Herbal remedies for asthma are safe

if everybody's ready i'm gonna go ahead andget started i don't know if everybody's here yet but i'm it is a little after 6 so i guess weshould get moving so i want to thank everybody forcoming to the talk um, i am christina johnston i'm a neurologist that work that works atlakeshore health partners on i've been the in town practicing for thepast year so i've sort of met quite a few patients with ms in my first year ofpractice and

i was asked to do a talk to thecommunity about a common problem that i've seen so far and ms was like thefirst thing that popped into my head i thought um, there would probably be somequestions and things that um, there's been some new medicationsthat have come out over the past few years so i thought it would be a reasonable thing to review just kind of do an overview of what is ms uh what are the symptoms of ms, howdo we diagnose ms and then some of the newer therapiesthat have come out over the past few

years i wanted to kind of touch base on those and then will beplenty of time for questions at the and i didn't get really really specific abouta lot of things cause i knew there was going to be probably a lot a questions so um but we'll have plenty of time forthat at the end okay also i wanna apologize ahead of time ihave a cough drop in my mouth cause i'm getting over bronchitis so i apologize in advance um

okay so i have nothing to disclose i'm independently employed i don't work foranybody else except for lhp so just want to get that out of the way ahead of time so what is ms what happens with ms? um ms is a chronic disease in the that affects thecentral nervous system that means that the brain the spinalcord and also the optic nerves which are the nerves that project to the eye and allow us to see can be involved in thisprocess

um, everyone has an immune system thatnormally fights of diseases such as bacteria and viruses any sort of infection and we think that the reason ms occurs is becausethere's a sort of case of mistaken identity that the immune system mistakes the central nervous system as a foreign object or foreign being and itunfortunately attacks it and creates a problem so statisticallyspeaking everybody likes to talk about statistics a little bit to get a generalidea

of how big of a problem this theis in terms of our country um it affects approximatelythe statistics vary a little bit but around 350 to 500 thousand so um people in just the unitedstates alone worldwide there's over two and a half million individuals and the estimate that in in the unitedstates alone approximately 200 people per week are diagnosed with this diseaseso it is rather common um more so than a lot ofneurologic diseases and its probably affected a lot of

i means i'm sure a lot of people up herein this room are affected but even in the general community most of uscan say that we know someone or or know of someone that has or um a family member who is affected by msor a friend or something it's very very commonly seen. um, it typicallyaffects males less than females i we don't really knowunderstand why that is but the ratio is about two to three females to one male um but that's kinda what wesee typically caucasians are affected morepredominantly

um than african-americans althoughcaucasians african-americans and hispanics are the most commonly affected we don'talways see it as much in asians although it can occur and there's a few other ethnicities thisis not as common um children can be affected by thisdisease although it's very rare in my training i did see i a fewchildren that were affected but mostly it occurs in our younger years it kind of the the sayingis that it affects a person when they're

in the prime of their life theirtwenties or thirties or forties or fifties when they're really you know doing greatthey're living their life they're having children they're getting married and this happened so it tends to occur kind of in the northernareas of the world the united states predominately inthe united states it's even more in the upper portions of thecountry as you get more south it doesn't seem to be as prevalent andthat's the case across the world so

europe japan some of those areas are moreoften effected northern european countriesspecifically tend to have a higher predominance of ms as well we're not really sure what that is theresome theories about that vitamin d or sunlight exposurecould be playing a role in why that occurs more commonly than nearer to theequator because it's very infrequently seen in the countries that are closer to the equator the life span a person with ms is

generally about on the average only afew years shorter than the normal life span of atypical american so you know people who are diagnosed withms still live a full life only they have to sort of um deal with thesymptoms and the chronicity of this disease so we still haven't identified exactlywhat the cause of the disease is but there's a lotta research so i just put this slide in because thisis i found this on-line and it's a picture above many famous faces

who have been affected by ms i think that's teri garr annette funicello who just passedaway she was seventy years old so she lived a long time with ms richardpryor ann romney was in the news with the lastelection kinda brought a lot of attention toward ms and raised a lot of questions about itmeredith vieira's husband i think richard cohen is his name he'sum a famous individual who's been in thenews a lot about you know what

attention toward ms and jackosbourne was diagnosed a few years ago so he's been in a few newspapers and magazines over thepast year so that i've seen so but it is it does affect anybody so so getting into a little bit moredetail about specifically what is it so everyone's brain and spinal cordare you know consist of nerves and thenerves are lined by a protective barrier called the myelinsheath so the analogy that we use is

that it's like an electrical cord with a protective you know insulation around the cord and that's the case withthe nerve so what happens is that the normalnervous system connects the brain to the spinal cord tothe nerves in the extremities which connects with the muscle andallows us to do things like move walk feel a sensation uh, visualize theworld so when the immune system attacksthe the myelin or the covering up the nerveit creates a disruption in the signal

