I Quit Tecfidera. Until I Quit Quitting Tecfidera.

I have a long history of quitting. I quit cigarettes decades ago. At least a dozen times. When cigarettes hit the intolerable price of $1.30, I reached my tipping point. I never bought another pack. From what I hear, cigarettes are considerably more expensive in the 21st Century. My being a quitter must have saved me a fortune.

When I reached my tipping point to quit Tecfidera, it had nothing to do with money. Thankfully. My copay was $0. No one should have to quit an MS drug because they can’t afford it.

My quitting Tecfidera had nothing to do with any conviction I can beat MS through exercise and diet (see photo of my Monday morning breakfast: spinach, husband’s grilled swordfish, asparagus, onion, radish.) I’m doing everything I can, but I don’t expect any cosmic reward. As my dad often says: Life isn’t fair. Chances are, Gentle Reader, you breakfasted on something like half a bagel with cream cheese —foods I’ve  forbidden myself from eating—and your immune system merely thanked you for it. My immune system may have thrown a hissy fit over such a meal. Or not. I’ve past the point of taking such a risk.

I quit Tecfidera because I didn’t understand how it worked, or if it worked, or if it would work for me. (Thank you, A., for researching the chemical processes.)  I could tell Tecfidera made my skin furious if I didn’t take an aspirin first. I avoid food that makes the MS monster mad. Why would I take a drug that makes the MS monster mad?

I quit Tecfidera because every time I considered I might quit, I felt at peace. The rest of the time, I felt…flummoxed.

So I told Dr. Z  I quit. I told my husband I quit. I told the drug company I quit. Nobody gave me any guff. Then I called the NIH.

You’ll need some backstory. I’ll be the first to admit I am a terrible blogger. For years, I’ve ignored basic blogging etiquette, such as adding a photo to a post, or including a provision for comments. For a long while, I’d let my domain name lapse. I could never be bothered to comment on MS blogs that I find inane and boring. Or even comment on ones I find fascinating. I dropped out of Facebook, so I no longer pulled in those followers. Gentle Reader, it’s a wonder you made it here at all. You must have a genuine interest my story, and I thank you. Which is why I apologize for having violating a basic norm in storytelling, which is to tell a whole damn story—beginning, middle and end.

A few months ago, I’d had this idea I would take you through one day in the life of an MS patient visiting the NIH for a clinical trial. I created a new category on my blog: “TRAP trial.” I wrote a few posts.  This series got as far as about 9:45 am, EST, in my day of the life in the TRAP trial. And then a cataclysmic event occurred in my actual life with MS—maybe my drug was dropped?—and I posted about how everything was upended. And didn’t look back. I never wrote the post I’d planned about meeting up with the nurses who have literally held my hand through my MS trials. Or the post about meeting the brilliant woman, young enough to be my daughter, who has developed an app that allows me to perform clinical MS tests myself from the comfort of my own home. I never wrote the post that explains how Dr. Bielekova persuaded me to join the TRAP trial in the first place. And I never introduced you to the indomitable Dr. W. This is some shabby storytelling, indeed.

Let me begin to make amends by introducing you to Dr. W. She has quite the reputation. This is a woman who worked her way to the top on the not terribly level playing field of NIH, where, to this day, only 22 percent of tenured research scientists are women.

When my NIH nurse discovered Dr. W would assume my clinical care, the nurse told me I’d been assigned a neurologist who works only when she wants, and only on projects that interest her. That’s pretty badass.

Meeting Dr. W was like witnessing a 60’s era Katharine Hepburn stride into clinic. There was a hint of horse stable residue clinging to her expensive yet practical shoes. Dr. W springs from a Kentucky pedigree, and bonded with me over her knowledge of Cincinnati. Every subsequent time I’ve seen her, she refers effortlessly to minute details of conversations we’d had months before. Either she is a prodigious note taker, or she doesn’t forget a thing. I suspect the latter.

When I called Dr. W to announce I’d quit Tecfidera, the script didn’t run as it had when I’d rehearsed it on all the other players in my various MS spheres.

Once she got over her surprise that I was on Tecfidera in the first place—she’d been favor of Ocrevus—she insisted I get on “some MS drug” and stay on it.  Even Tecfidera would do. It was the only way I could rejoin the TRAP trial.

