specialist at an academic center, reach out to their social worker for community assistance programs.

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

Here is My Question:
Can I have MS and abnormally low iron levels

Answer:
Multiple Sclerosis and Iron levels are unrelated. Therefore, both may occur at the same time. 

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

Here is My Question:
WBC count is 2300. Hip fracture 8 months ago resulted in 3 pins inserted in bone. I am very thin and my doctor said I might need them removed eventually because they cause pain in thin people. I am having MS symptoms - pseudo exacerbation. Could this be the cause?

Answer:
If I understand you correctly, you are experiencing pain at the hip fracture site and a pseudo exacerbation related to the pain. This is certainly possible since hip pain or any lower limb pain can dramatically increase spasticity and spasms and worsen mobility. If this is the case, see the orthopedic surgeon to determine the source of the pain.

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

Here is My Question:
RRMS diagnosed age 14 immediately following onset. Treated with Rituxan x 3.5 yrs, full health, then switched to Ocrevus age 18 yrs in 8/21. Soon began chronic infections for months, advanced severe bacterial and COVID pneumonia. Now completing IVIG and recovering. 1) How now to manage MS? 2) lower dose/Rituxan/Kemsimpta, other DMT? 3) can I consider no DMT for at least a period of time to restore my immune system? 4) any suggested dietary plan- Best Bet? Thank you!

Answer:
Not knowing the details of your case, let me provide some information so you can ask your neurologist (MS specialist) some important questions.

1. You are very young and already immunosuppressed. But because you are young, your immune system will be restored over time. After prolonged repeated rituximab and ocrelizumab treatments, this repletion of your immune system can take several years. 
   Your physicians can monitor your B cell subsets to determine when they are repleted. It will be important to know when central memory B cells and Plasmablasts begin to return. ARUP (a commercial lab) has a nice B cell subset analysis panel that can be used for this purpose
2. Ask your physicians to consider continued immunoglobulin replacement therapy until your IgG levels remain normal; 
3. One option for treatment that may help control viral infections and benefit your MS is  Beta-Interferon. There are many brands available including long acting Pegylated Interferon. These are all administered by subcutaneous injection. The Beta Interferons are still quite useful treatments for MS but may cause flu like side effects when started. The side effects can usually be controlled with acetaminophen and ibuprofen. If you do start a Beta Interferon therapy, make sure your physicians monitor you closely with repeated MRI scans beginning 3 and 9 months after starting treatment. If your MRI scans are stable at 9 months, you can lengthen the interval between scans.
4. Most of the other treatment options may lower lymphocyte counts to an unacceptable level, which is to be avoided in your immunosuppressed state. You can reconsider these options with your physicians after your B cells subsets and immunoglobulin levels are both repleted.

Good luck . See what your doctors think and work with them to find a good solution.

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

​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.​

Here is My Question:
I'm taking Tecfidera and have no issues so far but I'm expecting supply disruption that can take up to 1 week, now my question is am I going to experience any issues when I get on the tablets again? Thank you

Answer:
It is possible that some of the initial side-effects you experienced when first starting Tecfidera may reappear after restarting Tecfidera a week later, but these should be minimal and resolve quickly if you are not having problems now.

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

Here is My Question:
Can chronic inactive lesions still cause problems and can these problems get worse? My balance is getting worse as are my eyes. Thanks

Answer:
There is no sure way at present to differentiate chronic inactive from chronic active MS lesions during life with a tissue biopsy. These terms are pathological descriptions without a definite correlate on MR imaging. That said, there are many ways for MS to progressively worsen in those individuals who do not appear to show any changes on MR imaging over many years.  Examples of ways in which MS can worsen over time despite no change on standard MR imaging of the brain or spinal cord include the following:

1. Progressive demyelination and axonal injury in the spinal cord. The spinal cord, particularly the thoracic spinal cord, is difficult to image and detect enlarging or new lesions during the progressive phase. Accurate measurements can usually detect atrophy of sections of the spinal cord, but this is not done in standard practice.
2. The demyelination is occurring in the cerebral cortex. Demyelination in the cortex is not visible at all with standard imaging techniques
3. The worsening is due to progressive axonal transaction or energy failure in chronic lesions on MR imaging. This often takes years to become visible
4. The worsening is due to widespread synaptic or axonal injury in gray matter or white matter networks that appear normal on MRI
5. The worsening could be due to the normal aging process superimposed on prior damage from MS. Remember, our brains normally atrophy at a rate of 0.1 to 0.2 percent per year in health individuals. If there is already damage from years of MS, this further rate of "normal" age related atrophy will become more apparent because of exceeding the threshold of neurological reserve.