transmission and so the signals can't get from the brainto the leg or to whatever is affected and it creates a problem so it usually happens when inflamation occurs after the attck of the immune system on the myelin so what happens with that is an attack aclinical attack a relapse a flare whatever term you choose to use our or yourneurologist uses to use but that's what it is so it's a suddenonset of neurologic

sometimes meaning weakness numbnessanything like that that comes on and doesn't go away for atleast 24 hours for some people it lasts for you know 3-4 daysfor some people it lasts several weeks and some people never i mean it canpersist longer so typically though that's not the casetypically it's a short term a few days a few weeks and then itgradually starts to improve which is why i sort of people can havesymptoms and then they get better and they ignore it and they don't even knowthat they have symptoms of ms. oftentimes ithappens to a 24-year-old 25-year-old you

know a young person they get better and they don't thinkanything of it until something happens later so that's the classic pattern that we here of relapsing remitting so a relapse followed by a remissionmeaning healing and going on with normalactivity so the symptoms can come on later inlife usually in this in the setting upinfection if we're stressed out if we're tired

and it's the result of the sclerosis left on the brain or the sclerosis just means a scar soafter the brain is attacked or there's a damage tothe nerve there's a scar that forms as it healsbut that scar doesn't have the same capacity that ithad prior to its damage so it can leave residualsymptoms going forward. over the course of one'slifetime you can see a decline in physical activity you can see a declinein cognitive ability so there are some chronic components tothis disease which is what

leads to the disability component you know and and managing thesechronic symptoms is you know that's my job that's what theneurologist sort of managers and and deals withon a routine basis so i put an illustration in here and actuallytried to put into my slide but it didn't work soi'm gonna actually just go to the youtube website it's not my video but i found it onlineand i thought it was a fantastic illustration

of the pathology that justtried to explain multiple sclerosis, ms is a disease thataffects the central nervous system the cns which consists of the brainspinal cord and optic nerves everything we do whether it's taking a step, solving aproblem or simply breathing relies on the proper functioning of thecns to understand how ms may impactthe cns we must explore the disease at thecellular level in the brain millions of nerve cellscalled neurons continually send and

receive signals each signal is a minute but necessarypart of intricate cns orchestrations thatculminate in the actions sensations thoughts andemotions the comprise the human experience normally the path over which a nervesignal travels is protected by a type of insulation calledmyelin sheath this insulation is essential for nervesignals to reach their target in ms the myelin sheath is eroded

and the underlying wire like nerve fiberis also damaged. this leads to a breakdown inthe ability of the nerve cells to transmit signals it is believed that the loss of myelinis the result of mistake in attacks by immune cells immune cells protect the body againstforeign substances such as bacteria and viruses but in ms something goes awry immune cellsinfiltrate the brain and spinal cord seek out the myelin

and attack as ongoing inflammation andtissue damage occurs nerve signals are disrupted this causesunpredictable symptoms that can range from numbness or tingling to blindness andparalysis these losses may be temporary orpermanent that was a really nice illustration ofwhat i tried to explain but obviously i can't do the video as nicely that explained itbut i thought that was a good explanation sort of of what thephysiology of ms is just so that you can

all understand if you weren't aware already so again why does it happen we don't reallyknow there's a lot of theories out there there's been a lot ofinvestigations about what specifically causes it because for for like i said it affects us at ayounger age so there's a theory that it's gotta be viral i mean we're all exposed to varyingviruses throughout our lifetime the one that's most commonly thrownout there is the epstein bar

virus which many of us were exposed toin childhood some of us were affected and got mono from it some of us hadno symptoms of it and they think it could be contributing or have some some role in making the immunesystem go awry and creates this this disorder as i stated earlier vitamin d hasrecently become a sort of big focus of ms and especially in preventingrelapses because we we think that low vitamin d levelslow sunlight exposure kinda that northern latitude

thing that i talked about beforethat that has some implication in in the relapse in and the and the incidence of worsening disease so there's a lot ofresearch going on in that and a lot of physicians now are starting to monitorvitamin d levels and if they're low which most people inmichigan have a low vitamin d level we're starting to replace it and kind ofget those level up a little bit into a more therapeuticrange because we think it'll help genetics is also something thatthey're looking into it can run in families

there's definitely a large number of you know families that do have msthat runs in the family but they haven't identified a specific genetic linkage i mean i have a number of patients in mypractice in my training i saw a lot of people that you know their parent was diagnosedor they had a sibling who had been diagnosed with ms so it it seems like it has some sort ofgenetic linkage but we just haven't really identified it yet

so ms is a broad diagnosis there are four typesof ms. the most common and the most significantly more common is the relapsing-remitting multiple sclerosis that affects about eighty-five percentof people who are affected by ms it's clearly the most common a much much less common is a primaryprogressive multiple sclerosis i'm not going to spend a lot of time onthat one or any of the others because it just it's not as commonly seen butprimary progressive multiple sclerosis

you don't really see the relapses the patients who are affected by that they they get a symptom and they don'trecover from it so there continue anytime that they havea new attack on their system they just continually decline but they don't havelike an outward attack and then recovery so it's a little bit differentand we think it might be a little bit thethe physiology of it is obviously a little different we haven't clearlyidentified that either there are not as many therereally aren't any therapies for that type of ms either and relapsingremitting

