Archive for the 'Multiple Sclerosis' Category

Expecting the Best in Pregnancy and MS

 Pavle Repovic, MD, Ph.D, Neurologist, Multiple Sclerosis, Swedish Neuroscience Institute

Considering that multiple sclerosis (MS) affects primarily women of childbearing age, it comes as no surprise that for many patients MS and pregnancy often occur together. The issues to consider when discussing pregnancy and MS include:

• How pregnancy affects MS

• How MS affects pregnancy

• How MS treatment should be managed throughout pregnancy

The Pregnancy in MS (PRIMS) study of 254 patients revealed that pregnancy is generally protective against MS relapses, in particular during the third trimester. In contrast, the same study found a rebound of relapses during three months post delivery, with 30 percent of women experiencing a relapse within three months after delivery. Several strategies have been proposed to avert the risk of postpartum relapse, including the use of prophylactic IVIG or corticosteroids. More recently, exclusive breast-feeding has been found to offer some protection against postpartum MS activity; however, this finding was disputed in a subsequent study.

There is no evidence that MS impairs fertility or leads to an increased number of spontaneous abortions, stillbirths or congenital malformations. MS also does not increase a woman’s risk of preeclampsia or premature rupture of membranes. Pregnant women with MS are 1.3 times more likely to undergo antenatal hospitalization and to have a Cesarean delivery, and they are 1.7 times more likely to have infants who are small for gestational age 6.

Except for glatiramer acetate, all MS disease-modifying treatments (DMT) have documented in utero harmful effects in animal studies and are therefore FDA pregnancy category C agents. Glatiramer acetate is a category B agent and is not known to have harmful effects in animal studies, although human studies are lacking.

For these reasons, the National MS Society and most MS specialists advise women who intend to become pregnant to discontinue therapy. Given their pharmacokinetics, we suggest the following schedule based on the type of therapy: one month (glatiramer), two months (fingolimod) or three months (interferons, natalizumab) prior to anticipated conception. It is less clear when to resume the therapy following the delivery.

Because only a minuscule amount of medications is excreted in mother’s milk, some MS specialists advise patients to resume therapy – with the exception of fingolimod or natalizumab – as soon as possible, even in women who intend to breast-feed. In the event of an MS relapse during or after the pregnancy, treatment with high dose intravenous methylprednisolone is generally considered safe for both mother and baby.

Questionable Hope for CCSVI

James Bowen, MD, Neurology, Multiple Sclerosis, Swedish Neuroscience Institute 

Once again, multiple sclerosis patients’ area buzz over a new theory and treatment for the disease. The theory is called chronic cerebrospinal venous insufficiency (CCSVI); and, this time, social media is driving the patient excitement.

CCSVI is based on a controversial idea that impaired venous drainage of the brain due to blockage in venous structures causes MS. Increase in venous pressure promotes leakage of blood across capillaries, with inflammation resulting from the iron deposition into the brain. In 2009 Paolo Zamboni, M.D., reported that virtually all MS patients in a study had abnormalities in the jugular or azygous veins, whereas no control patients had such findings. The Zamboni, or Liberation, procedure involves either angioplasty or stenting of the abnormal vein. Many MS patients are understandably enthusiastic about this theory and treatment.

There are, however, a number of problems with the CCSVI theory that patients and MS neurologists should consider.

• Diagnostic criteria for CCSVI are not standardized or accepted

• CCSVI does not seem to explain the distribution of white matter lesions or the relapsing and remitting course that most patients experience

• CCSVI does not explain the presence of inflammation in MS lesions

• Iron in MS lesions is contained within macrophages, not erythrocytes or free, as predicted by the CCSVI theory

• Other diseases with increased venous pressure do not resemble MS

• Venous drainage is highly redundant, so stricture of a vein usually does not increase venous pressure in the brain

• Changes in muscle tone or posture from neurological disease may explain some venous blockages; and neurological disease can lead to lower venous blood flow due to circulatory auto regulation

