Ask the Doctor
Can Lesions Disappear?
By Dr. Jack Burks
Chief Medical Officer for MSAA
Dr. Jack Burks
Q: I was diagnosed with RRMS in 2009. After trying one MS therapy, I switched to Tysabri, and have steadily improved in function. When I was diagnosed, I only had a couple of lesions on my MRI, but my lumbar puncture was positive for bands and I've had many MS symptoms. My last MRI showed no lesions.
I have just moved and was referred to a new neurologist. Due to this MRI, this neurologist has told me that I "can't possibly have MS," and has stopped all treatment. (I am a veteran and this has been through the VA.) He tells me that lesions never go away, and that he suspects errors in my history. Could he be correct? Can lesions disappear?
A: You are in a difficult situation. I would gather your previous records, including MRIs, lumbar puncture results, and medical evaluations that showed MS and ask your neurologist to review your records. If there is still a conflict, I would get another opinion from a VA doctor with MS center expertise, or a non-VA neurologist if you have the resources. MS lesions can fluctuate, but reverting to a completely normal MRI provides cause for your neurologist to be concerned.
After he reviews your complete records, he will be in a better position to judge. He may want to see the actual abnormal MRIs in the past and not just read the reports. Also, he may want to talk with your previous neurologist to get a better understanding of your MS prior to starting Tysabri.
Q: I was diagnosed with MS in 2004. I've been on a few different injectable drugs and have had bad experiences with them. As an option, I would like to try LDN (low-dose naltrexone).
Which brings me here to ask, why is it so hard to get someone to help me with this? I know it's not specifically approved for MS, but it's been helping people. Is it wrong of me to want to try this?
A: I am sorry that you have had problems with the approved MS therapies. They help most people with MS. LDN is not FDAapproved, so many neurologists are not enthusiastic about prescribing this drug. It appears relatively safe and some people feel better when taking it. However, it is not a substitute for FDA-approved diseasemodifying therapies.
Nonetheless, you can probably find a neurologist or general practitioner who is willing to prescribe LDN. To learn about studies of LDNandMS, and to ask for the name of a nearby doctor, you can visit the LDN website (at www.lowdosenaltrexone.org).
You might consider revisiting an MS injectable drug option with an MS expert. Although this has not been helpful in the past, you may still be able to benefit from one of the currently available therapies. If not, another alternative is to ask your neurologist about the new FDA-approved drug called Gilenya. It is the first oral medicine approved for the longterm treatment of MS. Your neurologist can explain the benefits and risks of this new drug, and since it is different from the other medications you have tried, it may be helpful to you. Tysabri is another option that you may want to discuss with your doctor. It also has a different mechanism of action and is given via IV infusion once monthly.
(This question comes from a nurse.)
Q: With new drugs coming on the market that suppress the immune system, combined with the fact that individuals may produce certain white blood cells to fight infection, I am surprised that I do not see any recommendations in the study literature on a "washout" period for other medications that one may currently be on prior to starting these medications once they are approved.
For example, if someone is on high-dose steroids, Tysabri, or cyclophosphamide,* would it be reasonable to have a period of a month or more between the last dose of a current medication and the first dose of new medication? And if so, how would you deal with a relapse during that time?
*Cyclophosphamide (Cytoxan) is a drug not specifically approved for MS but is sometimes prescribed for certain individuals.
A: Great question! Unfortunately, the treatment trials do not usually address the question of "washout."Without data, it is hard to make any recommendations. Opinions vary when data are lacking.
My opinion (not based on data) is that a washout period for some drugs seems reasonable. The ABCER drugs (Avonex, Betaseron, Copaxone, Extavia, and Rebif) as well as steroids are not likely to need more than a week or two washout. Tysabri washout-period opinions vary from one to six months. I favor a two-to-three month washout with Tysabri before starting Gilenya. Similarly, Gilenya may require a two-to-three month washout before switching to another MS therapy.
If one has an exacerbation during the washout period, I would give this patient a short course of steroids, which has a short "half life" (or duration in the body). Novantrone and Cytoxan are long-acting drugs and I would give a three-to-six month washout period for these drugs.
Remember, these suggested washout periods are based on my opinion and not based on scientific data. These washout periods are subject to individual interpretation and other MS experts may recommend different lengths of time to wait between switching from one MS treatment to another.
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Jack Burks, MD is the chief medical officer for MSAA. He is a neurologist and the director of program development at the Multiple Sclerosis Comprehensive Care Center, Holy Name Hospital, in Teaneck, New Jersey. Dr. Burks is a member of the Clinical Advisory Board of the NMSS. He has written and edited three MS textbooks, as well as numerous chapters and articles on MS. In recent years, he has lectured and evaluated patients in more than 30 countries.