Top 100 MS Questions

1. What is multiple sclerosis (MS)?

MS is a chronic disease of the central nervous system (CNS) which affects mostly young people between
the ages of 15 and 45 years. The CNS includes the brain and the spinal cord. MS is not a disease of
peripheral nerves or muscles.

2. Is MS an autoimmune disease?

MS is thought to be an autoimmune disease. In this type of disease, the body’s immune system, which
normally fights infections and protects itself, inappropriately attacks parts of the body; in the
case of MS, myelin (the protective sheath around the nerves) and axons (a part of the nerve itself)
are the immune systems targets.

3. Does MS affect survival?

In general, MS does not affect survival. With the current state of medical care and new treatments,
the vast majority of MS patients are expected to live close to a normal life span.

4. What are the common symptoms associated with MS?

Some of the most commonly reported symptoms include numbness, tingling, pain, weakness, clumsiness,
loss of vision, double or blurred vision, tremor, imbalance, urinary urgency and/or frequency,
fatigue, depression and heat sensitivity. Each case must be carefully evaluated; the presence of any
of these symptoms does not confirm the diagnosis of MS.

5. What is optic neuritis (ON)?

Optic neuritis (ON) causes decreased vision sometimes accompanied by eye pain that develops over a
few hours to a few days. Patients usually recover vision within a few days to few weeks. The risk of
developing MS after experiencing ON depends on the brain MRI scan among other factors. In the
presence of brain MRI abnormalities, the risk of developing MS after an episode of ON is high, with
several studies suggesting 80 to 90% of these patients will go on to develop MS. However, before
confirming the diagnosis of MS, a thorough diagnostic evaluation is required. Optic neuritis can
also be seen in many other diseases such as lupus or sarcoidosis.

6. Does heat sensitivity make MS worse and what is Uhthoff’s symptom?

Exposure to hot ambient temperatures (a warm summer day, hot tub, etc) can make some MS symptoms
worse, but does not worsen the disease itself. This phenomenon was first observed by Wilhem Uhthoff
is 1890 and is referred to as Uhthoff’s symptom. It is estimated that 30-40% of MS patients are heat
sensitive. In the 1950s, a hot water bath test was developed as a diagnostic test for MS. Patients
with suspected MS and heat sensitivity would feel uncomfortable in a hot water tub and this would
help the clinician in supporting the diagnosis of MS. For this reason fever, hot baths, sunbathing,
and heavy exercise may have to be avoided by some MS symptoms. These symptoms usually improve after
the patient cools down or returns to an air-conditioned environment.

7. What is transverse myelitis (TM)?

Transverse myelitis (TM) means inflammation of the spinal cord. Symptoms are usually numbness and
weaknessof the legs, and difficulty urinating. Depending on where the inflammation is located in the
spinal cord, TM can cause hand and arm numbness and weakness as well. TM is typically sudden in
onset and reaches its peak within one or two days. The risk of developing MS after experiencing TM
depends on MRI scan of the brain and spinal cord. The doctor may therefore order a brain and spinal
cord MRI scan to evaluate this risk of developing MS in a person who experiences TM. Many other
diseases such as lupus, infections, or vitamin B12 deficiency can cause spinal cord symptoms.
Therefore, a careful diagnostic evaluation of TM is needed before confirming any diagnosis.

8. How is pain associated with MS?

Pain is commonly reported by MS patients. Various types of pain that have been described in MS
include: burning pain, electric shock-like sensations, deep continuous aching pain, pain related to
muscle spasms, and band-like sensation in the chest or abdomen. Pain could be acute (sudden onset),
chronic (persistent over a period of time), or episodic (off and on). Because pain from MS can be
hard to distinguish from pain seen in other common disorders, it should be carefully evaluated
before any recommendation of treatment is made.

9. How is fatigue associated with MS?

Fatigue is one of the most common symptoms of MS and can be challenging to treat. It can affect a
patient’s ability to work and interfere with day to day activities. MS fatigue can present as an
overwhelming need to nap, as motor fatigue where a patients legs get tired quickly during walking,
or as cognitive fatigue where it becomes hard to concentration on a task for a long period of time.
The patient may experience severe fatigue and yet appear quite normal to others.

10. How are coordination, balance and tremors associated with MS?

MS patients can develop clumsiness, poor balance and tremors in arms and/or legs. Some times these
symptoms can be treated with medications. However, they can be very difficult to treat.

11. How are weakness and spasticity related to MS?

Weakness is a common symptom of MS; it is due to a problem of the brain or the spinal cord, not from
a problem with the nerves or muscles. It could involve one or both sides of the body and can be
confused with a stroke. Spasticity, or limb stiffness, is commonly associated with MS weakness and
can make moving a weak limb even more difficult. Spasticity can also cause severe tightness of the
legs leading to pain and discomfort. Spasms can also occur episodically and sometimes every day.
Fortunately, spasticity can be treated effectively with a number of different medications.

12. How are cognitive dysfunction and MS related?

Short-term memory loss and mild difficulty with thought processing can be seen in up to 45-65% of MS
patients. These symptoms rarely progress to severe difficulties with memory and thought processing,
such as those seen in Alzheimer’s disease.

13. What is the relationship between mood disorders and MS?

Depression and mood swings are not unusual in MS. They can often be treated effectively with
medications. Rarely, a patient may initially present with behavioral and emotional problems leading
to further work up and MRI scans revealing abnormalities consistent with MS.

14. How is abnormal eye movement associated with MS?

MS can cause many different kinds of eye movement abnormalities. These abnormal eye movements may
result in double vision or blurry vision. Sometimes the neurologist may seek the opinion of another
expert known as the “neuro-ophthalmologist” who may help manage these symptoms with either
medications or special glasses.

15. What is Lhermitte’s Sign?

This symptom (although incorrectly referred to as a sign) is named after the French neurologist (Jean
Lhermitte) who first described it in 1924. Lhermitte’s sign is an electric shock-like sensation
radiating down the back and into the arms or legs when the neck is bent. It is a common MS symptom,
but can also be seen in other diseases affecting the upper spinal cord.

16. What are the Episodic symptoms of MS?

Episodic symptoms (symptoms that come and go) are common in MS. They are typically abrupt in onset,
last only a short time (few seconds to few minutes), and resolve on their own. They can occur
several times a day and may include loss of balance, slurred speech, double vision, dizziness,
painful tingling, electric shock-like sensations, or repeated muscle contractions. These episodic
symptoms do not indicate the patient is having a seizure (See Treatment).

17. What urinary symptoms are associated with MS?

Urinary dysfunction is also a commonly reported symptom of MS. Different types of urinary symptoms
seen in MS patients are:
Urgency (Inability to postpone urination once the need has been felt)
Frequency (need to urinate more often)
Incontinence (Loss of bladder control)
Hesitancy (Trouble starting and maintaining urination)
A combination of the above
Most of the times, the neurologist may be able to treat the urinary symptoms with medications.
However, it is always useful to consider an opinion from a urologist who may do additional studies
to determine how the urinary bladder if filling and emptying, and prescribe appropriate
medications.