Studies that have been performed to date have not supported the CCSVI theory. Preliminary results from the Buffalo Neuroimaging Analysis Center at the University at Buffalo, The State University of New York, found 56 percent of patients with MS, 42 percent of those with neurological diseases other than MS, and 23 percent of controls met criteria for CCSVI. This group found a decrease in cerebral venous volume in MS patients compared to normal, whereas blockage in venous flow would be expected to induce vascular dilation and increased venous volume. At the recent ECTRIMS (European Committee for the Treatment and Research of Multiple Sclerosis) meeting in Sweden, groups from Gotteborg, Berlin, Padua, Amsterdam and London found no evidence for venous obstruction in MS patients compared to controls. A study from London, Ontario, found that venous blockage increased with age in both MS and controls. A study from Beirut, Lebanon, found venous changes in only 9 percent of patients after their first MS attack, increasing to 92 percent with advanced MS, possibly suggesting a late finding that is unrelated to the cause of the disease. Nevertheless, as anecdotal reports continue to circulate of individual patients with dramatic responses to treatment of CCSVI, the theory has been of great interest among MS patients and has become the subject of a significant number of studies.

Before CCSVI can be considered as contributing to MS, three criteria should be required.

1. Venous blockage must be shown to be increased in MS patients relative to healthy controls and other neurological diseases. This would demonstrate an association between CCSVI and MS, but not prove causation.

2. Treatment of CCSVI should stop the progression of MS symptoms in placebo controlled, blinded, multi-center studies. This would prove that CCSVI contributes to MS, but not prove causation.

3. MS should develop in humans or animals with venous blockage.

The scientific community is taking CCSVI very seriously. Most of the studies currently under way are testing whether MS patients have venous blockage. The National MS Society and the MS Society of Canada funded seven 24-month studies in June 2010, totaling $2,400,000 of ultrasound, MRI and angiographic techniques to determine whether venous blockage is specific to MS patients in both adult and pediatric populations. The MS Society of Italy is contributing £900,000 (nearly $1.3 million) to study the question. The Buffalo Neuroimaging Analysis Center is conducting a study of venous imaging, as well as a small treatment trial. Saskatchewan and MS Research Australia have also initiated large studies.

The risks of the Liberation procedure in MS are not entirely understood, though stent migration and fatal intracerebral bleeding have already been described. Only controlled studies will teach us the true complication rate. In the meantime, most MS neurologists are recommending that patients await the results of current studies before proceeding with this controversial treatment. 

Multiple Sclerosis Center 2nd Annual Art Show 2011

 

Bobbie Severson, ARNP, Multiple Sclerosis Center, Swedish Neuroscience Institute

 

The Multiple Sclerosis Center at Swedish Neuroscience Institute is hosting its Second Annual Multiple Sclerosis Center Art Show at the Bellevue Arts Museum on Saturday and Sunday, June 18 & 19, 2011 from 11:00am to 5:00pm.  There will be an ‘Artist Only Meet ‘n’ Greet, Sunday June 19th from 3pm – 5pm

Entry Criteria:

  1. Anyone living with, or touched by, MS can enter the MS art show.
  2. All abilities welcome.
  3. All art is accepted unless you are otherwise notified.
  4. You do not need to be a patient of the MS Center, at Swedish, to submit your art.
  5. Art may be: painting, photography, sculpture, metal, crafts, etc.
  6. Art limit: 2 pieces per artist. Please mark each entry as primary and secondary.
  7. Submission Deadline:  May 13, 2011 by midnight. 

Important information: 

Submit your name, name of artwork, biography of artist (optional, not to exceed 200 words), and a statement about the art piece (optional, not to exceed 200 words).

Indicate whether you want your email address and/or phone number to be disclosed with the biography as contact information for the artist.

This is an art show. There will be NO sale of art. Any sales must be conducted privately through the contact information provided.

Enrollment:  Email msartshow11@gmail.com for an entry form. Submit form by May 13, 2011.

For Questions:  Email msartshow11@gmail.com or call Chaz Gilbert 206 320 2552.

Misc:  Details regarding drop off and pick up of art will be emailed to you once you upon submission of your entry. We do not take responsibility for any damaged art. Any art not picked up after the show will be donated to the MS Center and/or other charitable organizations.

Multiple Sclorosis Center, SNI

James Bowen, MD, Multiple Sclorosis Center, Swedish Neuroscience Institute

The Multiple Sclerosis Center continues to grow. We have added an additional MS nurse, Reiko Aramaki, RN. Reiko joined us from the Evergreen MS Center. She is certified by the International Order of MS Nurses and will expand our ability to respond to patient’s needs.