multiple sclerosis does have a number of therapies so i wanted to really focus on that type for this talk secondary progressive multiplesclerosis is kinda something that you see later in life in the disease processafter you know you've had it for a numberyears you start to sort of not have as many relapses or not as often and and things just start to quietdown or they seem like they quiet down but what we know about that is that inthat stage the relapses become less

prominent but the disability part seems to become more evident so thescarring on the brain that occurred earlier in life now starts to affect us more seriously and then progressive relapsingmultiple sclerosis is very for a rare but it is a is a conditionwhere there's a progressive componentthat can have relapses but that you know you you have a relapse but you don'tcompletely recover and it's more profound

than in relapsing-remitting so it's a littletricky to diagnose you don't see that one as often either this is sort of a illustration of the the type that i just described this oneat the very top here is called benign multiple sclerosisthat you know it it we don't see thatone a whole whole lot there's a very few people that have multiple sclerosis but they the completely return back tonormal and they just don't really

develop disability over their lifetime it definitely occurs it's just not ascommon and we don't we don't tend to focuson that one as much either those people are usually kinda groupedin with the relapsing-remitting because it is so soimilar there's relapses the disability just doesn't seem to beas profound but you can see with this illustrationwas trying to say is that with with each relapse there's a sort of apeak in disability the the y-axis here's the disabilityfactor this is time

so as our lifetime goes on there's a arelapse and we get better but if you notice youdon't completely return to baseline you may have a teensy bit of aresidual weakness or whatever your disability is and then a few years go by and then youhave another relapse and maybe you still don't return exactly to that baseline atyou are at and as it goes on it's just a little bitgradual progression of the disability component with primary progressive as i said there'sjust really no relapses there's

just a continual steady increase in theamount of disability over time but you just don't seethose peaks in sudden onset of symptoms the secondary progressive form here isvery similar but as i said there's just a much more you know a much less recovery to to the baseline there and it just as youget later in life to even the relapses become less prominentso and then this is the progressiverelapsing

so symptoms i mean everybody wants knowwhat are the symptoms i think so many people in my office who come and say i think i have ms i've been readingon the internet i think i have ms please tell me i don't have ms. i can't tell you how many times i seethat and then there are the people that come in they possibly do have ms so how how do we how does theneurologist know well i mean obviously this is a greatillustration because it shows that it

affects every part of the body essentially oftentimes initial symptoms canconsist of loss of vision in one eye or optic neuritis sudden wake up onemorning can't see out of an eye pain painful vision gradually progressesover a few days and then after a few weeks starts toreturn that's very commonly seen as one of the initial symptoms of ms it can vary though i mean some peoplecan have episodes of double vision or sudden

imbalance but as i said earlier in thetalk but symptoms have to be sorta consistent and last for more than 24hours so when people come to me and say i woke up this morning my leg is numband later in the afternoon it back to normal that's not ms okay certainly sensation can be affected numbness paresthesias meaning tingling burningthat type of thing that can that can definitely be msbut it's not something that you know we wake up with in the morning and it'sbetter by afternoon

that's different weakness oftentimes the initial symptoms orlater symptoms of a relapse or weakness that affects a limb you know my arm is all the sudden clumsier orheavier than it used to be and it's just not getting better and i think something's wrong its it's aprofound neurologic symptom that doesn't get better or doesn't get betterright away okay with the spinal cord involvement you can see things likebowel and bladder dysfunction

urinary incontinence urinary urgency having to go all the time difficultyemptying things of that nature. it can affectour swallowing it can affect our speech it can affect our cognition arefocus our mood are energy level i mean everyone who hasms the most common complaint is fatigue. i'mtired i have no energy i have to take a nap every day becauseit's just it wipes you out so these are the symptoms but it's theway the symptoms present and the duration and

and that that really helps theneurologist to to hone in on this could possibly be an ms symptom. so as i said when someone comes to meand they want to know how do i know if i have ms a neurologist is gonna really you know teasethrough the details of the history the history to aneurologist is the most important thing because i wanna know what is happening right nowbut i also want to know what has happened before

i mean what in your earlier you knowyears have you presented with or have you had and yourignored it because it got better you didn't think anything of it um the timing of it as i said how longdoes it last how when did it go away. has it ever comeback um that's really really critical tomaking a diagnosis the neurologic exam is obviously veryimportant um and can only you know a neurologistis probably the only one who can do it very well

um it's a challenging thing to do umthe imaging of the brain and spinal cord is very important before we had mri ms was much moredifficult to diagnose because we didn't have specific pictures wherewe could see the lesion or the inflamation or the attack um sometimes now less commonly we we still do a spinal tap to make ananalysis of the spinal fluid and see that there's evidence and inflamation but thirty years ago anyone who possiblyhad ms

got a spinal tap nowadays that's notnecessarily the case mri has significantly brought us muchmore advanced and we don't always have to dothat now evoked potentials which are the visual um the visual testing to see ifanyone's had optic neuritis i mean we used to have to do thosethings to really solidify a diagnosis and sometimes we didn't know sometimeswe had to wait now we sometimes may have to wait alittle bit to see if there is another relapse or see if there are new symptomsthat develop

but most of the time or very very often we can figure it out rather quicklybecause i technology has advanced so much but again i do see people sometimes where i say this is a clinically isolated syndrome you have a high likelihood of developingms based on your symptoms based on your imaging but it's not ams yet because they're very strict criteria that a neurologist uses and i'm not going to get into all that cause it's really boringand so this is a typical mri of apatient who's been affected by ms.