18. How is bowel dysfunction associated with MS?

Bowel symptoms are common in MS, especially constipation. Bowel incontinence (loss of bowel control)
may also occur, and may respond to treatments (See Treatment).

19. How is sexual dysfunction related to MS?

Sexual dysfunction is common in MS. Common symptoms include erectile difficulties, impaired vaginal
sensation and lubrication, decreased libido, and difficulty in achieving orgasm. Many of these
symptoms may respond to medications.

20. How is MS diagnosed?

There is no single test that can diagnose MS. It is a clinical diagnosis, meaning the diagnosis has
to be based on the patient’s history of symptoms, neurological examination, and investigations
including MRI scans.

21. What are the different types of MS?

There are two broad classes of MS:

Relapsing-remitting multiple sclerosis (RRMS) is the most common type of MS (80-85%). This form of
MS is characterized by relapses or attacks (SEE BELOW SECTION ON MS ATTACKS) with periods of
stability in between (or remission). This type of MS usually starts in the late twenties or early
thirties and is almost three times more common in women than men. Later in the disease course, RRMS
patients may stop having frequent attacks but slowly start progressing. This stage of MS is referred
to as Secondary Progressive MS (SPMS). Patients with SPMS can have relapses but usually have a
progressive course.
Primary-progressive MS is the less common form of MS (10-15%). In this type of MS, patients do not
experience relapses and progress steadily from the very beginning. This type of MS tends to occur
more commonly in some what older people, usually in their forties or fifties. Unlike RRMS, men and
women with PPMS tend to be affected equally.
Rarely, patients who have had PPMS for several years may have an attack that can confuse both the
patient and the neurologist regarding the type of MS. This is probably the most rare type of MS in
which patients with PPMS may experience a rare attack. Such patients are referred to as Progressive
Relapsing MS.

22. What tests are used to diagnose MS?

The MRI of the brain and spinal cord are the most important tests because more than 90% of the
patients who have MS also have changes on the MRI scan consistent with MS. Other useful tests to
consider are the lumbar puncture (spinal tap) and evoked potentials (see below). Blood tests and in
some cases a chest CT scan are needed to rule out other diseases which can mimic MS, like lupus and
sarcoidosis.

23. What if the brain and spinal MRI are normal?

If both the brain and spinal cord MRIs are normal, the diagnosis of MS, although still possible, is
very unlikely. In this instance, a lumbar puncture may be recommended. Furthermore, it may be
necessary to examine the patient at frequent intervals and repeat MRI scans as needed.

24. Is a lumbar puncture (also called a spinal tap) necessary to diagnose MS?

No, a lumbar puncture (LP) is not necessary to confirm the diagnosis of MS. The LP is a relatively
simple procedure that can be done in the doctor’s office in about 30 minutes. It involves giving
local anesthesia in the lower back before inserting a small needle into the lower back to obtain a
small amount of fluid. This fluid, called cerebrospinal fluid or CSF, bathes the spinal cord and the
nerves coming out of it. Almost 80 to 90% of MS patients have immune system abnormalities in the
spinal fluid. These abnormalities can be seen in other disease as well and therefore, the doctor has
to keep in mind the clinical “picture” when interpreting the result of the spinal fluid.

25. Evoked potentials (EP) and MS

Evoked Potentials are tests that measure the brain’s response to certain types of stimulation. They
are less sensitive tests than MRI and LP in diagnosing MS but may still be helpful in certain
situations. Three kinds of EPs are used by neurologists:

Visual evoked potentials (VEP) look for abnormalities in the visual system, particularly the optic
nerves.
Brainstem auditory evoked potentials (BAEP) look for hearing abnormalities in the inner ear and the
hearing centers in the brain.
Somatosensory evoked potentials (SSEP) look for abnormalities in the transmission of sensation from
an arm or leg through the spinal cord to the brain.

26. Which diseases can mimic MS?

The list of diseases with clinical symptoms or MRI results that can mimic MS includes, but is not
limited to:

Lupus

Sarcoidosis

Sjogrën’s syndrome

Vitamin B12 deficiency

Lyme’s disease

Stroke

HTLV-1 myelopathy

Vasculitis

Genetic mutations that can stroke (CADASIL)

Genetic mutations that can cause abnormalities of myelin (also known as leukodystrophy)

Leber’s hereditary optic neuropathy ( a genetic mutation that can lead to progressive loss of vision
and blindness along with occasional MRI abnormalities)

Mitochondrial diseases. This is a group of diseases which are as a result of genetic abnormalities
that can cause symptoms and MRI scans mimicking MS

Each of these should be carefully evaluated depending on the patient’s history and neurological
examination. Not every single disease mimicking MS needs to be ruled out in every case.

27. What is the appropriate strategy for a patient suspected of having MS but with a normal
examination and investigations?

Sometimes MS can take several years to be confirmed. In this situation, the patient should be
followed periodically by a neurologist. Based on the patient’s history and neurological examination,
it may be helpful to repeat brain and spinal cord MRI scans as needed. However, symptoms alone
should never be used to confirm the diagnosis of MS. Objective evidence is required to support the
diagnosis of MS.

Symptomatic Treatment of MS

Symptomatic treatments approved for use in patients with MS

Generic name
Market name
Symptoms Indicated
Baclofen
Lioresal ®
Spasticity, cramps, stiffness
Tizanidine
Zanaflex Ô
Same as baclofen
Cortitcosteroids
Solumedrol, Prednisone
MS attacks
Dextromethorphan/Quinidine
NuedextaÒ
Pseudobulbar Affect
Dalfampridine
Ampyra ®
Walking

28. Which MS symptoms can be treated?

MS is associated with a number of symptoms including vision difficulties, speaking and swallowing
difficulties, weakness, numbness, pain, limb stiffness, clumsiness, tremors, bladder, bowel and
sexual dysfunction, thinking and memory problems, depression, fatigue, and episodic symptoms. These
symptoms may affect a patient’s functioning and well-being. Treatment of symptoms may improve
quality of life and day to day functional ability. However, symptomatic treatments do not slow down
the disease from progressing. Often symptomatic treatments used in MS were originally approved for
other indications (diseases) but through clinical experience have become useful drugs to treat MS
symptoms.

In January of 2010, the FDA approved Amypra, a medication to help MS patients walk better and
faster. This is a symptomatic treatment taken by mouth twice daily. It can be very effective in
patients who have leg weakness, are sensitive to heat, have poor physical endurance. Overall, it is
very safe but it is contraindicated in patients who have a history of seizures. The use of Ampyra
and its side effects should be discussed with your neurologist.

