http://neurology.medscape.com/Medscape/Neurology/AskExperts/MS/2001/12/NEUR-ae105.html

Question

How would you treat a 16-year-old girl who has relapsing remitting multiple sclerosis (RRMS) and diabetes mellitus type I? In the last year, she has suffered 3 relapses of MS. These were treated with IV methylprednisolone, but after the last relapse (spinal cord) she did not completely recover.
During this year she also was receiving immunoglobulins (0.2 g/kg BW) monthly. Should interferons or mitoxantrone be considered now, as it seems that the disease is so active?

Zvonca Rener Primec, MD

Response

from Mark S. Freedman, MD, 12/6/01

A number of aspects of this question deserve attention. First is the issue of using disease-modifying drugs in a young patient with MS. None of the many treatment trials in MS involved patients younger than 18 years of age, primarily because of consent problems. Extrapolating the information to this age range is fairly commonplace, however, and there is at least no reason conceptually to believe that the agents would not have the same benefit as in adults.

Second is the comorbid insulin-dependent diabetes. Diabetes is also an autoimmune disease and in your patient's case is probably a "package deal" with the MS; a number of autoimmune diseases can be seen concurrently in the same individual (eg, MS with SLE, hypothyroidism, B12 deficiency, vitiligo, diabetes, inflammatory bowel disease, or even rheumatoid arthritis). Treating MS with a disease-modifying drug might well affect the status of the diabetes. Certainly, to have continued relapses requiring steroids is not going to enhance good glucose control.

I am not sure about the rationale for the use of monthly immunoglobulins. There has been really only one strong study[1] demonstrating the use of this regimen in the dosage range indicated, but we anxiously await a large phase 3 study to verify this effect with some MRI outcomes. Three relapses in a year, especially while receiving the immunoglobulins, would suggest this treatment is not effective for her. Administering mitoxantrone in such a young woman might well be disastrous, possibly rendering her sterile for life.

It would also be of interest to know just how many years she has had her disease and whether these 3 attacks are all within her first year. If so, then this does suggest a worse prognosis, as does early incomplete recovery from attacks.

I would strongly consider treatment with one of the disease-modifying drugs.

Given the anxiety over the possibility of this being a "bad prognosis" patient, I would go straight for a high-dose, subcutaneous interferon beta-1a 44 mcg 3 times weekly, if available, or subcutaneous interferon beta-1b 250 mcg every other day. If there is concern over the interferons affecting the diabetes (there is no evidence that it does, either positively or negatively) then glatiramer acetate can be tried, as it is felt to be more disease-specific. She can be followed closely for a year and a decision can be made to continue this therapy or not, based on relapse rate. There is no mention of the patient's MRI status; the amount of T2 disease burden would also be of interest. Depending on availability, MRI can also be used to assist in making a clinical decision.
 

References
 

1. Fazekas F, Deisenhammer F, Strasser-Fuchs S, et al. Randomised placebo-controlled trial of monthly intravenous immunoglobulin therapy in relapsing-remitting multiple sclerosis. Austrian Immunoglobulin in Multiple Sclerosis Study Group. Lancet. 1997;349:589-593.