so i have two views here um this is asagittal image and this is an axial image of a typical mri so what we're seeing here is these areas here here here here sort of along the middle of thebrain this is the these are the eyes here this is the back of the head the spinal cord starting to develop downhere so we're as a neurologist, we look kinda alongthe center of the brain where ms likes to hang out

it tends to affect the portions near tothe ventricle which is this portion here and these are the ventricles here andhere as well and in both images you see these areas of inflamation these bright spots on the brain and theyreally like to hang out near the ventricles we don't know why but um that's the sort of classic picture of what an ms brain looks likethese areas where the inflammation is located is probably when arelapse occurred so we like to monitor mri's going downthe road after a diagnosis is made

to monitor the progression of thedisease to monitor if the the medication that you're on isworking it really provides a lot of information this is a picture of a spinal cord that has um a lesion on it so kinda just ageneral illustration of what we're looking forwhen a neurologist orders an mri that's why we want to get so what do we do for treatment umthere's no cure but we have significantly advanced intherapies over the last twenty years

um there's at this time still enormousamount of research in ms, um, they as i said in the last three years there'sbeen three new therapies that have come out which i'll talk about in a few minutes um there's a lot of drug trials goingon right now there's clinical trials there's you know in the lab trials going on andwe're moving very much toward toward um you know better therapies and therapies that areworking much much

um stronger at reducing relapses andminimizing disability which is really important so obviously though it's still abalancing act because we have to maintain our immune system and find atherapy that allows our immune system to be suppressed enough so that it's notgoing to continue to attack itself so it is rather challenging and that'swhy it's taken so long to get to where we are now wehave therapies available that work with minimal side effects and um you know that you can be on for a long along period of time

so the treatments that we do haveavailable obviously the acute relapse is when something happens most the the themainstay is steroids it still is it was fifty years ago um when you havean acute relapse if anyone has ever um had a relapsesteroids are kinda the mainstay it ek expedites the healing process it doesn'tcure anything but we want to get you back to your baseline as soon as quickly as possible and get you backon back on your feet. um, the diseasemodifying therapies are the ones that i'm gonna spend most my time talkingabout and the symptomatic therapies um

i'll touch on a little bit but that'sreally individual so you know based on what your symptoms arethere's there's multiple treatment options but it's sort a veryindividualized so in 1993 was the first um disease modifying therapy that cameout it was betaseron it was an enormous breakthrough for mspatients because all the sudden there was something to put to be on to reduce the relapse rate andto reduce the potential of of progressing withdisability

um since since that time so in 20 years we've come up with 8 fda-approveddisease-modifying therapies actually i think there's actually 9 butone of them i didn't include because i don't see people using it much anymorebecause it has a lot of bad side effects so kinda moving away from that one sincewe've gotten some newer ones um ah all of the disease modifying therapiesthat are on the market um have been shown to reduce relapsesmost of them have been shown to at least reduce the progression of disabilityand many of them have

have also been shown to reduce the thenew lesions seen on the mris that we that we periodically check so most of the actually all the therapies are generally safe and well tolerated when i say generally there are a few um significant complications withseveral of the therapies that we very closely monitor and we look out for and and we're very on top of those ah potential risks so we'll talk about that um on avaerage the injectable disease modifying therapies have been shown to reducerelapes by 30 percent

the injectable um have been around the longest um only in the last three years are therepills available now so most people who have had ms this long have been on injectabletherapies of some kind um all have an anti-inflammatoryeffect on the immune system so reducing inflammation bringing theimmune system down to a more manageable level and reducing the relapses um most of thetherapies require some kind of blood monitoring

there are a few that don't require as much butthere are you know a maintenance test that oftentimes have to be done to ensurethat it is it safe to continue beyond so the first category is that i'm gonnatalk about are the interferons interferons are normally present in our immune system and betaseron is the first one thatcame out it's also called extavia it's believed to suppress the movement of t cells which are a typeof immunecell across the blood-brain barrier sothere's a there's a wall between like

the the blood flow and the brains cellsthemselves and so the immune cells have to sort of transpose across that and invade thebrain to cause the attack so this medicationwas aimed at reducing that transposition ofthe t cells across the barrier the barrier into the brain this is aninjectable medication every other day it's been around the longest there'sbeen a lot of people who are on it at first and then since that came out there's afew others that have come out as well in

