Ask the Doctor

Q: I began taking interferon beta-1a (Avonex®) in 2002, and began hormone replacement therapy (HRT) in 2003, stopping after a little more than a year and a half. In 2005 I was diagnosed with breast cancer, even though I was not at any increased risk for cancer. I wondered if the HRT might have started the cancer at a time when Avonex was suppressing my immune system. I reported it to Biogen, who said they were required to report it to the Centers for Disease Control and Prevention (CDC). These may well be two excellent drugs, but perhaps they should not be taken together. What are your thoughts on this, and do you think a survey should be taken among women taking immunosuppressive drugs to see if others have also been diagnosed with breast cancer?

A: To begin, I want to clarify that the interferons do not "suppress" the immune system, as anti-cancer drugs do, so they are not considered immunosuppressants. Instead, they are referred to as immunomodulators, which indicates that they "modulate" the immune system. This means that some of the processes and/or components of the immune system are altered, causing them to behave differently. The same is true for glatiramer acetate (Copaxone®).

No data has been found to implicate the combination of interferon with HRT in increasing the risk of cancer. Recent data is reassuring in that interferon beta-1b (Betaseron®), after 16 years, did not show an increased risk of cancer when taken alone or in combination with any other medication. All three of the interferons as well as Copaxone have several years of data behind them. This type of data reduces the need for additional surveys.

Many of the cancer-fighting drugs do suppress the immune system, and those used to treat MS include mitoxantrone (Novantrone®), methotrexate (Rheumatrex®, Trexall®), azathioprine (Imuran®), and cyclophosphamide (Cytoxan®). With these types of drugs, there could be an increased risk for some cancer-type complications, but efforts are made to minimize this risk.

Q: My wife has had MS for 14 years. Over the years she has developed paralysis and complains of intense "burning pain" in the leg, shoulder, and arm. We have brought this to the attention of her neurologist, family doctor, and the physician who installed and services her Medtronic® pump (for the Baclofen® she needs to control spasms). No one can find a drug that will give my wife any relief... except for perhaps morphine... which makes her into a "zombie." At this time she is not taking any drug to control the pain. Do you have any suggestions?

A: You mention that your wife is receiving Baclofen, which works to reduce spasticity (stiffness) and spasms. Since spasticity and spasms cause pain, taking Baclofen can help to reduce the pain associated with these symptoms, and hopefully your wife is experiencing some relief through this treatment. When this drug is administered by an implanted pump, it is infused directly into the spinal fluid (intrathecally), and the benefits include greatly reduced dosing, increased effectiveness, and significantly fewer side effects. So it sounds as though your wife's physician made a good treatment choice.

In addition to Baclofen and other anti-spasticity drugs such as tizanidine (Zanaflex®), different types of medications may be used to treat MS pain. These include anti-seizure medications, such as gabapentin (Neurontin®), carbamazepine (Tegretol®), and phenytoin (Dilantin®). Tricyclic antidepressants such as imipramine (Tofranil®) can sometimes be helpful as well. In severe cases, some doctors might prescribe a narcotic-type of drug using an intrathecal pump similar to the Baclofen pump, providing the same benefits as listed in the previous paragraph.

For more information on pain management, you may refer to previous issues of The Motivator. In the Fall 2004, Winter 2005, and Spring 2005 issues, a three-part pain management series was given in the Symptom Awareness column. These articles provide information on the different types of MS pain, different medications that may be prescribed, the benefits of keeping a pain diary, and CAM therapies (such as acupuncture, acupressure, massage, and others) that may be of help in managing pain.

Please visit MSAA's website at www.msaa.com and click on "publications," then select The Motivator, to view these previous issues. If you do not have access to the internet, you may call MSAA at (800) 532-7667 to request free copies to be mailed to you.

You may also seek a second opinion from another MS professional by visiting an MS center. You may find a listing of centers belonging to the Consortium of MS Centers (CMSC) by visiting their website at www.mscare.org and selecting the "MS Centers Directory" listed on the left side of the screen. If you do not have access to the internet, please contact MSAA's Helpline at (800) 532-7667 to speak with a Helpline consultant, who would be happy to assist you in locating an MS center in your area.

Please note that depression often accompanies chronic pain and I would advise that you be aware of the warning signs. Among others, these can include: depressed mood, lost interest in activities, change in appetite, negative feelings and thoughts, difficulty sleeping or excessive sleeping, restlessness or fatigue, and diminished ability to concentrate and make decisions. The Symptom Awareness column in the Fall 2005 issue of The Motivator discusses symptoms and treatments. Please follow the instructions mentioned earlier to view a copy of this article.

Q: I'm a 64-year-old man who would be in good health minus the progressive form of MS. I recently heard that people with progressive MS do better after they discontinue using interferons. Is there any truth to this? I've been taking Betaseron for 10 years and still have some mild side effects. Am I wasting my money?

A: Betaseron, along with the other disease-modifying treatments for MS, are indicated for individuals who are still experiencing inflammation in the brain and disease flare-ups with their MS. If you have the progressive form of MS and are not experiencing flare-ups, then you would not meet the established criteria for this treatment group. If your MS symptoms have remained basically stable during the 10 years while taking Betaseron, however, the possibility exists that the Betaseron continues to help you. Your doctor would be the best judge of your situation.

No evidence supports the idea that people with progressive MS do better after they discontinue the use of interferons. As noted above, immunomodulatory therapies are not indicated for progressive types of MS, specifically those types of MS which are non-inflammatory. This means that in clinical trials, no evidence has been found that such drugs would be beneficial to these forms of MS. Of course, if you were to discontinue the drug, you would no longer have the expense or experience the mild side effects. I advise that you discuss your situation with your doctor.

You may also seek a second opinion from another MS professional by visiting an MS center. Please refer to the answer from the previous question for information on locating an MS center in your area.

Jack Burks, MD, is a neurologist who specializes in MS. He is vice president & chief medical officer for MSAA, as well as president of the Multiple Sclerosis Alliance. Additionally, Dr. Burks is a clinical professor of medicine in neurology at the University of Nevada School of Medicine in Reno, Nevada, and a member of the Medical Advisory Board of the National MS Society. He has edited two textbooks on MS, and in the 1970s, Dr. Burks established the Rocky Mountain MS Center.

To Submit Questions to Ask the Doctor

If you have a question that you would like to ask, please submit your question to:

MSAA
Questions for Ask the Doctor
Attn: Andrea Borkowski
c/o Dr. Jack Burks
706 Haddonfield Road
Cherry Hill, New Jersey 08002

Readers may also send in questions via email to aborkowski@msaa.com. Please be sure to write "Ask the Doctor" in the subject line.

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