29. Can you treat ataxia and tremors in MS?

Ataxia (difficulty with balance and coordination) is a difficult symptom to treat. Most drugs have
little effect on ataxia. Similarly, tremor is also a difficult symptom to treat; medications used
for tremor may only be partially effective. These include clonazepam, tegretol, INH, and keppra.
Several centers have studied the effect of a deep brain stimulator (a device implanted into the
brain) on tremor. This procedure is typically used for tremor seen in patients with Parkinson’s
disease. However, in some MS patients, improvement in hand function has been reported.

30. How do you treat bladder dysfunction in MS?

MS can cause bladder symptoms. Bladder symptoms can also develop from a urinary tract infection or
UTI. In order to determine the cause of bladder symptoms, the doctor may order a urine test called
urinalysis that may detect an infection which can be confirmed by a culture and sensitivity test.
However, many of the symptoms from a UTI can mimic symptoms from a urinary bladder affected by MS.
These symptoms include urgency, frequency, incontinence, and retention. It is best that you discuss
these symptoms with your doctor before any medications are prescribed. An assessment by a urologist
to evaluate urinary bladder function can be helpful.

31. What are some preventive measures for bladder dysfunction?

Optimizing fluid intake (6-8 large glasses of water a day)
Scheduling times to urinate throughout the day
Scheduling self catheterizations (if instructed to do so by a urologist)
Making toilets more available (bedside commodes, portable urinals for both men and women)
Pelvic muscle strengthening exercises (see Rehabilitation section)
Recognizing skin rashes and improving skin care

32. What are some preventive measures for bowel dysfunction?

Optimizing fluid (6 to 8 large glasses of water a day)
Optimizing fiber intake (20g/day)
Encouraging defecation when the urge is felt
Maintaining a regular schedule for bowel movements

33. How do you manage bowel dysfunction in MS?

MS patients can often have bowel symptoms and most commonly constipation. Rarely, this is severe
requiring regular medications prescribed by a doctor. However, often times, bowel symptoms can be
managed by a bulk or high fiber diet. Additionally, the following measures can also be helpful:

Non-habit forming agents including bulk forming agents (psyllium) and stool softener (docusate
sodium)
Habit forming agents: oral stimulants (milk of magnesia, bisacodyl), rectal stimulants
(suppositories, enemas)
Other prescription medications including enemas are also options to consider but generally as a last
resort. It is best to discuss this with your doctor.

34. Where can I learn more about bowel and bladder related issues?

For more information regarding the bowel and bladder issues, call or check online with the National
Association For Continence, phone # 1-800-BLADDER (http://www.nafc.org/).

35. How do you treat cognitive dysfunction in MS?

Cognitive dysfunction (problems with thinking and memory) can occur in at least 50% of MS patients
although some studies suggest an even higher percentage. The cause of cognitive dysfunction is not
well understood in MS although MRI studies suggest involvement of grey matter that may contribute to
cognitive dysfunction in MS. However, most patients with MS who develop cognitive symptoms do not
progress like patients with Alzheimer’s disease or other forms of dementia. The treatment of memory
and other cognitive symptoms in MS requires careful evaluation before suggesting any medications.
Most medications used to treat cognitive dysfunction in MS are usually approved for other diseases
such as Alzheimer’s but used as “off label” in MS. Two such examples include AriceptÒ and NemendaÒ,
although properly controlled studies have yet to be conducted in MS to prove the efficacy of these
agents to treat memory problems in MS.

A new drug approved for the treatment of MS patients who have pseudobulbar affect (PBA) was approved
by the FDA in 2011. PBA is a condition in which patients can not control their emotions and
uncontrolled episodes of laughing or crying. This can be very debilitating. The name of the drug is
Nuedexta which can be very helpful for patients with PBA. The use of this medication and its side
effects should be discussed with your neurologist.

36. How do you treat depression in MS?

Depression is an important symptom and diagnosis to recognize. It is very common in MS and can lead
to a variety of symptoms such as fatigue, loss of appetite, or lack of interest. Conversely, many of
these symptoms lead to the diagnosis of depression. Addressing depression and treatment of
depression can improve the patient’s quality of life. Psychologists or psychiatrists familiar with
treating MS patients can be helpful. There are a number of drugs which can be used for the treatment
of depression: Selective Serotonin Reuptake Inhibitors (SSRIs) are often preferred because they have
fewer side effects compared to other classes of antidepressants. However, it is important to know
that there are several options to choose from and should be discussed with your doctor.

37. How do you treat painful episodic manifestations?

Episodic symptoms causing pain such as trigeminal neuralgia can be treated with different types of
antiepileptic (anti-seizure) drugs (carbamazepine, gabapentin, topiramate, phenytoin and
pregabalin), anti-spasticity agents (baclofen) or with some of the antidepressants proven to be
useful in chronic pain (amitriptyline, nortriptyline, duloxetine). If medical treatment fails to
control the symptoms, more invasive treatments such as injecting phenol or ethanol to block nerve
conduction or surgery to ablate (cut) nerve roots can be considered.

38. What are some measures used to treat fatigue?

Fatigue is one of the most common and bothersome symptoms of MS. It can be experienced by patients
who otherwise are doing well even in the early stages of the disease. The mechanism of how fatigue
is caused in MS is not well understood.

There are non-pharmacological and pharmacological measures to deal with fatigue.

Non-pharmacological measures include avoiding aggravating factors such as heat, excessive exercise,
and fevers. Also, low intensity physical activity (yoga, walking, exercising in a cool pool) has
been show to help reduce fatigue in MS patients. Afternoon short nap or rest can be very helpful if
possible. Relatively lower carbohydrates (sugars) around mid-day are best avoided to minimize the
“highs” and “lows” associated with them. Normal sleep cycles at night can also help is controlling
fatigue. Treatment of depression may also improve fatigue.
Pharmacological therapies for fatigue are generally modest in their effect and after some time tend
to become less effective. There is no controlled trial that has shown unequivocal efficacy of these
drugs in controlling MS fatigue. However, on a case by case basis, they can be very effective. These
drugs include amantadine, modafinil, CNS stimulants, antidepressants, 4-AP (4-aminopyridine) and
levo-carnitine. The use of all of these agents in treating fatigue is considered “off-label”.

39. Treating nystagmus in MS?

Nystagmus (rapid involuntary back-and-forth eye movements) is one of the most challenging symptoms
to treat. Some studies suggest that memantine (NemandaÒ) may be effective. Medications such as
baclofen, clonazepam, and gabapentin have shown modest improvements.

40. How do you treat Spasticity in MS?

There are a number of drugs used to treat spasticity (stiffness, spasms, or cramps caused by MS).
These include baclofen, tizanidine, clonazepam, and diazepam. Other medications including tegretol,
carbatrol, trileptal, and kepra can also be used to treat severe episodic spasms. In difficult
cases, baclofen can be administered directly into the spinal fluid through an implantable pump. For
focal hypertonia (stiffness) affecting one arm or one leg only, botulinum toxin can be used. Daily
stretching exercises may help temporarily decrease spasticity and help prevent muscle
contractures.