the same category it's approved for relapsing-remittingmultiple sclerosis it as i said reduces relapse and byabout thirty percent so it's a pretty reasonable numberit does have the unfortunate side effect of them flu-like side effects with the injectables but um for its different for everybody and wehave you know wonderful nurses that we you know use totrain our patients to help sort of minimize those unfortunate side effects

um interferon um beta-1a are the avonex and the rebif this isthe same medication but in a different form in a little bit different dose so avonex is a is a once-weeklyinjection um it reduces relapses as i said byabout thirty percent as well all the interferons are about the same interms of numbers it's been shown to slow disabilityprogression which betaseron did not and also reduce the mri leasions that are seen

mmm so avonex is once a week rebif isthree times per week under the skin both have flu-like side effects unfortunately but as i said for most people it'susually worse in the beginning when you're starting the therapy as you sort of get established on thetherapy the flu-like side effects do tend to dissipate and you sort of learn how to how to manageit you pick a day that sorta works for you that you're able to be a little under the weather and stillkinda go on with your day to day

functioning with both of these medications um bloodmonitoring is required you have to monitor the lever we monitor the the the white count to make sure thatyou still have a good immune system in that the platelets and other things haven'tdropped so we do do periodic blood monitoring with the both of thesemedications the other injectable medication is glatiramer acetate or copaxone copaxone is a different category ofmedication that's not an interferon

its actually a combination of aminoacids that are believed to be found in the themyelin or the on the a it resemble the mylan and itsupposed to suppress the t cells and reduce inflammation um it's approved for relapsing-remitting multiple sclerosis as well it does also have a 30 percentreduction in relapse rate it has not been shown to decreasedisability

um but it is widely prescribed it everyday under the skin it has very minimalside effect it has no flu-like side effects it is tolerated by most people who dothe injections and its kind this is the one i kinda tellpeople it's like being a diabetic you sort of just do your shot every day and you justgo on with your your day so this is one that'sbeen very widely prescribed for women who want to have children it'ssafe during pregnancy this is the only

one that has been shown to be safe for pregnancyfor women that are in their childbearing years andaffected by ms this is one that is often used because you know you don'thave to go off of it you don't have to go back on it for some of these medicationsit takes several months before they reach full effectiveness so that's a nice that's a nice perk tysabri is a once-a-month infusion tysabri is a very wonderful drug when itcame on the market it was like the breakthrough it was i believe 2007 ihave to look that up specifically but

it may have been 2007 when it came onto the market and it was pulled from the market a yearlater because of an infection of the brain that was foundto occur called pml pml is a viral infection that isirreversible and it can result in death it canresult in very significant disability and it is not taken lightlyby any neurologist it is a wonderful drug now in the sensethat it's once a month you go for your fusion yougo home and that's it for the month and you feel great and there's no sideeffect and its a fantastic option

but it has very specific protocol that has to be very closely adhered toonly approved neurologists and approved centers canadminister this medication you have to have very strict criteria with every infusion you have to havea patient who is incredibly willing to adhere to the rules and it it is very closely monitored but it has a reductionrelapses of by about 67 percent so far surpasses all the other ones

it slows disability progression andreduces the mri lesion and it's a great drug but i'll tell youhave seen pml and it's not great it's horrible itkills people its it is worse than ms so that's why we don't we don't pick thisfor every person with ms this is a medication thatis reserved for patients who have failed other therapies and are havingprogression and we need to do something stronger but it's a great drug

yes when it is used yes as is the case with some ofthese other medications that we'll talk about so these are the new oral therapies so anyother a 50 and tech for their of health which is awesome no injectionmany more so don't wanna make you mine in 2010 it's a once-a-day tablet it has areduction in relapse is about fifty percent

but unfortunately this one has um someunfortunate cardiac side effect that we have to really closely monitored there have been some reports of suddencardiac death with this medication so we have to pick patient to have no history of cardiac problems arevery minimal risk risk of cardiac disease on it has it produces a disease progressionit reduces mri region on it up believed to keep the lymphocytes inside the lymph nodes andprevent them from

i'm going to go to the brain so that'show we think it works i'm this one can also affect our visionin 'cause a macular degeneration so that's something that has to be screenwhile on this medication on there's a little bit of bloodmonitoring of the screen for z/os oster or her on that shingles by rest but its job it's a good medicine to it's been outfor three almost three years now and there's a number people on it andthey're doing great sold that was the first one

i last follow by your weather pro why wealways called theraflu my careful in mind is a agent that has beeni around for i'm not not here for thenight um left phone in my which is anotherderivative i love up here for the night or similar has been around for much longer so we dohave some information about this on similar products and it was approved as a once-a-day tab what you is believedto have hit a flamer three properties that reduce the lymphocytes and the

in the central nervous system thespecific seven or a little little sticky to me i don't completelyunderstand that exactly but its i'm it's been around and it'sstarting to be prescribed more commonly on it has a specific similar with theinjectables about 30 percent i'm however the big the big fancystatistic here is that eighty percent left new lesions on mri which is youknow a really important i factor for forpatients this is %uh pregnancy category axoanyone who's in there childbearing age range is probably notgoing to be a good candidate for this

