Should I conclude my therapy isn't working?

Here is My Question:
I have been taking Aubagio for 3 years. Currently experiencing a flare and recent MRI shows new lesions and old lesions now active. Should I conclude my therapy is not working. Prior to this I was on Avonex for 11 years.

Answer:
The answer to your question depends on the circumstances. Let me provide several examples to illustrate my point:

Example 1: You were placed on Avonex at the onset of your disease 14 years ago with virtually no significant disease activity over 11 years and little loss of function. You became sick of injections and switched to aubagio with no relapses or MRI activity until this recent attack,  your first in many years. In this case I would be looking for something that precipitated or caused the recent attack, such as an upper respiratory tract infection, influenza or a chronic urinary tract infection. You may continue to do well on aubagio if the infection is treated, perhaps with the addition of a course of steroids to clear up the current inflammatory activity in your brain.  In this situation I would get rid of the Aubagio if it is felt that the use of this drug is increasing the number of infections you’ve experienced over the past few years or making you at higher risk of infections. If not, you may be able to continue on Aubagio

Example 2: You were on Avonex for 11 years despite getting  worse over time with or without relapses and probably with MRI activity if this was analyzed correctly. You switched to Aubagio because you were worried about side effects or risks with other DMT choices. You are continuing to experience active disease after 3 years of treatment and continue to lose function over time but are still able to walk with assistance.  This is just the first time you’ve experienced a relapse with MRI activity in several years. You are now under 55 years of age. If this is the case you may be a candidate for highly active treatment such as Alemtuzumab (Lemtrada), Ocrelizumab or Natalizumab (Tysabri). You may still be a candidate for highly active treatment if the details of your case are different than presented in this example, but I would need to obtain more information.

Example 3: Your situation lies somewhere in between these two extreme examples. The choice here would be highly dependent on the details.

Generally, I would only recommend staying on Aubagio if example 1 is more consistent with your case. Your neurologist is in a better position to know the details of your case and advise you further.

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