What should I consider to select the best medication for my multiple sclerosis?

Here is My Question:
I have been dx with RRMS for 2 year; I have been on Copaxone since diagnosis and Rituxan for another medical condition - Ocular inflammatory syndrome which is significantly improved on Rituxin. However, I've had a mild to moderate relapse on both drugs. I am considering staying on combo- but there is thought to moving on? What is your advice if could generally comment. I am considering Lemtrada. The ophtho would have to agree. Exercise, diet and spirituality are my coping methods. Thank You.

Answer:
It is hard to answer your question without knowing the details of your case. For the purpose of my answer I will assume you have an average  case of MS and received the usual dose of rituximab (1000 mg IV X 2 doses every 6 months) in addition to the copaxone. Given these assumptions here are some issues to consider:

Alemtuzumab is a great drug but causes prolonged immunosuppression and a significant risk of autoimmune disease (involving thyroid, platelets and kidneys). All of these issues can be managed. The bigger concern with someone early in the onset of MS , especially if they are relatively young with an uncertain chance of significant worsening over the next 5-10 years, is the potential for long term direct and indirect negative consequences of this treatment ?  For instance, how long can you be treated and retreated with alemtuzumab and will this lead to other complications related to prolonged immunosuppression? What if you require other treatments, such as Tysabri, in the future? We know that a prior history of immunosuppression increases the risk of developing progressive multifocal leukoencephalopathy (PML) on Tysabri therapy. Therefore, treating with alemtuzumab first would create greater risks on Tysabri and potentially other DMTs as well.

I would only consider Alemtuzumab in your case if I thought it likely that your disease would significantly worsen and limit your activities and ability to work and function within the next 5 years. Otherwise, I would consider an alternative disease modifying therapy.

I hope this helps in your decision making. You will need to discuss your risk factors for near term disease progression with your MS specialist before you will be able to make this decision wisely.

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


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