41. What are some medical interventions for men with sexual dysfunction?

Oral agents like sildenafil, urethral suppositories like prostaglandin E1 (PGE1), and injections
like papaverine, phenoxybenzamine and PGE1 can be used for erectile dysfunction.
Vacuum suction devices, or pumps, are used to create an erection. When using a hand pump or a
battery-operated machine, air is suctioned out of the tube, creating vacuum around the penis. This
causes blood to move into the penis and erection to occur; a band is then placed at the base of the
penis to maintain the erection and the device is removed.
Penile implants, both inflatable and non-inflatable are available. The advantages and disadvantages
should be discussed with a urologist.

42. What are some medical interventions for women with sexual dysfunction?

This is a difficult subject to address because the relative availability of medications and devices
helping women with sexual dysfunction is minimal. Use of lubricants for vaginal dryness is
recommended. A number of natural or herbal supplements have been advertised on the internet with
claims of success. We suggest discussing all of these options with your doctor. A good website to
visit to learn about sexual dysfunction and available treatments is www.aafp.org, and click under
the “news and publications” section for female sexual dysfunction, evaluation and treatment.

43. What is an MS attack?

An MS attack (also called exacerbation, flare up or relapse) implies worsening of symptoms that is
usually abrupt and develops within a day or two. The symptoms can be entirely new to the patient or
simply be worsening of previous symptoms such as leg weakness that become a lot worse within a day
or two. It is believed that focal areas of severe inflammation can lead to an attack experienced by
the patient. Therefore, quick recognition of anattack by the neurologist is important. This may help
in successful and timely treatment leading to complete recovery.

44. How are MS attacks treated?

In evaluating an MS attack, it is important to check for an infection (such as a urinary tract
infection), which can precipitate an attack or cause old MS symptoms to recur (a
pseudo-exacerbation). In such cases, when there is evidence of active infection, it is best to treat
the infection or wait for it to subside before instituting any treatment for the relapse.

Typically, MS attacks are treated with high-dose intravenous (IV) steroids, one gram a day for 3 to
5 days. Under certain circumstances, such as in patients with poor venous access or when a patient
is traveling away from home, steroids can be given orally.

Steroids used for the treatment of the MS attack are not muscle builders or performance enhancing
steroids. The steroids used in MS and often in other conditions such as arthritis or asthma,
decrease inflammation. The goal of steroid treatment of MS attacks is to speed up the recovery of
deficits and minimize tissue damage from severe inflammation.

Studies are underway to compare the efficacy of intravenous versus oral steroids in the treatment of
MS attacks. It is possible that comparable doses of oral and intravenous steroids may be equal in
their effect.

45. Is it necessary to administer steroids in the hospital?

No, if a patient is clinically stable and safe at home, then IV steroids can be administered at home.
However if there is a risk of falling or other safety concerns, or complicating medical conditions
such as diabetes, then it is preferable to admit the patient into the hospital for this treatment.
In case of diabetes, it is always preferred thatthe patient receives steroids in the hospital to
closely monitor blood sugar levels and give insulin as needed.

46. Is it necessary to take an oral taper of steroids after the IV course?

There is no good data to prove that an oral taper with prednisone is needed after finishing a course
of IV steroids. Some neurologists use oral prednisone because in their experience their patients do
better with the taper. This option should be evaluated on a case-by-case basis. There are some
studies suggesting that oral steroids given after IV steroids make no difference on recovery from an
attack.

47. What are the side effects of steroids?

Short-term side effects usually resolve once the steroid course is over or soon there after. They
include:

Mood irritability
Euphoria (sense of well being)
Headache
Flushing of the face
Increase in appetite, weight gain
Metallic taste
Heartburn
Increase in blood pressures
Increase in blood sugars
Oral and/or vaginal fungal infection
Overall increase in energy
Side effects seen with prolonged steroids that can persist or even become permanent complications of
steroid use include:

Osteoporosis (thinning of the bone)
Menstrual irregularities
Cataracts
High blood pressure
Diabetes
Suppression of the immune system leading infections

48. Do steroids have an effect on long term outcome of the disease?

This subject is still a matter of debate. Recently some studies have shown steroids to have a
beneficial effect on long-term outcome while other studies failed to do so.

The main indication for steroid use in MS is the treatment of an attack. However IV steroids can be
used on a monthly basis as an additional treatment to stabilize active disease, which is not being
controlled by the current therapy (for example, either Interferon beta or Copaxone®). This type of
disease stabilizing approach can be continued for several months.

If steroids cannot be used or are not effective, other option to consider is plasmapheresis.

49. What is plasmapheresis?

Plasmapheresis is a medical procedure used to “clean” blood. It is done at an outpatient center or
hospital and usually takes 3 to 4 hours to complete. The procedure requires placing an intravenous
(IV) line in one of the big veins in the neck or under the collar bone. The IV line takes blood into
a machine which removes the “water” or “plasma” part of the blood and replaces it with “neutral”
protein fluid. This procedure is thought to remove inflammatory substances contained in the plasma
which may be contributing to the MS attack. The procedure is typically repeated 5 to 6 times on
alternate days. However, the exact mechanism of why plasmapheresis works to help recover from an MS
attack is not well understood. Overall, it is a safe procedure but more expensive and difficult to
perform than giving steroids to treat an MS attack.

50. What are disease modifying therapies (DMT)?

Currently, thirteen drugs (or DMTs) have been approved by the FDA for the treatment of
relapsing-remitting and relapsing forms of MS.

Generic name

Market name

Year Approved

IFN beta-1b

Betaseron ®

1993

IFN beta-1a

Avonex Ô

1996

Glatiramer acetate

Copaxone ®

1997

Mitoxantrone

Novantrone Ò

2001

IFN beta-1a

Rebif ®

2002

Natalizumab

Tysabri ®

2006

IFN beta-1b

ExtaviaÒ

2009

Fingolimod

Teriflunomide

Dimethyl Fumarate

Alemtuzumab

Peginterferon beta-1a

Glatiramer acetate

Glatiramer acetate

GilenyaÒ

AubagioÒ

TecfideraÒ

LemtradaÒ

PlegridyÒ

Copaxone 40Ò

Glatopa ™ (Generic version of Copaxone 20mg)

2010

2012

2013

2014

2014

2014

2015

At this time, there is no FDA approved DMT for PPMS. Based on individual case scenario, the neurologist
may consider treatment options in an attempt to slow down the disease progression. However, there needs
to be a clear understanding that there is no large study which has unequivocally established the
effectiveness of any therapy for PPMS. Novantrone was approved by the FDA in 2001 for worsening RRMS or
progressive relapsing and secondary progressive MS.

