The Management of Side Effects

The use of immune modulating medication has led to a whole new topic of discussion, that of side-effect management. It should be emphasized that none of the immune modulators (as distinguished from immune suppressants) usually has severe side-effects. The incidence of side-effects forms a bell-shaped curve, showing some who have no side-effects while others have many. Most have some side-effects that clear over time.

Glatiramer acetate has the fewest side-effects. Its daily subcutaneous injection usually causes some redness and itching at the injection site when treatment is initiated. That usually lasts about 20 minutes and often stops after a few weeks. Occasionally increased stiffness occurs. Hives sometimes indicate an allergic reaction. One unique side-effect does occasionally occur; it is very infrequent and usually does not recur, but some people may experience a sudden warm or hot sensation throughout the body along with chest tightness, shortness of breath, and a feeling of depression. This lasts about twenty minutes and will abate. If an aggressive approach with emergency medicine is applied, increased problems occur; thus, it is recommended that if this side-effect is present, rest for twenty minutes and do not panic.

The interferons are known for their flu-like symptoms. Fever, nausea, and muscle aches are common when treatment is initiated. These are clearly dose related. At full dose Avonex® has fewer side-effects because it is given at a lower total dose each week. Knowing this, it is recommended that high dose interferon (Betaseron®, Rebif®) be initiated at a quarter of the final dose each time it is taken until the side-effects abate. The dose then is increased to a half dose until stable, then three-quarters, then full. This is called dose escalation. Medication that will lower temperature is helpful (ace-toaminophen, ibuprofen, etc.) given four hours before, at the time of injection, and four hours or as necessary after.

Injector guns decrease the side-effects to some degree. That is true for all the subcutaneous treatments. Small needle injections of interferon (Betaseron®, Rebif®) lead to more skin discoloration than the longer needle injection (Avonex®). These skin reactions are diminished by the injector guns. Common sense tells us that intramuscular injections are best performed by a helper. That is not true for everyone but it holds for most people who have any problems with coordination or weakness. If pain occurs with the injection, icing before and after may help. Anesthetic creams can be used to numb the area prior to injection if needed. Skin reactions may respond to cortisone cream. If one develops actual skin breakdown, a decision as to whether the treatment can be tolerated must be made. With interferon therapy, blood and liver tests should be monitored for a period of time, because sometimes significant changes can occur. Often we accept considerable abnormality to these but they need watching.

The body reacts to foreign medication by producing antibodies. Some of these may affect the potency of the treatment. Research continues as to the true meaning of these and how they can be altered. In the meantime, there appears to be little relevance to measuring them because they correlate poorly with effect.

Mitoxanthrone (Novantrone®) comes with the above mentioned heart concerns but it can also suppress the function of the blood and liver. Care must be taken that the i's are dotted and the t's crossed; that may be best done by a physician who is used to administering such chemotherapy agents (an oncologist or cancer doctor).

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