We weren’t on a FaceTime call, so she couldn’t see my facial expression drop like a hangdog Spenser Tracy after receiving a tongue-lashing from his whip-smart leading lady. While I have already demonstrated I can persuade just about anyone else of the diminishing returns of taking MS drugs after the age of fifty, I didn’t even try to argue with her.

I told Dr. W I would go back on Tecfidera.

I would rather quit quitting Tecfidera than quit the TRAP trial. Barring a new cataclysmic event interrupting my life’s narrative, I promise I will devote the next post to explaining why this Lab Rat thinks it’s worth it to resume Tecfidera and scurry back into the TRAP.

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Flummoxed (Part 4 of 4)

My friend Monica also has MS. She does not medicate. Which is not to say she does not treat her MS. Monica chooses her activities carefully. She exercises every day. She chooses her food carefully, following a Wahls-like diet, or what some of us call an auto-immune protocol. (AIP) Monica is also an exceptionally kind and gentle—non-inflammatory—person. (Am I implying MS is an expression of a personality defect? I hope not. I’m just observing that it’s hard to create a spark without any friction. Every life has friction. Monica seems to have a talent for not creating any friction, herself.) Monica never tries to talk me into living medication-free. I never try to talk her into taking medication. (I might have made a recommendation to take Singular, an allergy drug that has been shown in the lab to transform the brains of old rats into brains that function like young rats. But that’s for another post.)

When Monica texted to ask what our neurologist had to say about my rash, I wrote, “Z says he will support my decision even if I stop taking FDA approved drugs. But it’s such a tough call. If I’m wrong, and I get an exacerbation, I’ll blame myself. If overheating on this drug gives me an exacerbation, I will also blame myself.” I was perhaps exaggerating  (or as we as say in my family of origin, ‘over-exaggerating’) when I texted about the perils of overheating. Overheating merely creates pseudo-exacerbations, or transient worsening that last until the MS host cools off. Pseudo-exacerbations sure feel like the real thing, but they don’t bring on permanent damage (as far as we know.)  You see how Monica and I are opposites? Even after years of daily work to mellow out, I still have a tremendous talent for creating friction out of thin air.

Monica texted, “Yes, it’s a tough decision. Think we should decide not to blame ourselves either way. I will always support you, wwld* :)”

*wwld is of course short-hand for what would Lisa do? Feel free to sprinkle this liberally all over the internet, like lesions on an MS MRI.

Note that when I texted that I’d decided to drop the Tecfidera, Monica didn’t text back, “told ‘ya so,” or “welcome to revolution against rapacious Big Pharma” or anything. The Lisa she knows is a much better person than Ms. Lab Rat.

Her sweet response was not at all surprising. I didn’t expect to get any guff from Monica. The guff, when I got it, came from an entirely unexpected quarter.

 

 

 

Flummoxed (Part 3 of ?)

I get a phone call from my youngest sister, PYT, a.k.a. Pretty Young Thing, just as I am flopping down in the driver’s seat after a lightweight workout with my toys at the gym.

PYT has three Young kids, four and under, who are competing with me for her attention. I win. Intermittently.

I tell her I’ve capitulated. I’m taking my new MS drug just as the doctor ordered, thirty minutes after an aspirin. “I splurged and got myself the kiddie kind.”

“The orange ones? The chewables? The ones that taste like mom loves you and everything is going to be OK?”

“Exactly.” Oh, it is great to talk to someone who knows precisely what the aspirin summons—not only the specific taste, but the specific aura our mother would convey while doling it out.

Now that I take Tecfidera after an aspirin, and a meal with a bit of fatty food—I love my avocado, I love my coconut milk—I don’t get a rash. Or an allergic reaction. Whichever. Dr. Z. had warned me it might take weeks for the rash to stop flaring up. The rash had stopped immediately.

And yet. I don’t trust the lack of rash. You know those times when your room is a mess and your mom has threatened to inspect and you shove all your miscellaneous underwear and books and socks and chewed pencils under your bed, and it’s still a mess but it’s a hidden mess? Well, PYT and I never did that. The hidden mess was our middle sister’s speciality.  (She’s the pragmatist of us three.)  Our  messes were always flagrant—out in the open. And no, we never got points for honesty. But we’d always thought we ought to. Go ahead, roll your eyes. This is not a sentiment I’m proud of.

Am I the same person now? Hell, no. I suspect I’m not the only person with MS passing (less and less often) in public as able-bodied while actively concealing I’m a total hidden mess.