51. How soon should treatment start in RRMS?

It is likely that patients may benefit from early treatment. The majority of MS experts encourage early
treatment once the diagnosis of RRMS is confirmed or as soon as the clinical event suggestive of MS has
occurred with all investigations pointing towards the diagnosis of MS. There is significant data to
support the benefit of early treatment in patients who have experienced just one attack of MS but have
MRI evidence to support the likelihood of developing MS in the future. These patients with just a single
attack are sometimes referred to as having “Clinically Isolated Syndrome” (CIS). Most experts agree that
CIS simply represents the first demyelinating episode.

52. How does interferon-beta therapy work?

Most data suggest that IFN beta works by healing the blood brain barrier that separate the brain from
the circulating system, (the passage through which blood is carried into the brain). This healing
prevents the inflammatory cells of the immune system from entering the brain. These cells are called
lymphocytes and could be potentially harmful to myelin. There may be other mechanisms by which IFN beta
therapy may be helpful in MS.

53. How does Copaxone work?

There are several mechanisms by which Copaxone may work in MS. Recent data suggest that it works by
changing the harmful inflammatory cells into the non-inflammatory healing cells of the immune system.
These healing cells have been shown in the animal model to penetrate in the brain and minimize
inflammation. Further work is ongoing to understand this unique property of Copaxone.

54. How does Tysabri work?

Tysabri is a drug that blocks the passage of inflammatory cells of the immune system from entering the
brain and the spinal cord. (Through blood brain barrier)

55. How does Novantrone and other chemotherapy drugs work?

Novantrone is a chemotherapeutic agent and chemotherapy drugs are used in MS to suppress the immune
system. By doing so, it is assumed that harmful cells of the immune system will be killed and not causes
inflammatory damage in the brain and spinal cord.

56. How does Gilenya work?

Gilenya works by “trapping” immune system cells (lymphocytes) in the lymph nodes and other lymphoid
tissue. These cells remain trapped in the lymphoid tissue as long as the drug is taken but the effect is
reversible within a few weeks after stopping the drug. It is believed that the immune system cells
continue to perform their immune activities although more information is needed regarding the long-term
safety.

How does Aubagio Work?

Aubagio modulates the immune system and has anti-inflammatory properties. Although the exact mechanism
of action for Aubagio is not fully understood, it may involve a reduction in the number of activated
lymphocytes (Immune system cells) causing inflammation in brain and the spinal cord.

How does Tecfidera work?

Tecfidera is thought to inhibit immune cells and molecules, and may have anti-oxidant properties that
could be protective against damage to the brain and spinal cord, although its exact mechanism of action
is not known,

How does Lemtrada Work?

Alemtuzumab selectively targets a protein abundant on Immune system cells (B cell & Tcell). Treatment
with alemtuzumab results in the depletion of circulating B and T cells thought to be responsible for the
damaging inflammatory process in the brain and spinal cord.

How does Glatopa work?

Glatopa is the generic equivalent of Copaxone (glatiramer acetate) 20mg with the same mechanism of
action which is thought to act by modifying immune processes that are believed to be responsible for the
pathogenesis of MS.

How does Plegridy work?

Plegridy is an interferon beta with extended half-life to permit a less frequent dosing schedule. The
mechanism of action is similar to the other Beta interferons which are mostly work by healing the blood
brain barrier (the passage through which blood is carried into the brain).

57. Is one drug better than the other?

Comparative data is conflicting. Several studies have suggested that interferon beta given at high doses
and more frequently such as Betaseron® or Rebif® may be superior to low-dose weekly interferon beta
(AvonexÔ) in reducing the frequency and risk of having relapses. Other studies have contradicted these
observations and have suggested that dosing and frequency of interferon-beta has no impact on the
relapse rate in RRMS. Similarly, there is no convincing study to suggest that Copaxone is better or less
effective than interferon beta therapy in RRMS. Since MS is a lifelong disease, one needs to keep in
mind the long-term effect of these therapies, their safety for long-term use, and their ability to
reduce sustained tissue damage in the brain and spinal cord. Achieving these goals can be difficult in
an individual patient and should be discussed in detail when choosing a therapy.

Tysabri is another promising however, long-term data with Tysabri is lacking and there are no head to
head studies to compare it with interferon-beta or Copaxone.

Recently, two large head to head studies with almost 3000 MS collectively enrolled, demonstrated that
interferon beta (BetaseronÒ or RebifÒ) and CopaxoneÒ were similar in their effect on reducing the
frequency and risk of having relapses. Similarly, they also showed a similar effect in slowing the
disease from progressing. These two studies suggest that in early and mildly affected MS patients, all
therapies seem to be very effective.

58. Is it possible to combine drugs to achieve a better effect?

This is a major focus in the coming years to achieve better efficacy by combining drugs. Preliminary
studies suggest that the combination of interferon beta and GA is safe. However larger studies, which
are currently ongoing, are needed to confirm that the combination therapy is clinically effective. Other
trials are also underway examining a variety of combinations.

59. What are the side effects of Interferon beta?

Most of the side effects can be managed by careful blood test monitoring and use of over the counter
drugs such as ibuprofen or acetominophen. However, if side effects persist, then alternate therapies
should be considered.

Injection site reaction (redness, itching, pain)
Injection site necrosis, though rare, can be seen with Betaseron® and Rebif®
Flu-like symptoms (fever, chills, muscle pain, malaise)
Abnormal white blood count and liver function tests
Menstrual disorders (see fertility issues)
Depression
Fatigue
Spasticity (may worsen preexisting stiffness)

60. What are the side effects of Copaxone?

Injection site reaction (redness, itching, pain)
Immediate post-injection reaction that occurs in approximately 10% of patients. This reaction includes
chest discomfort, flushing, palpitations, or shortness of breath which start within few minutes of the
injection and resolve spontaneously within a half-hour; it has never been reported to have any serious
consequences. This reaction does not constitute an allergic reaction. Patients can continue with their
injection therapy.
Over all, the IV infusion of Tysabri is very well tolerated. Patients may experience occasional
abdominal bloating and headache. However, these are mild and transient.
During the infusion, patients may experience “infusion reactions” that usually involve rash, chills, and
general uneasiness. Usually, these are mild but occasionally can be severe and require immediate
assessment. In such cases, these reactions may be allergic in nature requiring discontinuation of
therapy. In the original clinical trials of Tysabri, 3 out of 3000 patients taking Tysabri combined with
another drug developed a very serious brain infection called Progressive Multifocal Leukoencephalopathy
(PML). Two of those 3 patients with PML died. The exact risk of developing PML using Tysabri alone (not
in combination with other drugs) is unknown at this time; however the risk is assumed to be around 1 in
1000. Patients on Tysabri may be at risk for other serious but yet unknown infections. PML occurred with
Tysabri used as monotherapy.
As of March 3, 2015, there have been 541 (538 Multiple Sclerosis, 3 Crohn’s Disease) confirmed PML cases
worldwide.
As of March 3, 2015, overall PML incidence: 3.87 per 1000 patients. 23% of patients have died; 77% of
patients are alive with varying levels of disability
On August 15, 2011, a blood test to evaluate the risk for developing PML was approved by the FDA. This
blood test detects antibodies made by the immune system against the JC virus that causes PML. Thus far,
data from thousands of patients indicates that approximately 50% of the patients (and general
population) test positive for the antibody. If tested positive, the risk for developing PML is
considerably higher than a patient who tests negative. This information can be very helpful in planning
treatment with Tysabri as well discontinuing treatment with Tysabri.
Patients receiving Tysabri are registered in a national program (TOUCH program) monitored by the
manufacturers (Biogen Idec) and reported periodically to the FDA. This program requires that every
serious adverse event experienced by a patient receiving Tysabri, be reported to the TOUCH program.