medication because it's very risky i'm category act in the medical worldmean absolutely not cannot get pregnant onthis medication even males who on could potentiallyimpregnate their wives are supposed to be warned about that because that's beenfound from and also to be a problem so we haveto monitor blood pressure and we have to do a tv screen but this is a once-a-daymedication that is an option for people if you're me onyour childbearing years and it's okay to be on something like this

than this is a great option i i mean i'm i'm really excited about the final southi'm and tech for there is the most recent one that just came out a fewmonths ago it's a twice-a-day medication it has alittle bit different i'm back in them mechanism of action apredominately work from the anti-oxidant pathway from which is kinda a new thing i meanwe vote we always hear about anti-oxidant thing as both a drink all these and accident you know throughyou said that thing for

it that there there is a lot of ongoingresearch in this area so there's probably going to be more drugs in thefuture coming out in the area this heather a reduction relaxes by of53 percent on disability is also decreased by 38percent the side effect prior profile is prettygood i mean it it does cost them flashing for people the face feel a little hotfor about an hour so after your does tends to get better after about an hourfrom what i'm told and tends to minimize over the course ofthe first few

first few weeks by the end of the firstmonth and told that much better i'm it can cause an upset stomach somegastrointestinal discomfort but its sounds like a great drug alsovery little fight a fact starting to see i mean i have a couplepeople are there now i haven't heard a lot about feedback fell i've talked with some colleagues whothink it's great i worked in a center that this was a medication on in the research trial i so great great day out on the fun thismedication was available

in europe for psoriasis so it's been onthe market for a long long time and they have a lot of good data thatits safe and effective of l so this is a great option for people so with all these nomads how did theneurologist user how does the patient on you know how do they know if theircandidate for these new medications well that's complicated a little bit armyou know for patients that have been stable on their injectablemedications it's really hard to to take them off abit right away knowing that they're doing so while

for patients who have horrible sideeffects they've been he never have an accident when he nearly there forwhatever the case maybe they had their compactness and the they just have had horribletolerability issue 3 years and now these pills are available i mean that's areasonable option but it's very individualized with eachcase scenario its it differ on thought process into why would weswitch for some people they they do fine airduct herbal medications but they're just getting worse

and they need something different andthese are available and they have a different mechanism action so it's a different way offighting of immune system so that's a reason to pick it for some people they have no symptomsbut there are my eyes are looking worth and something needs to be done so thatdisease progression or disability doesn't occur in 10 years so i mean there are a lot of thoughtsthat go into a neurologist mind when we meet with you every visit to talk totalk about your therapy

i'm it's not an easy choice on it's it's a it's a big it's a bigdecision to switch therapies and there's risk with which in therapyand their side effects were searching therapy so is very individualized anyone knowthem if they know all about the the risks of medication and it'sit's a case by case decision so what if i for one person thenecessary pie for the next person so what if you think you have an ass orwhat if you know somebody who that you are concerned might have my math the tosee somebody about it they need to get

evaluated by a neurologist somebody whois familiar with a mass who can really look into it on becausewhat we know about a mass and what we've seen even before before i was even born and31 years old well i mean this has been a long foraround for a long time and you know my trainers have been doingthis for a long time they saw people when there was nothingto do and every year things got worse but now withtherapy things slow down and and people areliving longer with left disability with

more functionality there no one not me it's now they have amassedbecause they can you know have less and less symptoms as they'relike 10 cause on and if you don't get treatment as soon as possible or as early as you can then the risk forrelapse is increase as and with that is disability so theearlier you're suspecting sometimes the girl you should see somebody inc andfigure it out for people who have been diagnosed withms and have been living with us for years that the whole different you knowit's a different ballgame

arm the symptomatic therapies are as isaid earlier very individualized there's plenty of medications out there to treat the fatigue to treat thespecificity to treat the depression to treat the bladder problems to you know i mean there's there's lotsof things that we have in its obviously with one thing is that work we trysomething out then if you know something doesn't work we stick with it but its its it depends on the same foundit depends on the person but i'm you know that's a conversationyou have with your neurologist

so when when a piece with a mask onthrough my office and i see them and i say howare you doing me not the time to say all my fightersfiring me or are not sleeping or how or and on thetop i mean because thats that the conversation thatyou have with your neurologist is how are you doing mean when when iwalk in there are many say how are you know that's what i'm i'm great but i'm thesafari me i mean that's what the neurologist newsnow that's how we decide how to treat

your symptoms and what to change in what to dodifferently so physical therapy is a great optionoccupational therapy for people who have you know you know different i mean it'sdifferent for everybody but those are great resource to the physical therapist in this town areawesome their top-notch i've sold many greatresponses from people that have gone physical therapy for youknow not just amassed we have a really great

