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Playing Defense

“Preventive Care” is a term we hear a lot these days. What it actually means can be diff erent from person to person, and from doctor to doctor.

Generally speaking, it means taking steps and making choices to lower your risk for illness, or to get a head start on identifying health problems that may be on the horizon. For practical purposes, this usually means an annual visit to your primary care provider, who’ll determine, based on your age, sex and other factors which, if any, screening tests are necessary. There’s also an educational component to preventive care, where a patient will be asked about certain aspects of their life and counseled on any potential risks they could pose — for example, we’re commonly asked if we smoke cigarettes, and medical professionals are quick to point out the associated risks.

Preventive care is an important tool in keeping us healthy, so much so that most insurance providers in the United States cover a long list of preventive services at or near 100 percent. It’s even a major component of the Affordable Care Act, which requires insurance plans to cover such services. From the payer’s perspective, spending money on preventive care now means healthier people in the long run, and healthier people are less expensive to insure.

Preventive care is, at its heart, playing defense. We all face a certain amount of risk for various illnesses, whether they’re acute or chronic, and whether they manifest through no fault of our own or are brought on by our own behavior. Preventive care puts us in the best position to defend ourselves and reduce that risk.

What Good is Preventive Care When I Already Have MS?

Wouldn’t it be nice if those of us with MS could concentrate only on that disease? It’s certainly a big enough part of your life that you shouldn’t have to worry about anything else.

But the reality is MS is just a part of the whole. Your MS diagnosis doesn’t make it any less likely that you’ll face all the same risk factors for all the same illnesses as anyone else.

In fact, living with MS and its unwelcome symptoms can greatly complicate your experience with other illnesses. And having other illnesses, in turn, can increase your MS-related symptoms. In this issue of InforMS, we’ll take a look at some common themes in MS as it relates to various other conditions, and provide you with some resources and advice to stay on top of your own preventive care.

You’re Not Alone – and Neither is Your MS

While every person’s experience with MS is different, it’s important to acknowledge that we’re all dealing with some similar experiences. Aft er all, we’re all still very much human beings, and if there’s one thing human beings do, it’s get sick. Just because we’re living with one chronic illness doesn’t mean we don’t catch a cold, or get the flu, or even something more serious.

After 20 years of living with multiple sclerosis, Cathy was surprised to find out she had coronary artery disease. “It seems like if you have MS, you definitely should not have to get anything else,” she said. And Cathy’s story is certainly not uncommon.

When you’re living with MS, managing the disease and all that is involved with your neurological care — treatment regiments, MRIs, infusions, and the varying challenges of managing your MS symptoms — it begins feel all-consuming and can overshadow attending to your other health care needs.

People with MS are still susceptible to other health problems common to all people, with one unique caveat: when MS is part of the picture, it becomes even more important to manage all aspects of your health care proactively and intentionally.

Doctors focused on a chronic illness have a term for all those other things you may be dealing with: Comorbidities. That’s the medical world’s term, generally defined as when a person has more than one health condition. Living with comorbidities alongside your MS can be extremely complicated, and that makes it particularly important to do what you can to prevent those other health problems.

Read on for general preventative care recommendations to discuss with your doctor, including vaccination and screening guidance, and strategies and tools for effectively managing your health care with your provider team.

Comorbidities and MS

Approximately 125 million Americans have one or more chronic medical conditions.

The most common comorbidities among people living with MS are hypertension (high blood pressure), hyperlipidemia (high cholesterol), depression, anxiety, and chronic lung disease. Other comorbidities include cancers, arthritis, irritable bowel syndrome, and sleep disorders.

Research studies show us that living with MS and these other health problems have been associated with longer delay in the onset of MS symptoms and MS diagnosis, more severe disability, faster disability progression, and a higher mortality.

Risk factors for developing other health conditions are generally the same as for those who don’t have MS. They include poor diet (high in calories, sugar, and sodium and low in nutrients), low levels of physical activity, smoking cigarettes, abusing alcohol and drugs, and engaging in risky sexual behavior.

Possibly the most common and dangerous risk factor is obesity. According to the Centers for Disease Control and Prevention

(CDC), an estimated 93 million American adults are classified as obese – that’s nearly 40 percent of people between the ages of 20 and 59. The CDC also warns that obesity increases risk for heart disease, stroke, type 2 diabetes, and certain types of cancer. Obesity also complicates mobility in people with difficulty walking. Obesity is associated with higher disability and lower physical activity.