61. What are the side effects of Tysabri?

This data is updated on a monthly basis.

62. What are side effects of Novantrone and other chemotherapy drugs?

Novantrone and cytoxan are chemotherapy agents used in MS that are administered in an outpatient
infusion center. They can not be given at home by home infusion nurses. Usually, it can take up most of
the day to complete the infusion. All patients should follow instructions given by the doctor very
closely and report any new symptoms and side effects promptly.

Nonatrone is usually administered every 3 months at a fixed dose until a total dose of 140 mg/m2 has
been given. Higher doses are associated with heart failure. Before every dose of Novantrone, an
echocardiogram should be performed to assess the cardiac status of the patient. If the cardiac output
function declines below a pre-specified level, then Novantrone should be discontinued. Once a dose of
140 mg/m2 is reached, no further dose of Novantrone should be given.

Another chemotherapy drug called cytoxan is usually given once a month and can be given for 6 months to
a year. It also requires careful monitoring although there are no known cardiac side effects associated
with cytoxan.

The most common side effects reported with chemotherapy drugs used in MS including Novantrone or cytoxan
are:

Decrease blood count (CBC) with a possible risk of infections
Abnormal liver function tests (LFTs)
Fatigue
Nausea and vomiting
Hair thinning and hair loss
Cardiac toxicity (seen only with Novantrone)
Bladder irritation (seen only with cytoxan)
Menstrual cycle abnormalities and loss of menstruation (usually temporary)
Treatment related leukemia for example AML & ALL (reported with Novantrone)
There is a remote possibility of cancers (associated with cytoxan)
Despite the list of side effects, chemotherapy can be a highly effective short-term measure to stabilize
rapidly worsening MS. Therefore, it is important to discus the benefits versus risks with the doctor in
a careful manner and obtain a second opinion if necessary.

63. What are the side effects of Gilenya?

As with most drugs that are approved by the FDA, the vast majority of the patients usually tolerate the
drug well without any significant problems. However, due to the effect of the drug on a variety of body
systems, patients need to be monitored closely and regularly. Furthermore, because the drug has been
approved for a short period of time (September 2010), long term data is still needed. Common and serious
side effects that may be associated with Gilenya include:

Infections
Slow heart rate with the first dose
Swelling behind the eyes (macular edema)
Malignancies
Difficulty with breathing
Liver injury
Immunosuppression

64. How can I know if a drug is working for me?

Evaluating if a DMT is working can be difficult. A patient often needs to be on a medication for at
least a year or two before a determination can be made. Generally speaking, if the patient is
experiencing fewer or no attacks with no signs of disease progression, then in all likelihood, the
patient is responding to therapy. This information combined with periodic MRI scans can be very helpful
in assessing if a particular therapy is working.

65. How long should a patient take DMTs?

This question is often raised by patients, especially those who have been on therapies for several
years. The current view is that patients should be on therapy all the time in order to reduce the
inflammatory and degenerative damage from the disease. Only during pregnancy, are women encouraged to go
off therapy. However, until careful studies are conducted to address this issue, patients should remain
on DMT indefinitely just as patients with high blood pressure or diabetes require lifelong therapy.

66. Should I have another MRI of the brain or spinal cord if my disease is not controlled?

Obtaining periodic MRI scans can be very useful in monitoring the disease and response to therapy. There
is no consensus on how often MRI scans should be obtained, but annually for the first couple of years
after starting therapy may be useful. Further scans can be obtained as needed. The MRI scan usually
includes the brain only but can also include the spinal cord as needed.

67. Are there any interactions between the DMT and other drugs commonly used in MS?

The interactions between DMTs and other drugs used in MS have not been fully evaluated. However, results
from controlled trials of the DMTs did not suggest any significant interaction with commonly used
therapies in MS.

68. What if my insurance does not cover the DMT or what if I have no insurance?

DMT are expensive and may cost $15,000 to $23,000 per year. However, all these drugs are FDA approved
for RRMS and most insurance companies will cover them. The amount covered and the patient’s out of
pocket co-pay, however, may vary from one insurance plan to another. Each insurance plan has a different
deductible and co-pay that the patient needs to know about.

If the patient has no insurance or inadequate insurance coverage, the drug companies that make these
DMTs have patient assistance programs which can provide these patients with free or reduced-cost
therapy. Furthermore, there may be federal or state funded programs that may cover the cost of these
medications.

69. Does MS affect fertility?

There is no conclusive data to suggest that MS affects fertility or the health of the fetus.

70. Can a woman with MS have children?

Yes, but pregnancies should be carefully planned. A woman should be taken off her DMT for one or two
months before attempting to become pregnant. Currently, it is advisable that pregnant women should not
take DMTs during pregnancy. Furthermore, it also recommended that DMT should be postponed if the patient
wishes to breastfeed after pregnancy.

71. What will happen to MS during pregnancy?

Pregnancy creates a state of immunosuppression. This is a natural protective effect of pregnancy.
Therefore, women with autoimmune diseases such as MS tend usually experience improvement and tend to
have lesser relapses during pregnancy. However, there appears to be a higher risk of an MS relapse
(attack) during the post-partum period (six month period following delivery). This does not mean that
every woman after delivery will experience an attack. If there is prior history of attacks with previous
post-partum periods, then it is best to resume DMT soon after delivery.

72. Is it safe to breastfeed for women with MS?

It is safe for a woman with MS to breastfeed. Currently, it is not known if DMT can be secreted in
breast milk. As a precaution, most experts suggest that DMT should be postponed if a woman plans to
breastfeed.

73. Are oral contraceptives safe if I have MS?

Birth control pills can be used by women with MS just as women without MS. The same precautions have to
be kept in mind regarding the long-term use of birth control pills.

There is emerging data that women with MS treated with a pregnancy hormone (estriol) given as a pill can
be beneficial. Studies are underway to examine the safety and effectiveness of oral estriol combined
with Copaxone in women with MS.

74. Can I have a vaginal delivery if I have MS?

In general, women with MS should be able to have a normal vaginal delivery. The use of local or general
anesthesia, or “C-section” should be decided by the obstetrician based on the state of labor and the
health of the mother. There is no contraindication to giving any type of anesthesia or pain control to
women with MS.

75. DMTs and fertility

Mild to moderate menstrual irregularities (delayed menses, intermenstrual bleeding and spotting, heavy
menses) have been noted in the clinical trials with IFN beta (BetaseronÒ) but not with other DMT.