i'm community with wonderful resource sso i find take advantage of that term in patients and i always make that an option on assistive devicessometimes are very helpful for you know foot drop or whatever the casemay be on you know when upper extremities arespastic and it's hard to go grab things are open jars and its its there's things available forthat so you have to talk to neurologist about it so that we can get get to the healthyyou need

living environment something had to bechanged living in a house that doesn't have a ton affairs you know bathroom accommodation thingslike that so that we can minimize complications exercise is always you know i never tellthem not to exercise i mean there's out there different degrees of exercisersdifferent things to do exercise is really important healthydiet good sleep home you know stuff stressmanagement hard stress management is something that andthe doctor can preach to you and any

person can preach to you but it you know i mean every person hasstress and everyone deals with it differently but it is important because when you'remore stressed your symptoms are accentuated and it's really important tosort of keep that under control and if you're struggling with that toask for help support refer great till i'm for porkribs are wonderful in the sense that they can give you someone from listen to yourstruggle

and also you know here what other peoplehave gone through it it's wonderful in some cases they can make you a littlenervous that oh my gosh i am i gonna be in a wheelchair because that's the mostcommon fear everybody and and i will tell you it'snot it's getting better i mean people are doing better forlonger with the advancement a medication so i thinkthe people that are weird wheelchairs thirty years ago if they were to havebeen diagnosed now maybe wouldn't be in a wheelchair asfeeling or maybe not ever its it's two things have changed andthings have advance and we definitely

are making a lot of strides so i put the fight in here actually wehave a handout over here with this information so these are justsome wonderful online resources that of anybody familiar with them but thenational ms society is a fantastic resource for helping with you know disabilitybenefits for insurance for work for all sorts of questions that we facein our day-to-day routine when you're living with a math i'mnamath lifelines them a active sources those are both onlineresources that can answer questions that

can provide i'm you know there's a mentor their i what i think both of themactually i must leave by the time as active force have resources to talk with a mentor ifyou need just somebody to talk to or someone who's been there there therethose resources there on the ms. foundation & spa sharedsolutions is great because they help with you know in questions at work questionsabout injectable therapies how to make

things better if you're struggling from they're they're wonderful ownersays that can provide way more our answers to questions that probably ican hit and fell i use them a lot self and on your side and i went a little bitover arm there's about 10 minutes left i'll have out safer any questions so i hopethat wasn't too boring or 200 perfect i okay thank you i

the the question why is on i hadmentioned some speech sometimes and the question was what would be somespeech something that frontal lobe lesions while i suppose that's a complicatedanswer as as is the case with most neurologyfrontal lobe lesions if they involve them older pathway can affect you know themechanics above the mouth so can make you have a more defarthritic or more about flirty your speech

are making about the throat so couldhave more modest phonic or some kind of like problem i know how to explain that very well butit it can make your your speech down a little thicker because thethe vocal cords and the the the throat doesn't move as nice andeasy as it use to sell i'm that would be the most obvious thingi would think of so the question i was in the videopresentation there was a comment about how the the pathway or about the pathophysiologyof an ass is that detects the mylan

but also that attacks the nerve fiberitself meaning axe on and that is true what we learned about our math with mriis that when the mylan is damaged the accentbeneath it can start to wither away because it isthat we don't know why that happens but probably because it isn't protectedas well and so the signal isn't being train ducted as well and the nervestarts to die of a little bit and we know that because i'm mri we seethese black holes is what they're called buttheir holes

in the brain that occur almost on a bitlike a stroke but it's not a stroke it's completely different ideology but it's a hole where the the nerveitself has basically sort of deteriorated we didn't really know that until mri sothe theory has changed a little bit and that's where we think the diseasedisability long term comes from is when those black hole or the the axeon itself has started to be this integrated oraffected is when the the secondary progressive disease comethen we've only learned that over the

past twenty years but you it without contrast it's actually i'm aon the t1 sequences which i'm i have many sequences that we lookat and when we're looking for active information we always look at the flarefake ones are the key to flare sequence that those were the sequence as shown inthe images during this presentation but they're also the sequence called t1and that does demonstrate the black hole so we don't see it an early amassed wesee then later on that

cell but yes that's a wonderful questionwe didn't know that for a long time i'm the question foreverybody is does the number i've lesions on mricorrelate with the number relapses or the number are the severity ofdisability i got answer is no i'm there are mri's they look horrible like the 1i showedyou i've no idea that beijing was i i just picked that picture because ithought it was a good illustration but mri can be horribly deceiving and look where the like that and havevery few clinical symptoms

okay the opposite case can occur whenthe brain never really look that bad but the location of the lesion can be inthat specific precise location that it put leaves you with a lot a disability so patients who havebrain stem or spinal cord lesions and not a lot inthe outer portions of the brain can have a lot of disability in lifereally bad and their brain doesn't look that bad so it doesn't always correlate but the reason we monitor mri is becausewe wanna see is there any new

regions that have had some sort ofclinical correlation because there is a silent component andmath because every new lease and doesn't always have a symptom so not in my training are not in my career time i'm i get a repeat didn'thear the question on can we use combination therapy toimprove the immune system fight against i mathi'm the reason the answers now we don't dothat i'm and the reason is because for example in