PYT knows me, the past me, the one who’d railed against the hidden mess. She gets my reservation that maybe taking the aspirin is just the same as shoving a mess under the bed. Does the aspirin genuinely alleviate my body’s resistance to the drug, or does it just push the resistance under the surface, where it can’t be seen?

We ponder this distinction as my four year old nephew explores the new paint he’s created by reconstituting dried out markers and as his twin sister mixes that paint with an entirely unacceptable color and as their younger brother decides it’s time to pee.

We wonder if the new drug is even worth it, given the conclusion of the meta-analysis of over 28,000 MS patients from 38 clinical trials that most current DMTs (Disease Modifying Treatments) are fairly useless for the average patient by the time they reach my age. We ponder Dr. Z’s point that I might be an “outlier” — which sounds kind of cool — unless “outlier” means that without drugs I might be the one to get hit with an exacerbation that could permanently disable me further. His distress over this possibility is nothing to dismiss. I’ve looked around his waiting room. Not everyone with MS has the luxury of describing themselves as a hidden mess.

I share the latest conclusion about the three types of MS—which is that relapsing/remitting, secondary progressive, and primary progressive MS are not three different diseases, but rather, three phases of the same disease. The FDA approved DMTs may prevent relapses, but do nothing for other processes known as “compartmentalized inflammation,” which do not show up on MRI’s.  These are the messes under the bed, so to speak. Or more specifically, the messes inside the cells.

We speculate that maybe all those years I had credited Zinbryta for stopping my MS attacks, the change could have really been more of function of my slipping insidiously from relapsing remitting MS into a more progressive phase of a disease, where the breakdown can’t be detected by the MRI, but rather, by the lumbar puncture.

“It’s like a vicious dog that hasn’t bit anyone in twelve years on a muzzle, and I’ve credited the muzzle. But maybe the dog has just mellowed out with age.”

PYT chimes in, “And maybe the muzzle has been annoying for the poor dog.”

PYT and I are both dog lovers. We aren’t fond of muzzles.

I say, “Maybe we just have to be realistic about my MS. It’s a progressive disease. Slowly but steadily, I’ve been progressing. The drugs that work to stop relapsing remitting MS can’t do a thing about the kind of progression I’m experiencing inside my cells. Maybe it’s time to stop fooling ourselves by my taking a drug that only helps for an early stage of MS. I might be way past that phase.”

PYT says, “It sounds to me like you have taken your last Tecfidera.”

My flummoxed feeling is lifting. I starting to feel like myself again. (Talking with a sister will do that.) I share the last thing Dr. Z. said to me, “I will support you even if you don’t want to take any medication.”

His unconditional support means so much. PYT warns me that our mother and my husband will resist my urge to give up the medication. “As they should. They love you. They want to protect you.”

Protect…me? When we were growing up, I never cast myself as the damsel in distress. But that’s the role MS has forced me to play my entire adult life.

 

 

 

Flummoxed (Part 2 of ?)

I find it super uncomfortable to read articles in scientific journals. Even articles about MS. Even articles about MS illustrated with lots of pretty graphs. Maybe…especially articles about MS. These are articles I have to understand as though my life depended on it. Because it does.

You know how some people publicly (and most people privately) grouse about how higher math is irrelevant for most of us after we get out of school—so why make students suffer? Well, I wish I’d paid more attention when I was taught statistics. Turns out, I need to understand them in real life. I wish I’d had a semester or so learning to become a fine print detective, that the teacher had made terms like  “de facto” feel like shiny keys to hidden treasures. I wish I’d not learned to gloss over any text in the form of an equation like this one:

IDPDrugversusPlacebo=100%(1(1IDPDrugversusIFNβ100)(1IDPIFNβversusPlacebo100)).

Because no one is going to tell me the stuff I am learning by reading research articles in Frontiers in Neurology. Stuff like: “Higher efficacy treatments exert their benefit over lower efficacy treatments only during early stages of MS, and, after age 53, the model suggests that there is no predicted benefit to receiving immunomodulatory DMTs (Disease Modifying Treatments) for the average MS patient.”

I admit, I haven’t been going to enough MS Society events. But all too many of them are paid for by pharmaceutical companies, who may have a conflict with informing you that, after you reach a certain age,  their drugs are no longer particularly useful. (Not to mention, some of their drugs are not particularly useful at any age.) I don’t know about you, but I know an awful lot of people over the age of 53 who are taking a DMT (Disease Modifying Treatment.) These treatments can cost in excess of $7k per month. Very few of these people seem particularly well. More than a few complain of side effects from their medications. What would they think about this article? Have they been enduring pills/injections/infusions that are doing them more harm than good? Have I?