76. Are DMTs harmful during pregnancy?

There are no controlled studies on the use of DMTs during pregnancy in humans. Therefore, it is
difficult to comment on their safety during pregnancy.

The FDA gives pregnancy safety categories to drugs based on available human and animal data. Categories
designated by the FDA are A (safe to use during pregnancy), B*, C**, D***, and X (proven to be harmful
to the fetus and absolutely contraindicated).

Categories B, C, and D are assigned based on the varying levels of safety with category B being safer, C
less safe than B, and D being less safe than C.

Copaxone is assigned category B while interferon-beta, Tysabri, and gilenya are assigned category C by
the FDA. Novantrone and cytoxan are category D. See below for detailed explanations of categories B and
C.

*Category B: controlled human studies indicated no fetal risk, but there are no human studies OR there
are adverse effects in animal studies, but not in well-controlled human studies.

** Category C: no adequate human or animal studies have been conducted OR there are adverse fetal
effects in animal studies, but no available human data.

***Category D: Adequate studies in pregnant women have demonstrated a risk to the fetus.

77. How are MS attacks treated during pregnancy?

The risks and benefits of using steroids during pregnancy should be carefully evaluated. It is advisable
to avoid them during the first trimester of pregnancy when the major fetal systems are being formed to
avoid any congenital defects or other abnormalities. Steroids may be safer during the second and third
trimester of the pregnancy. Other therapies like plasmapheresis (PP) have been shown to be safe during
pregnancy and can be used for severe attacks if needed.

78. What is the ADA and how does it affect patients with MS?

The American Disability Act (ADA) was enacted in 1990. Under this act, employers with 15 or more
employees are required to provide reasonable accommodations for the qualified person with disability.
These reasonable accommodations are determined on a case-by-case basis and according to the physical
limitations of the employee. To be eligible for these accommodations, the employee should disclose that
he/she has a disability but not necessarily his/her diagnosis.

79. What is considered to be reasonable job accommodations?

Job accommodations are related to restructuring the physical environment (for example: enough space for
a scooter, ramps) and scheduling (for example extended lunch break for somebody who has fatigue).

80. What if the employer decides to terminate the employment of the person diagnosed with MS?

Under Title I of the ADA, hiring, promoting, layoff and termination must be made independently of the
disability status.

81. Is it possible to fire an employee because of frequent time off related to MS relapses?

Yes, it is possible. However, the Family and Medical leave Act (FMLA, 1993) allows an employee with a
serious medical condition to have unpaid medical leaves (up to 12 weeks per year) and to return to the
same position, if he/she is not holding a key job (an example of a key job is being the director of a
company). Unpaid medical leaves allow an employee to retain the health insurance benefits paid by for by
his/her employer.

82. Since MS is a chronic disease with potential physical limitations, is there any benefit from not
working?

As long as the employee is able to fulfill the tasks required of him/her, there is no reason to stop
working; in fact because of the ADA and FMLA acts, many patients are able to maintain a job for a longer
time. Working may be needed for financial reasons, to maintain health insurance, and for one’s own
satisfaction. The ultimate decision to continue working should be made by the patient and if needed in
consultation with the neurologist and employer, as deemed appropriate.

83. When an employee applies for a new job can he/she be denied coverage from the employer’s health
insurance because of MS?

Yes, he/she can be denied if the employer has already predetermined health exclusions criteria for his
employees. However this should be applied equally to all employees.

An employer cannot refuse to hire somebody because it may result in higher insurance premiums. Also, the
Health Insurance Portability and Accountability Act (HIPAA, 1996) enables a person with a disability to
be exempt from preexisting condition exclusions under the new employer. The employee, however, must
continue with their previous health insurance benefits as long as possible before being allowed to
transfer coverage to the new employer’s plan.

84. What are the qualifications for social security disability insurance (SSDI) and Supplemental
Security Income (SSI)?

Both SSDI and SSI are run by the Social Security Administration and both have the same medical
requirements for an employee to be eligible. You can learn more on the World Wide Web at:
http://www.ssa.gov/dibplan/index.htm, or by calling 1-800-772-1213.

A comparison of SSDI and SSI is shown in the following table.

SSDI
SSI
Worked and paid FICA
Financial need independently from previous work history or FICA
Paid taxes in recent years
Same as above
Too disabled to work
Too disabled to work
Unemployed or earning less than SGA*
Unemployed or earning less than SGA*
Affected by other worker’s compensation payment
Affected by other worker’s compensation payment
Not affected by non-work income or resources
Not affected by non-work income or resources
Waiting period of 5 months from disability determination to the start of benefits
No similar waiting period as in SSDI
Waiting period of 24 months for Medicare benefit
Immediate benefit from Medicaid
Work activity does not terminate benefits for at least 4 years
Work activity does not terminate benefits indefinitely
Part time work is possible without losing the money**
Part time work is possible without losing the money**
* SGA : Substantial gainful Activity , 500$ and 810 $ for beneficiaries who are blind.

** As long as the amount of money paid is less than the SGA.

Diet, Complementary and Alternative Medicine in MS

85. What is the Swank diet?

Several decades ago, Dr. Roy Swank (Portland, Oregon) developed a diet for MS patients which is rich in
polyunsaturated fatty acids (the kinds of fatty acids found in fish oil and vegetables). Presumably,
these fatty acids suppress the production of substances responsible for activating immune cells which
may cause damage to myelin and axons in MS. Although the Swank diet may be helpful in immune mediated
diseases such as MS, these claims have yet to be tested in rigorously tested controlled studies.

86. How is vitamin D associated with MS?

Several studies have a possible beneficial effect of vitamin D in some autoimmune diseases including MS.
Studies are underway to better define the role of Vitamin D in MS as an immune regulatory molecule and
not just as a vitamin. Currently, it is unclear as to what is the optimal dose of Vitamin D to act as an
immune regulatory molecule in MS. Most data indicate that higher blood levels of vitamin D may be needed
to have an anti-inflammatory effect of vitamin D. Those studies are underway. This should be discussed
with your neurologists so that blood levels and appropriate dose of vitamin D can be prescribed.

87. How are vitamin C, E and beta-carotene associated with MS?

Careful use of vitamins C, E, and beta-carotene according to dietary recommendations may be beneficial
in immune mediated disorders. There is no controlled data which proves the efficacy of vitamins C, E,
and beta-carotene in MS. Excessive use of these vitamins may be harmful. At this time, it is not
recommended that a patient take extra vitamin C, E, or beta-carotene (more than is found in a
multivitamin).

88. How is mercury associated with MS?

Mercury present in dental fillings was thought to be toxic to people with MS and that it could make
their MS worse. However, no studies have shown such toxicity and a clear cut relationship between
mercury fillings and MS.

