Here is My Question:
My 25 year old daughter was recently diagnosed with MS. She now has to decide which drug to start. She is very lucky as this far has no physical symptoms but does have 3 lesions in the white matter. Dr has diagnosed very mild and slow progression ( had 1 older lesion 18 months ago and now has 3 while on no meds). Suggestions would be great!! Not much out there on the new tecfidera
It sounds like your daughter has many options based on the information you provided. I assume she is functioning normally with minimal if any symptoms.
First of all, she should be on a DMT based on her continued disease activity. Please be careful with the terms you use. You question suggests that the 2 new MRI lesions are signs of “progression”. We consider new MRI lesions and relapses as signs of “activity” not “progression”. True progression means that an individual is symptomatically and functionally getting worse on a continual basis. It usually takes many years for any evidence of symptomatic Progression to appear, if ever. Now back to your question. Virtually any disease modifying therapy (DMT) would be acceptable in this circumstance.
Since she is young and her disease has exhibited minimal activity, I would suggest the initial use of DMTs none to have a good long term safety profile as long as they are well tolerated. The usual choices in this circumstance would be glatiramer acetate (either the brand copaxone or generic Glatopa) or one of the beta interferons. Glatiramer acetate is administered subcutaneously either daily or 3 days a week with notable injection site discomfort and reactions. Among the interferons, Plegridy and Avonex are great choices because of the less frequent administration (every 2 weeks and every week, respectively). Plegridy has skin reactions (subcutaneous injection ) and potential flu like side effects whereas Avonex primary has flu like side effects. In my experience about 15 to 20 % of people are not able to tolerate either glatirmer acetate or an inteferon and should be switched to another DMT. These are the DMTs I generally recommend for people with MS like your daughter.
Among the oral DMTs, Aubagio would be a good first choice. There have been few risks with this drug and it is well tolerated. Less than 10 % of people experience mild hair thinning that stops after about 6 months. You must get lab work to monitor liver function and must avoid pregnancy on this drug. If she decides to get pregnant or has any problems on this drug, it is easily to flush it out of her system quickly. Tecfidera is also not a bad first choice although side effects are often more noticeable in the first few months, it must be taken twice a day and there have been reports of very rare serious infections that require her to be monitored. Gilenya is usually well tolerated in younger people if there no heart problems and no history of diabetes. Generally, insurance companies tend to be more restrictive in the use of oral agents in early mild cases that have not tried injectible DMTs, so these may be more difficult to get approved at this point in time.
I probably would not consider any other DMTs at this time given her current circumstances but other agents could be used depending on her future course and response to these potential treatment options. As always, speak with your doctor about this information.
Revere (Rip) Kinkel MD
Director of the Multiple Sclerosis Program
Professor of Clinical Neurosciences
University of California San Diego
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