MS Learn Online. and. Holly: this time. for others. >>Kate

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1 MS Learn Online Featuree Presentation MS Treatments: Understanding Your Options Featuring: Dr. Benjamin Segal, Dr. George Kraft, Dr. Aliza Ben-Zacharia, and Dr. Susan Bennett Holly: I am on a disease-modifying therapy and it's been really beneficial for me. Mike: I do exercise and I do eat properly. I'm on a very low fat diet that my neurologist pointed me to when I was first diagnosed. Susan: I am not currently on a disease-modifying therapy. I have chosen not to be at this time. Cheryl: In addition to my disease-modifying drugg that I feell good about, it's working well enough, but sometimes I feel like I kind of miss the natural medicines I had done and other things that kind of give me a little boost. Susan: I take some vitamins and some naturopath hic herbal remedies once in a while. Vito: There are many options out there. What works for some people doesn't work for others. >>Kate Milliken: Hi, I m Kate Milliken welcome to MS Learn Online. Although there is still no cure for MS, effective strategies aree available to modify the disease course, treat exacerbations, manage symptoms andd improve function and safety. In recent years, we vee seen many more treatment options becoming available for people living with MS. In fact, theree is so much to talk about, we vee created a special three- their disease. In our second and third programs wee will learn more details part series devotedd to treatments. In our first program we will explore the different avenues people can utilize to treat about

2 disease modifying therapies. In this program we will get the perspectives of four health care professionals. Dr. Benjamin Segal directs the multiple sclerosis center and is a Professor of Neurology at the University of Michigan in Ann Arbor, Michigan. Dr. George Kraft is the Alvord professor of MS Research and the director of the Western Multiple Sclerosis Center at the University of Washington Medical Center in Seattle. Dr. Aliza Ben-Zacharia is a nurse practitioner at the Corinne Goldsmith Dickinson Center for MS at the Mt Sinai Medical Center in New York City. Dr. Susan Bennett is a physical therapist and clinical associate professor at the University of Buffalo. Thank you all for joining us on MS Learn Online. Let s begin with Dr. Kraft. Can exacerbations be managed? >>Dr. George Kraft: Kate, that sounds like a simple question, but it's really fairly complex. The first issue is to define whether it truly is an exacerbation the patient is having. I worry about over-treating exacerbations that aren't exacerbations. For example, a patient who has a bladder infection, and that can be fairly common in people with MS, especially women with MS. They have a little increase in fever and they may appear to have more numbness or there may be some motor involvement, or some problem that seems like exacerbation. That's what needs to be treated. The infection needs to be treated. However, if a true exacerbation is what the patient is having, then we treat patients typically with Solu-Medrol >>Kate Milliken: Nurse Practitioner Ben-Zacharia? >>Aliza Ben-Zacharia: If patient had very poor covering, it's a major attack that affect their gait and their function, their daily function, you may use plasma exchange, or it's called plasmapheresis. It's almost a dialysis of the plasma. You take it out and you clean it, filter it, and bring it back into the system. So, you do it only in extreme cases that patient had, again, a major relapse that affected the complete function. >>Kate Milliken: Dr. Kraft, what are the current disease-modifying therapies that are available? >>Dr. George Kraft: There are quite a few, Kate, and I'd like to list them by categories. First of all, there is the oldest category, which is interferons. Then there is