The Role of your Primary Care Physician

One critical component in getting a handle on preventive care measures to prevent other health problems is establishing your Primary Care Physician (PCP), and putting together a routine plan for regular office visits, checkups and screenings.

Many MS patients do not prioritize establishing a relationship with a PCP, for any number of reasons. For one, they’re primarily focusing on their neurological care. An MS diagnosis can quickly and easily become a person’s primary health concern, and rightfully so – MS is often the “elephant in the room,” and it’s very easy to dismiss other health concerns that may seem trivial in comparison.

It can also be a frustrating experience to find a PCP familiar with treating patients with MS – many just aren’t familiar with symptoms, symptom management and the various treatments that may be prescribed by a neurologist.

Some patients might also encounter barriers to accessing screenings and preventative services, and some may have anxiety about developing other conditions.

It’s important to have a PCP that you trust, and one that knows about your MS diagnosis. The fact is that many future problems can be lessened or even avoided entirely by identifying them early through routine health screenings. Your PCP needs to know about your MS and the symptoms you regularly experience to make sure they’re prescribing the most relevant tests and screenings for you.

Health Protective Behaviors

The good news is that data from the Institute of Medicine (US) Committee on Quality of Health Care in America suggests that 80 percent of cardiovascular diseases and 40 percent of cancers are preventable.

The committee cites four health protective behaviors as being linked with better health and recovery from illness: Being physically active, eating fruits and vegetables, quitting smoking, and taking medication as prescribed.

Physical Activity

Regular exercise is important for our general health – it’s good for the heart and it is also really good for the brain. Developing an appropriate exercise regimen that can help you decrease the symptoms and disabilities that is tailored to your interests, abilities, and needs is essential.

People who exercise regularly have better cardiovascular fitness, manage stress more successfully, are better able to regulate mood and fatigue, have more endurance, and the list goes on. Exercise improves the brain’s resilience because it increases blood flow and that brings the brain tissue more glucose and oxygen. It also makes the internal environment in the brain more hospitable to growth by releasing neurotransmitters, hormones and nerve growth factors that encourage the growth of new fibers. This strengthens the connections between neurons, so exercise is also one of the simplest and most direct ways to increase cognitive reserve.

People who exercise regularly are apparently better learners. Exercise directly influences learning by improving the brain’s ability to attend to and process new information. It does this by activating the frontal cortex – that part of the brain that controls executive functioning, attention, impulse control, learning and memory.

The more you exercise, the more you benefit, even if you have never exercised before. Doing an aerobic exercise program twice a week can improve mood, fitness, and brain health. In health, as in most aspects of life, it is what we do most of the time that counts, not what we do occasionally. A briefer and less strenuous exercise regimen that you can do four times a week is probably more helpful than a longer, more intense one that you can only manage every other Saturday. Developing an appropriate exercise regimen that is tailored to your interests, abilities, and needs is essential.

Diet and Nutrition

There is not a specific diet that controls MS, but we know that good nutrition is important for people with MS because it can have a positive impact on some MS symptoms and also lowers the risk of disease and other disorders. What we know is what’s good for your heart is good for your brain. Following a healthy diet pattern such as the Mediterranean Diet, the US 2015 Dietary Guidelines, or the DASH (dietary approaches to stop hypertension) diet is a reasonable option.

Incorporating healthier choices into your diet can feel overwhelming. It’s okay to start small and start slow. Stop eating one problematic food in your diet and add one vegetable and build from there. Also, please see the list of resources on page 17 help you get started or inspire you with great and diverse recipes.

Quitting Smoking

In a Norwegian city study published in Neurology in 2003, the risk of MS was significantly higher among smokers than among those who had never smoked.

A 2005 paper in the journal Brain supported the link between smoking and the risk of developing MS, and suggested that smoking may be a risk factor for transforming a relapsing-remitting clinical course into a secondary-progressive course.

Most of us are familiar with the risks smoking poses outside of MS. The CDC says smoking causes cancer, heart disease, stroke, lung diseases, diabetes, and chronic obstructive pulmonary disease (COPD), which includes emphysema and chronic bronchitis. All told, the most recent CDC estimates say cigarette smoking is responsible for 480,000 deaths in the US every year.

The National Institutes of Health provides resources to help quit smoking: visit smokefree.gov or call 800-QUITNOW (800-784-8669).

