Should I stay on Tecfidera or switch to Mayzent?

Here is My Question:
I am 55 years old and was diagnosed with multiple sclerosis 5 years ago. My first symptoms started more than 15 years ago but I was not diagnosed with the disease at the time. After my diagnosis I was put on Tecfidera and have been on the medication since then. It has done a good job controlling my disease. I have had no side effects while on the medication.

I had a recent worsening of symptoms that improved within 4 days. I had an MRI scan done and there were minimum new changes that do not explain my complaint. My doctor thinks that it might have been a pseudo relapse, or that I could be transitioning into the secondary progressive form given the length of my disease activity (more than 15 years now).

Here are my questions:

1. Do I remain on Tecfidera? I have done so well on the medication so far.
2. If I get off Tecfidera do I have to have a wash period of 4 weeks before starting another medication?
3. Do I switch to Mayzent since it is said to help SPMS? My doctor is leaning towards Mayzent. But I worry about its side effects especially since I get frequent migraines and then there is the risk of rebound if I get off it.
4. Would Ocrevus be a better option for me? Has an increased risk for breast cancer been observed in patients on the medication?

Your input is greatly appreciated. Thank you.

Answer:

Thank you for your question and providing the great amount of detail about your case

To summarize:

• Onset of your MS was probably late 30's but symptoms too minor or non specific to diagnose MS for 15 years.
  
• Diagnosis of MS at age 50 and started Tecfidera.
  
• Tecfidera well tolerated and effective until recent transient worsening of symptoms for 4 days with return to baseline level of function.
  
• Repeat MRI done with report of questionable new findings 

The easy answer is just to stay on the Tecfidera and monitor more frequently by Quantitative Clinical Performance Evaluations and another MRI in 6 months. Going forward I encourage you and everyone reading this post to thoroughly consider your goals or treatment and decide ahead of time what it would take for you to consider changing that treatment.

To answer your other questions
2. There is no particular reason for a wash out period if your lab values, specifically your absolute lymphocyte count is above the lower limit of normal range
3. I have heard nothing in your report to suggest you have SPMS. 
4. Ocrevus is a great drug. We have no evidence from your experience that either Mayzent or Ocrevus would be a better drug for you than the current tecfidera

Of course, your doctor knows your case better than I do and may have other information that you (and I) are not aware on which he or she is basing their recommendations. I would encourage you to have a full discussion with him or her about all the reasons for this recommendation to change therapy. Make them defend this decision.
Since we are not curing MS yet, we expect occasional hiccups and one every 5 years that last 4 days is not a major decision making event.

​Thank you for your question and providing the great amount of detail about your case

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