I'm sure I could think of other reasons, but these are the most important. Some people take an over-the-counter supplement, Alpha lipoic acid (600 mg twice a day), to help prevent further injury and deterioration from inflammatory stress in the nervous system. There are some very preliminary studies suggesting this may be helpful.

Good luck

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

Here is My Question:
I stopped using Butrans patches for scoliosis pain 3 weeks ago. My leg strength and mobility have really deteriorated. Will this pass? Is there a connection?
Thanks.

Answer:
You should direct this question to your neurologist. He will know the strength of your prior Butrans patch, other medications that may be contributing to your sense of weakness and the reason you needed such a strong narcotic for pain. This will go a long way to answering your question. 

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

Here is My Question:
Recently been smelling strong cigarette smoke, pain and weakness in left arm and leg, neck and shoulder pain and shooting pain in head. Rectal spasms when the weird smell occurs. I have Crohn's Disease and convinced I have MS. Being referred to neurologist. Alongside depression and memory lapses. I’ve had this in episodes for past few years on and off. Hip pain etc. can’t find anything on MRI. Docs says not stroke but I know this is nervous system. Could this be start of MS flare?

Answer:
I suppose your symptoms could be related to any number of things including MS. Your upcoming neurological evaluation should provide you with the necessary answers to your question. 

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

Here is My Question:
Does a person's height have anything to do with the effects of medications such as Baclofen? I am very short and wonder if the medicine lasts longer for me and I should take it less frequently.

Answer:
The size of a person, which is partially governed by height, can affect the volume of distribution and half-life of many medications. Doctors and pharmacists should be well trained in these particulars. This is particularly important for medications with a small "therapeutic window". For drugs with small therapeutic windows the concentration in the blood stream must be kept within a relative narrow range to be effective without causing side effects or toxicity. 

Baclofen does not have a small therapeutic window and the effective dose can vary dramatically from one individual to another for a variety of reasons. We therefore start with low doses and gradually increase the dose until a desired effect is observed or unacceptable side effects occur.

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

​Here is My Question:
Do I need to go to the hospital for new symptoms of MS if I don’t have a neurologist?

Answer:
You should contact your primary care physician, if you do not have neurologist to determine if a trip to the hospital is necessary for any new or recurrent symptoms.

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

Here is My Question:
Does MS make you loose hair?

Answer:
MS is not associated with loss of hair (called alopecia). Loss of hair has many causes including some of the medications used to treat MS. Contact your primary care physician for further information.

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

#multiplesclerosis
#MS
​#hairloss

Question:
Can I get a nose piercing with MS?

Answer:
There are no problems, related to the diagnosis of MS, of any body art including piercings and tattoos. Some tattoo dyes may have ferromagnetic properties that can heat up in a magnet and cause irritation. Piercings do not create a problem unless they cannot be removed during the MRI procedure.

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

Here is My Question:
The one neurologist in town that did a lot of tests on me, now refuses to do any follow up appointments. My question is, where can I seek another neurologist when I’m having all the symptoms of MS and it’s debilitating my day to day life?

Answer:
A physician has a continuing responsibility of care until they discharge you back to your primary care physician (PCP) or you establish care with another specialist in the same field. Please check with your PCP to see if the neurologist sent a final consultation note with recommendations. If the neurologist did not send such a note, your PCP should request that this be done.

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

Here is My Question:
My legs are feeling stiff and hurt after sitting or laying down. I'm also a bit off balance. I first felt knee pain, then stiffness. Thank you.

Answer:
It is very common for people with MS and people with arthritis to experience stiffness and discomfort in the legs after prolonging rest sitting or lying down. It helps to stand, walk, and stretch every 20 minutes. There are many reasons this problem can worsen from time to time. For instance, this program is often worsened by colder weather. I would suggest discussing this further with your doctor. If no obvious problem discovered, I would suggest stretching more frequently before starting new medications

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

Here is My Question:
I have asked for reasonable accommodations at my work. I teach. One semester it was provided. The last three it was not. I have asked repeatedly and they said they would process it, but it had not been handled. I have a lecture podium and a really tall chair with wheels. I’m 5’4 and have weakness sometimes. I have straight up fallen trying to get into the chair in front of my class. My department says they would handle it, but nothing ever gets done. I have noticed they’re putting pressure on me in other areas that are ridiculous and irrelevant…inconsistent with how they treat my colleagues. I sent ANOTHER request for my accommodation (chair without wheels and a lower desk….totally not unusual). I also contacted my union representative.

What gives?? What can I do??

Answer:
Discrimination in the workplace against those with disabilities is usually more subtle. Meet with your union representative and approach human resources together. Make sure the supporting documentation from your MS specialists meets all your workplace needs. Unfortunately, you may need to find an attorney who handles workplace discrimination law. Remember, you are a protected class.

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