3 the next oldest category, which is only one, glatiramer acetate. It's four amino acids that mimic the antigenic site on the myelin. And then we have some infusions. We have monoclonal antibodies such as Tysabri or natalizumab. And then more recently we have the oral medications, the Gilenyas, the new example of that. And one more category and that is the chemotherapeutic agents, such as mitoxantrone and that type category. >>Kate Milliken: Let s turn to Dr. Segal on this one. What is the difference between symptom management and disease-modifying therapy? >>Dr. Benjamin Segal: Symptom management involves the use of drugs or other therapeutic interventions to alleviate or reverse symptoms that patients experience, such as spasticity, such as pain, such as fatigue. However, those drugs don't actually alter the clinical course of multiple sclerosis itself and don't stop the disease process. Disease-modifying therapies are used in order to actually suppress the inflammation and other destructive processes that are occurring and causing damage to the central nervous system in patients with multiple sclerosis. These drugs decrease attack rates of patients with relapsing-remitting multiple sclerosis and hopefully also decrease the risk of progression or slow down progression. >>Kate Milliken: Let s turn to Dr. Kraft. What role does rehabilitation play in treating MS? >>Dr. George Kraft: Oh, it's vital. I've maintained for a long time that rehabilitation is the only way to improve function in a patient with MS. Let me give you an example. Let's say you've got a patient with severe MS who is bed-bound. If I give them a wheelchair, that is rehabilitation and then they are able to get around. So, we are improving their Kurtzke EDSS from something like a 9 to at least a 7.5. And if I give them a walker, maybe they can walk. That makes them improve further. And rehabilitation tools and techniques are definitely important in managing patients who have more severe MS, more advanced MS. >>Kate Milliken: Dr. Bennett what about your perspective on this. What role does rehabilitation play in the overall treatment of MS? >>Dr. Susan Bennett: Well, rehabilitation is extremely important not only in helping an individual recover their function after they have had an exacerbation of the disease, but really from the total perspective of health and wellness. We know certainly from much of the research that the stronger an individual is from an exercise perspective, that can actually have an effect on strengthening the immune system. And obviously the stronger you are and the higher functioning you are, if you do have

4 a relapse of the disease, the opportunity for recovery is going to be enhanced if you're going into unfortunately having that exacerbation, a stronger, healthier person. There is also tremendous research now demonstrating the effectiveness of physical therapy as well as occupational therapy in helping individuals regain activities of daily living, their ability to ambulate not only at home but within the community, ability to climb stairs. And then, again, once the rehabilitation is completed, the recommendation is that we prescribe an exercise program, whether it's a home exercise program that might be easier for the patient to perform, or they go to a facility where the individuals that are providing the exercise training know multiple sclerosis. >>Kate Milliken: Let s turn to Nurse Practitioner Ben-Zacharia. How do complementary and alternative therapies fit into disease management? >>Aliza Ben-Zacharia: I think they do fit, but they fit more as a complementary treatment, not alternative treatment. So, you want to complement the treatment that we have that are approved for MS, either for the illness itself or the symptoms management. I use very often acupuncture for pain management. I use very often cranberry pill or vitamin C for patient that very often have bladder problems and frequent urinary tract infections. I usually do not recommend and I educate patient not to use complementary medication that may stimulate the immune system, like Echinacea, like melatonin, green tea. >>Kate Milliken: Dr. Segal, where do complementary and alternative therapies fit into disease management? >>Dr. Benjamin Segal: Many physicians who treat patients with multiple sclerosis recommend certain nutritional practices. For example, I and many of my colleagues advise patients to take supplements of vitamin D. There is also some belief that fish oil may be of benefit in MS, in particular, omega-3 and omega-8 fatty acids, which are plentiful in fish oil. Once again, clinical trials have not been done that directly prove that these supplements are beneficial, but they are safe and may be helpful. Another, I think, very useful complementary treatment for multiple sclerosis is yoga. It alleviates stress, it helps patients stretch, which may help prevent spasticity. >>Kate Milliken: Nurse Practitioner Ben-Zacharia do you have anything you d like to add to that?

5 Aliza Ben-Zacharia: I think the problem with CAM, which is an abbreviation of complementary and alternative medicines is that we don't have enough data, enough evidence base to say this is working. I think it's important to realize that some of this medication may harm patients and not really -- they will not really benefit from adding more, and it will be just costly physically and also emotionally to their illness. So, I think it requires a lot of education and discussion. The one thing that I always tell patient to share with me what medication they are taking. And when I talk to them I say do not share only the medication that are prescribed to you; tell me what you take on the side, over-the-counter, and they also may interact with the medication that we prescribe. Kate Milliken: We d like to thank Dr. Susan Bennett, Dr. George Kraft, Dr. Benjamin Segal and Dr. Aliza Ben-Zacharia and for joining us and offering their insight on MS treatments. If you would like to learn more about treatments, or any other information on living with MS, go to For MS Learn Online, I m Kate Milliken. Thanks for joining us.