the i text every trial those patients that developed p.m. i'll were alsoanother 30 some of them have been on avonex okay and some of them have been on otherchemotherapy drugs for other conditions and we think that that significantlyincreases the risk of infection and so we're incredibly leary i'veexposing people to too many infections because brain infections are veryserious so we don't take that lightly and most of the studies are are comparedagainst placebo

on there's very few trial to comparehead to head against another product but they do not allow people to be instudies with combination therapy for that reason because i've the risk ofinfection so it ecological box and a lot of peoplehave discussed that but in my training in my career and eveni think in the twenty years that they've beenavailable people are just not doing that i mean i've i've not seen that anywhere cell and in fact sometimes when we takepeople off medication and what's worse is something differentwe give them a little bit of a washout

period meaning some time to get that drive outother system so that that is not a risk exercise for that's great it's mentally therapeutic it obviouslyvery you feel better and we think that keeps you a mandatoryfor longer felt thank you that that's great can you still have amass if you don't have lesions on your brain probably not okay that i am there is a condition called honor mylatest after car which is a very into a

mass it's not an ass but it is usuallyconsist of spinal cord lesions with no liens on the brain and opticnerve so it's nerves on the eyes and spinal cord andnothing in the brain which it's very similar amassed but ifyou have a massive you have something on your bringing now in my opinion is in my opinion is a funbetter than vitamin d i'm i don't know the answer to that ithink it i think it might be i mean look at thepeople that live close to the equator

they don't have this problem see kinda wonder right but we don't havethat ability we'll we have you know how many month of cloudinessand no sunlight and it makes us all depressed and crankybut i mean it it does make you wonder bowlthat's all we have as the vitamin d3 for or a supplement inthis area the country's how often that's a hard question howoften it is is it in the arms versus the legs or probably refers tothe life versus the arms or both i'm i don't know that i've ever

paid attention to that truthfully ithink we notice when it's in the legs more of 10 because it affectstheir walking effects are emulation but the arms arenot taken lightly either i mean writing we are driving everything we do i mean idon't i don't really have an answer to that because i never really paidattention to watch is more prominent for a lot of people in effect 15 thebody so if the arm and a leg on one side for of but is it just one arm or justone lag i don't know which one mark on for andthis is a complicated disease because everybody's different not one singleperson with ms looks like the next

person it's very variable cell it which is thechallenge so that i thought he wants to knowbecause the location of the lesion that mri are so close to the ventricles in thecenter of the brain does that mean that there's somethinghaving to do with what we ingest into our bodies and that it's crossingthe blood-brain barrier somehow and affecting the brain in the centre portions fromsomething we ate

i don't know i i'm never heard back thatphiri inexpensive one for insurance is a lot of times are youknow people use their insurance if the payfor those expensive thing so that's why they hurts so much because insurancecompanies molpe the big box and if you don't haveinsurance or free insurance won't pay the static at the big bucks so i i truthfully i don't have enoughlot of knowledge about where that

cheapest devices are located i knowthere's just you know i i refer people to medical devicestores because every month options but i don't know that that you're rightthey're not they're not cheap it's such a in my practice i'm i don't want anyone i don't want anybodynot be on drug because they don't have insurance there are so many resources most ofthese drug companies will make sure you get the drug and andmost of them have assistance programs so that you can get it for free for ayear or two or you can pay

you have attend our copay or they almostall these drug companies bent over backwards to get you on their their therapies i meet my partnertrained in inner-city chicago in you know he he saw people who had nomoney no place to live and we're getting drugs so these drug companies will make surethat you can get therapy if you have a diagnosis so somebody who told me because they don'thave insurance enactment take their medication

i can i that's not enough for me me hi i really do work very hard to get peopleon therapy because i really strongly believe that you know idon't want to be disabled so i i want i want to make anyopportunity to keep you functional keep you livingas long as possible i think that's changing a lot now ithink one other one other company they know for sureabsolutely will pay for your dog if you can afford it and in fact actually to %uh the companythen oh well yes people with the

injectable the aft since the orals have come available imean i think i've only been here for a year okay so i've assumed a lot of people whohave been in this community and had a diagnosis and you know maybe they're just lookingfor a new neurologist so yeah people that i've had a long termdiagnosis and he did the injectables and couldn't deal with it both people have been offered drug itried to get them back on therapies

i really have because i'm especially forcoming in there are already using a cane or there already have been you know something going on or orthey're having relaxes and they're still me the biggest thing is clinically howare they doing it for not having relapses anymore and the baby there there stable or their may be progressing a little bityou know that's going to be a different situationbecause these medications are pro for relapsing forms

so on paper that is something we have tobe careful about because if you're not having relapses anymore it may not be covered cell these thesetherapies are only study in relapsing-remitting cases are notstudied in primary progressive they're not studying and secondary progressive so that's a little bit of anindividualized case as well but yeah if people have an offer theinjectable i am trying to get them back on yourtherapy is thank you so much to everyone okay