I’m not going to be too hard on myself for having trouble navigating the facts as presented. At one point, I’d sent a link to my son, who majors in math and economics at Vassar. My heart leapt when he messaged me back. Then I saw he was messaging with a question, not an answer: “Does this thing have cliff notes?”

When Dr. Z returns my call, I am stuck on one particular paragraph, which distinguishes higher efficiency drugs from lower efficiency drugs. I notice the drug I’ve lost access to, Zinbryta, is classified as a higher efficiency drug. Whereas Tecfidera, the drug that is causing my skin to redden and prickle, is classified as a lower efficiency drug. I’ve downgraded! Nobody likes a downgrade. And nobody likes their skin to prickle and burn.

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Dr. Z tells me he’d gotten the picture my friend Monica had taken of my angry skin. I ask him if it looks like an allergic reaction. The fine print that came with the drug was very clear on one thing: “Do not use Tecfidera if you have had an allergic reaction, such as welts, hives…”

I want him to use the word, “hives.” Instead he asks, “Did you take aspirin thirty minutes before you took the medication?”

“Like you told me?”

“Yes.”

“No.” I hadn’t wanted to mask the effect of the drug. I’d wanted to know exactly what my body thought of it. The reaction had been fairly unambiguous, I thought. Didn’t he?

He says rash is a common side effect, one that would generally recede after the first few weeks, or could be averted entirely if I were to take an aspirin beforehand.

I counter that even if this was a side effect, and not an allergic reaction, I just wasn’t sure the side-effect of this drug could ever outweigh the benefits of a low-efficacy therapy.

He says, “You’re talking about that paper again. Let’s remember that you may not need a high efficacy drug at this point in your disease process. You might be past the inflammatory phase of your disease. But you are not out of the woods yet. I have patients in their seventies and eighties getting relapses. I wouldn’t want that to happen to you.”

I don’t want that to happen to me, either. I promise I would give Tecfidera another chance. I would try taking the aspirin 30 minutes before the drug, as he had told me. And wait and see.

 

Flummoxed (part 1 of ?)

I took my first Tecfidera pill one week ago after dinner. About three hours later, I sat up in bed next to my soundly sleeping husband: it felt like I was wearing a prickly cap of molten lava. I sat there very quietly for a hours, a red-hot target,  wondering what to do.

Dr. Z did say that “facial flushing” was a common side effect of the drug. He had suggested I take an aspirin thirty minutes before taking Tecfidera. But had I done that? No. I had a rationale:  I always plan on not getting the listed side effects. I am as suggestible as the next person, which is to say, wildly suggestible. I try to compensate by kind of not paying attention to the fine print until I have to.  I have enough going on with my health without taking on any unnecessary burden of invented symptoms. By this semi-logic, taking an aspirin would have been given too much credence to a possibility of a side effect I’d rather not invent. Alas, I got the side effect anyway.

And then some.

As I sat there, sweating, burning, I thought, This cannot be good. Nothing feeds the demon of multiple sclerosis like elevated body heat. It makes symptoms leap into action like bacon grease on skillet. I realized I hadn’t even asked about the mechanisms behind how the drug worked. What if it didn’t work for me at all?

I was aware—and you may as well be aware, too—that MS drugs work less and less effectively as a patient gets older. I used to suspect that the daclizumab which had worked for me so well for me as an infusion in my thirties was simply less effective in the Zinbryta formulation I injected in my forties and at age fifty. But no. As it turns out, my cells were getting less effective. Here’s a link to a paper that illustrates it all beautifully. The paper is an easy read if you are fluent in statistical and neurological terms. Which I am not. But even I can read a graph with a steady downward angle and notice there aren’t even many people my age in MS drug studies to begin with. And when we are present, we make the results look a lot less spectacular. Long story short: If you want an MS medication to work at its best, be younger.

I wasn’t getting any younger. The new pharmaceutical options invented during my twelve years on daclizumab were turning out to be mostly inaccessible to me. My elevated antigen, and the associated higher risk of potentially fatal PML,  eliminated many of the new high performing drugs.  My elevated cancer risk eliminated Ocrevus, the only drug with promising results for people with progressing multiple sclerosis. Yes—I’d learned in an email from Dr. Bielekova that I am progressing. She’d written:

We also know much more about FDA-approved MS drugs in general then we knew when we met: these drugs are not a cure. Their efficacy is highest when they are started very early on in MS, but declines afterwards. They do not penetrate well into the brain tissue, where the inflammation hides. This type of inflammation we call “compartmentalized inflammation” and it is not inhibited by current MS drugs. You have some of this compartmentalized inflammation.