Outreach programs also continue. Dr. Bowen was recently interviewed by Kathi Goertzen from KOMO TV4 regarding CCSVI. This interview can be seen at http://www.komonews.com/home/video/106166123.html.

Also, Chaz Gilbert, a patient care coordinator won the Seattle Verizon Urban Challenge on 10/30/10, racing through 12 checkpoints in their city using only clues, their feet and public transit.

Exciting Advances in MS from ECTRIMS

There is exciting news from last week’s 26th Congress of the European Committee for the Treatment and Research in Multiple Sclerosis (ECTRIMS) in Gothenburg, Sweden.

ALEMTUZUMAB. 5-year data from a Phase II extension study for alemtuzumab, an intravenously administered monoclonal antibody, showed that the drug:

  • reduced annualized rate of relapse to 0.14 compared with 0.28 for interferon
  • reduced the risk for sustained accumulation of disability in remitting relapsing multiple sclerosis by 87% compared to 62% with interferon.

This is a remarkable agent with excellent activity in MS. Adverse events included immune thrombocytopenic purpura, thyroiditis and anti-glomerular basement membrane disease.

TERIFLUNOMIDE. A Phase III trial of oral teriflunomide in remitting relapsing MS showed:

  • a 31% reduction in relapse rate and increased time to first relapse compared with placebo
  • reduced the risk of sustained disability progression by 29.8%.

Side effects were mild and included diarrhea, nausea, liver function abnormalities and hair loss.

Alemtuzumab and teriflunomide are currently in Phase III clinical trials at SNI.

SNI PRESENTATIONS:

  • Dr. Jim Bowen presented a poster about ongoing demyelination and neurodegeneration in a patient who had undergone autologous stem cell transplantation.
  • Drs. Jung Henson and Mayadev reviewed the beneficial effects of exercise on functional and quality of life outcomes from SNI’s MS wellness program

FDA Approves First Oral Medication for MS

Dr Lily Jung, Medical Director of General Neurology, Swedish Neuroscience Institute

This week the US Food and Drug Administration approved the release of fingolimod (trade name Gilenya®), the first oral medication for the treatment of remitting relapsing multiple sclerosis. Swedish Neuroscience Institute is proud to have participated in the pivotal clinical trial that led to the approval of Gilenya.

Gilenya is a welcome addition to the set of medications available to patients living with MS. There are currently five injectable therapies and two intravenous therapies approved by the FDA for the treatment of MS. Although these treatments are very effective, many patients have been hoping for an oral alternative. Some patients are finding that they have “injection fatigue” or are running out of places to inject the medication.

It is important to note, however, that not all patients should switch to Gilenya. Patients with stable disease should remain on their medications. Patients need to be informed of the risks associated with Gilenya, including slowed heart rate, increased blood pressure, difficulty breathing, abnormal liver function, and infection, and how these risks may apply to them.

If you are wondering whether Gilenya is right for you, please ask your neurologist.

Swedish Summer Research Program a Success

On August 12, 2010 six undergraduate and three high-school students completed the 2010 Swedish Summer Research Program. This program is now in its second year and was led by Dr. Dan Rizzuto, Research Manager at Swedish Neuroscience Institute (SNI) and Dr. John Henson, Director of Neurology at SNI. The 10 week program included training in research ethics and basic neurology as well as weekly seminars from SNI physicians. Each student was also assigned to a research project and individually mentored by the physician investigator leading the research. The program was roundly considered a success by all participants. Of note, one participant and his mentor wrote a manuscript, entitled “The Impact of Electroconvulsive Therapy on Visuospatial Navigation and Memory”, which was submitted to the Journal of ECT.

Special thanks to all of the Swedish project mentors: Dr. Annabaker Garber, Dr. Mike Doherty, Dr. Jim Bowen, Dr. Bart Keogh, Dr. Ken Melman, Dr. Greg Foltz, Dr. Jill Jesurum, Dr. Cindy Fuller, Dr. Nameeta Shah, Dr. John Henson, and Dr. Philip Mease.

We will begin accepting applications in March for the Summer 2011 program. Stay tuned for further details.