89. How is hyperbaric oxygen therapy (HBOT) relate to MS?

HBOT has been studied in MS. However, the results were conflicting. It has not been shown to have a
beneficial effect on the long-term outcome in MS. With the availability of DMTs and other symptomatic
treatments, HBOT is not recommended to be used in MS.

90. How does hydrotherapy benefit those with MS?

Studies have showed that hydrotherapy, or pool therapy, may decrease spasticity (stiffness) in MS.
Patients who are interested in hydrotherapy can enquire with their local chapter of the National MS
Society (NMSS) if there is an “MS friendly pool” in their area. Local NMSS chapters can be found by
calling 1-800-FIGHT-MS (1-800-344-4867) or by visiting the National Multiple Sclerosis Society at
www.nmss.org

91. How is hippotherapy (horseback riding) benefit those with MS

Hippotherapy has been suggested to be of possible benefit in MS, particularly in reducing spasticity and
balance problems. This needs to be carried out with experienced trainers. More information may be
obtained by visiting the National Multiple Sclerosis Society at www.nmss.org or by calling
1-800-FIGHT-MS (1-800-344-4867).

92. How is the use of vitamin B12 associated with MS?

The use of vitamin B12 in MS has been subject of long standing debate. There is some anecdotal evidence
that it may improve fatigue in MS. Currently, there is no good evidence from any controlled study that
justifies vitamin B12 to MS patients who do not have vitamin B12 deficiency. It should be used only if
there is a documentation of vitamin B12 deficiency or is otherwise medically indicated.

93. What are some commonly used herbal therapies and MS?

Ginkgo biloba, Saint John’s wort, ginseng, kava, Echinacea, saw palmetto and primrose oil are some of
the commonly used herbal therapies; some of them are marketed in Europe as medications, whereas in the
USA they are available as dietary supplements. While herbal therapies may have some benefit in MS,
caution should be taken when using these supplements. There is considerable controversy regarding the
safety and efficacy of these herbal and natural therapies in MS. For a thorough and detailed review of
these therapies, please visit the National Center for Complimentary and Alternative Medicine (NCCAM) of
the National Institutes of Health at nccam.nih.gov

94. What is risk of developing of MS?

An individual’s risk of developing MS increases several-fold if a close family member has MS. While the
risk of developing MS for a person in the United States is approximately 1 in 500 (0.2%), the risk for a
person who has a parent with MS increases to about 1 in 40 (2.5%). Thus, the risk increases
significantly for a person whose parent has MS, but still remains relatively low.

In families in which MS occurs in many relatives, the risks for any given individual are significantly
higher than they are for an individual who has no family members with MS. The calculation of the exact
risk is complex and not well understood. The identical twin of a person with MS has a 25% to 30% risk of
acquiring MS, while a fraternal twin’s risk of acquiring MS is about 5%.

95. What is incidence of African-Americans (AAs) and MS?

The incidence of MS in native continental Africans is almost zero. However, that risk changes in the
African-Americans. Although it is unclear why MS is seen more commonly in African-Americans than
continental Africans, it is partly contributed by the genetic admixture from inter-racial marriages.
Several genetic studies have pointed to this possible factor. However, this remains as one possible risk
factor and certainly does not explain the risk of MS in African-Americans in its entirety. The influence
of environmental factors remains largely unknown and could contribute to the development of MS in
African-Americans.

Several studies have also suggested that MS in African-Americans tends to be more aggressive. The
frequency of relapses and the rate of progression seem to be faster than Caucasians. Moreover, it has
also been suggested that African-Americans with MS tend to respond less favorably to treatments than
Caucasians. These observations need to be replicated in larger number of patients in prospectively
designed studies.

Several large studies are now underway to better understand and treat MS in African-Americans.

96. What is the association between MS and other autoimmune diseases?

In general, having one autoimmune disease like MS raises the chance of having a second autoimmune
disease. Overall, the risk remains low but it is slightly higher than a person with no autoimmune
disease. Examples of other autoimmune diseases are myasthenia gravis, type I diabetes, Crohn’s disease,
rheumatoid arthritis, and lupus. Studies have shown the genetic risk factor of autoimmune diseases is
associated to certain genes that regulate immune system. One such region is called HLA-DR2, and has been
consistently associated with MS and other autoimmune diseases.

97. What is the role of infections in MS?

To date, despite years of research, no infection has been discovered as a cause of MS.

However, several viruses have been associated with MS. Most notably and recently, Epstein-Barr Virus
(EBV) has been associated with MS. This has created significant debate on whether it actually causes MS
or if it is merely as association since EBV is a very common global infection that typically resolves
spontaneously without any consequences. Other viruses that have been associated with MS in the past
include HHV-6, measles virus, and canine distemper virus. A bacterial infection called “Chlamydia” has
been associated with MS.

98. What is the association between vaccinations and MS?

In general, vaccination is safe in MS. Individual questions regarding vaccination and MS should be
discussed with your neurologist and family doctor. Flu shots are also considered safe and should be
given to MS patients if clinically indicated. Usually, elderly people, patients with weak immune
systems, or patients receiving drugs that suppress the immune system may benefit from receiving the flu
shot. Studies have shown that flu shots are safe in MS.

However, they may be rare exceptions. The purpose of a vaccine is to prevent a disease from occurring.
However, in rare instances, vaccines have been associated with neurological symptoms that may be due to
activation of the immune system as a result of the vaccine. Specific issues such as tetanus, hepatitis B
or international travel immunizations should be discussed with the neurologist and the family doctor.
Several factors such as the composition of the vaccine, general health of the patient, medications that
the patient is receiving at the time, risk versus benefit of receiving the vaccine may determine the
usefulness of vaccination in an individual patient.

99. Can MS patients exercise?

Cumulative evidence supports that exercise training is associated with improvement in quality of life.
Exercise is encouraged in MS. The benefits of regularly exercising in MS are enormous. There is good
scientific evidence from several studies suggesting improvement in spasticity, breathing, upper
extremity function, cardio-pulmonary conditioning, pain control, and muscle strengthening in MS.

Swimming and exercising in a swimming pool can be very helpful to MS patients. This is especially
helpful to patients who have considerable leg weakness and spasticity.

Individual customized exercise programs should be discussed with the neurologist. This could vary from
patient to patient. Comprehensive MS programs will have onsite resources or a referral program to
address specific needs of the patient.

100. What is the association between anesthesia and surgery in MS patients?

MS is not a contraindication to having anesthesia. MS patients can receive epidural, local and general
anesthesia as recommended by an anesthesiologist. MS also is not a contraindication for any surgery.
Patients are encouraged to discuss this with the neurologist in detail before any planned surgical
procedures requiring anesthesia.

101. What is the role of dental care in MS?

MS patients should undergo dental care as planned. Only those patients who are on immunosuppressants
(chemotherapy) or actively taking steroids should consult with their neurologist to discuss the risk of
infection prior to a dental procedure. In these circumstances, it may be advisable to take a course of
antibiotics before the dental procedure.