It had been validating to read that. I’d known it was getting more difficult to function, even as the MRI’s failed to reveal any new lesions. I’d known…deep in my cells, I guess, that those MRI’s weren’t telling the whole story.

And I knew, as I sat there and burned, that Tecfidera wasn’t going to do a thing for the compartmentalized inflammation caused by this latter phase of MS. At best, it would fend off the cruel, lesion producing exacerbations of my earlier phase of MS. It has been years since I’ve had to contend with one of those. But as Dr. Z put it, I was “not out of the woods yet.”

I’d been, briefly, on Dr. Bielekova’s trial of drugs that could possibly address the compartmentalized inflammation, but I’d had to withdraw from it once Zinbryta got pulled from the market. I could not return to the NIH (National Institutes of Health) until I started a new medical regimen. As the sky lightened, and the burning receded, I was thinking Tecfidera would not be the drug for me.

How did I wind up dutifully taking my next dose of Tecfidera that morning after breakfast? What persuaded me to give the drug another chance? I don’t believe in giving drugs a chance—not if they come with side effects. Back when Avonex came on the market in the ’90’s, I promised my then-neurologist I would give the drug a full year. I stopped breastfeeding my son to go on that drug. Those weekly Avonex injections gave me “flu-like symptoms” of fever and bone ache that lasted half the week. For my troubles, I got two severe MS exacerbations before that first year was through. I quit after the second exacerbation. The bone ache plagued me for years afterward. I’d felt like such a sucker.

Nothing happened immediately  after I took the pill. I played with my dogs, pulled some weeds, and went to yoga. My friend Monica and I were halfway through lunch when I asked her if my face was getting a little flushed. She said, “Now that you mention it, you’re bright red.” As we were leaving, she asked if I thought I could drive home safely. I said I’d be fine. But once I sat in the car, I looked down and saw my legs were red. I  ran across the parking lot, rapped on her car window and asked for a hug. She was out of her car in a flash.

Monica noticed my legs were “a funny pattern.” I will spare you the photograph she took. It matched the photo Google gave me when I typed in “hives.” I’d remembered the information packet explicitly said not to use Tecfidera if you have an allergic reaction. This looked like an allergic reaction to us. Monica insisted I call our neurologist, insisted on remaining by my side. She stayed with me as I left all the information with the clinic. Then I went home, and went on a research tear. By the time Dr. Z. called me, maybe a scant hour later, I was toggling between screens on my computer: my medical records,  the Tecfidera Facebook page, the Important Safety Information page on the drug site,  two challenging articles in the Frontiers in Neurology site. I was overwhelmed. Flummoxed.

Was what I had a side effect, or an allergic reaction? And did it really matter? My body didn’t like this drug. Twenty plus years of yoga and even more years of multiple sclerosis, had taught me to listen to my body.  Yet there was too much at stake to respond with mere intuition. I was eager to listen to my neurologist.

 

 

 

 

 

 

 

 

 

 

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A New Chapter Begins

Before I took my first dose of my new MS medication, my husband thanked me for making a wonderful soup. “If you die, you’re leaving on a high note.”

If anyone wants to snatch a loyal husband after I go, you should know the wonderful soup has a base of two cups of last night’s leftover fish soup from the local Chinese restaurant, one diced green onion, one cup of  home made bone broth, one can of full fat coconut milk, one cup of assorted frozen Costco fish, one teaspoon of pulverized ginger, a sprinkle of turmeric, half a cup of dulse,  and one other secret ingredient I won’t reveal because my husband said it was “comforting.” I want him to miss me just a little.

And I don’t want him to have to miss me quite yet.

To that end, I picked one of the MS medications least likely to provoke a fatal case of progressive mulifocal leukoencephalopathy (PML) because I love our life together very much. (That same life I once found so cursed by disease way back when I was objectively far less disabled than I am today.)

My local neurologist, Dr. Z., said that this is the drug he would choose for himself or his wife. There’s no stronger recommendation than that.

I am giving Tecfidera a shot. Thankfully, it comes in pill form.

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