Counseling Points Multiple Sclerosis - Spring 2015 - 6

received education about the risks of MS therapies

Table 1. Key Monitoring Steps for MS
Disease-Modifying Therapies

and that they are aware of their own responsibilities for monitoring and follow-up while receiving

Partial listing; consult current prescribing information for
each agent.

the drug. Determining the patient's level of health
literacy is an important aspect of this process. The

Fingolimod (Gilenya)11
* Electrocardiogram (ECG) and monitoring for
bradycardia on initial dosing

Agency for Healthcare Research and Quality

* Ophthalmic examinations to rule out macular edema,
at baseline and 3 to 4 months after initial dosing

that includes a number of useful resources toward

(AHRQ) offers an online Health Literacy Toolkit
this goal, including:17

* Complete blood count and liver enzymes (also
required for interferons, teriflunomide, and some
other agents)

* Health Literacy Assessment Tool and User's
Guide

Teriflunomide (Aubagio)12

* Training Program for Healthcare Staff on

* Pregnancy test and counseling of patients about risk
of pregnancy

Communication
* Telephone Reminder Tool to Help Refill

* Monthly liver function tests for first 6 months
* Tuberculosis skin testing

Medicines on Time

* Antibody testing for varicella zoster virus

Infectious Complications of MS
Therapies

Glatiramer acetate (Copaxone)13
* Skin examination for signs of skin breakdown
Interferon beta-1a and interferon beta-1b (Avonex,
Betaseron, Rebif, Extavia, Plegridy)14,15

The development of newer immunomodulating therapies for MS has introduced new infec-

* Monitor CBC and liver enzymes

tious risks and immune-mediated effects that are

* Skin examination for signs of skin breakdown

not normally encountered in patients with MS.

* Thyroid hormone levels in patients with history of
thyroid dysfunction or as clinically indicated

These include opportunistic infections, which

Dimethyl fumarate (Tecfidera)

16

are defined as "illnesses caused by organisms that

* CBC with lymphocyte count prior to initiating therapy

would not usually cause disease in a person with a

* CBC with differential every 6 months and as clinically
indicated

normally functioning immune system."18 Immu-

(Contains a partial listing; consult full prescribing

presentations of more typical infections (such as

information for each agent.)

herpesvirus), development of malignancies, and

nomodulation in MS may also lead to unexpected

In many practices, keeping up with this infor-

risk of autoimmune conditions such as thyroid

mation will warrant a need for new in-office pro-

disease.

tocols for testing and surveillance of patients with

Natalizumab increases the risk of opportunis-

MS to ensure that they are tolerating therapy and

tic infections because it prevents inflammatory

receiving the recommended tests to monitor for

cells from performing immunosurveillance of the

potential adverse events. Some practices also ask

central nervous system.19 This risk appears to be

patients to document in writing that they have

largely confined to one serious CNS infectious

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