What Do I Fear Most?
Treating MS patients: which is most fearful, the medicine or the disease?
My life as a doctor treating patients with MS can be divided into three fundamental tasks:
- Deciding whether or not a patient has MS.
- Treating patients with medications designed to prevent relapses and the progression of disability.
- Treating relapses and the chronic symptoms of MS in patients with an established diagnosis.
I would like to focus on the second of these tasks today. Prior to 1993, there were no FDA approved medications to treat MS. Today, there are seven, and many more are on horizon.
The fist-line agents used to treat MS in most patients (Copaxone, Avonex, Rebif, and Betaseron) have several advantages, and have been on the market for nearly 20 years, providing a long record of effectiveness and experience with potential side effects. In the United States alone, hundreds of thousands of people have taken these medicines with almost no serious, permanent side effects.
Disadvantages of these medications include:
- they are all injections
- they are only partially effective in preventing relapses and disability
- they often have bothersome side effects that make them intolerable to many patients
Whenever I start a patient on one of these medicines, I know that I am not going to violate the first rule of medicine: to do no harm.
With some of the newer medications for MS, this is not the case. Certain medications, namely Tysabri, Gilyena, and some of the chemotherapy agents such as Novantrone, may offer more protection against MS. However, these medicines have potentially devastating, even fatal, side effects—which is certainly not the case with the older medications.
Patients and doctors alike are faced with a difficult decision about which medicine is best to take for MS, a situation that will grow more complicated in the next few years as more medicines are approved. Yet, this is a good thing.
As I said earlier, prior to 1993 there were no FDA approved medications to slow down the course of MS. It is better to have many medicines to choose from than none at all, and I have treated many patients with other neurological diseases who would be grateful to have the treatment options available to patients with MS.
In deciding which medication to suggest to a patient newly diagnosed with MS, or when to recommend a switch from one medication to another, I have to ask myself: what do I fear more, the medicine or the disease? Without a crystal ball, this is an impossible question to answer, and doctors’ recommendations vary widely. Ultimately, it is up to each patient, with the advice and guidance of his or her neurologist, to determine which treatment option is best for him or her.