Adherence to Medication

It’s estimated that only about 50 percent of people with chronic diseases worldwide actually follow the treatment regimen that has been prescribed to help them manage their condition. That means half of people living with a chronic illness simply don’t take their medicine. Non-adherence is approximately 49 percent for lipid-lowering agents, 42 percent for oral anti-diabetic agents and 36 percent for antihypertensives.

The reasons for lack of adherence are complex especially when you are living with a chronic disease like MS where your needs and priorities can change over time. If you’re having trouble taking your medication, talk candidly with your healthcare provider. Working in partnership with your healthcare provider is critical.

Implementing Preventive Care

It’s important for individuals living with MS to ensure they are receiving preventative health services. Annual exams with your Primary Care Physician should include a physical examination, medical history, physical exam, and appropriate lab tests.

Below is a selection of current recommended screening tests from the he U.S. Preventive Services Task Force (USPSTF).

The USPSTF is an independent, volunteer panel of national experts in prevention and evidence-based medicine. The Task Force makes evidence-based recommendations about clinical preventive services such as screenings, counseling services, and preventive medications.  It is important to discuss these screening recommendations with your primary care physician.

For a full list of recommendations, visit the USPSTF website at uspreventiveservicestaskforce.org and click “Recommendations” in the menu.

  • Fasting Cholesterol (with HDL, LDL, and triglycerides) test for men age 35 and older and women age 45 and older.
  • Fasting blood sugar – screening for abnormal blood glu-cose as part of cardiovascular risk assessment in adults aged 40 to 70 years who are overweight or obese.
  • Cervical cancer screening in women aged 21 to 65 years with cytology (Pap smear) every 3 years or, for women aged 30 to 65 years who want to lengthen the screening interval, screening with a combination of Pap smear and human papillomavirus (HPV) testing every 5 years.
  • Mammogram – For women aged 50 to 74 years, the USPSTF recommends a biennial mammography. For women under the age of 50, consult with your doctor on individual factors to consider for potential earlier mammogram.
  • Fecal occult blood testing, sigmoidoscopy or colonos-copy for men and women starting at age 50 or have other risk factors and continuing until age 75.
  • Dental cleaning and examination every 6 months. Please see page __ for a more in depth look at the importance of oral health and MS.

Vaccination Guidance: A Short Course on Vaccines

Vaccines are developed against a variety of different disease-causing pathogens, including bacteria and viruses. There are at least three types of vaccines: whole virus/bacteria vaccines which are either inactivated (killed) or live but attenuated (weakened); and vaccines made with just parts of a virus or bacteria, typically part of the outer coat.

Most of the vaccines in common use for MS patients are the whole virus/bacteria type. Killed or inactivated virus vaccines are prepared by literally killing the pathogens (disease-producing agents) that make up the virus or bacteria. Although the virulent microorganisms are dead, they still possess the ability to provoke the immune system into producing antibodies and these protect the individual from the disease in question. Because the pathogens have been destroyed, killed vaccines do not, unlike live virus vaccines, have the potential to give the individual the disease produced by the pathogen virus or bacteria.

The other type of whole virus/bacteria vaccine uses “live” pathogens that are “attenuated”—or damaged—to make them made less virulent and harmful. This is often done by “passing” the strain multiple times, which means growing the virus repeatedly, selecting the strains that appear to cause less disease (perhaps in an animal model of the human disease), and thereby reducing its strength. Examples of live virus vaccines are the measles, mumps and rubella.

The typical Influenza A vaccines in common use in the last decade or longer have been available both as inactivated (flu shot) and live, attenuated (nasal). In addition, for many years there has been available a live, attenuated vaccine, taken by mouth (oral), which is also highly effective.

Flu Shots

Influenza, known to most of us as simply “the flu,” is a collection of viruses that typically cause well-known symptoms such as fever, aches, pains, cough, and stomach upset. It can sometimes be complicated by more troubling problems such as pneumonia. Influenza is a serious cause of death each year in the U.S., mostly in young children, the elderly, and those with severe chronic diseases, especially those that depress the immune system, including MS.

With the arrival of the flu season, questions and concerns regarding the flu vaccine are beginning to peak. Specifically, are people with MS at higher risk for the flu and should they receive the vaccine?

Should People With MS Get Flu Shots? The flu shot, representing a new version which is produced and distributed each year in order to protect individuals from the seasonal flu, is an example of an inactivated (killed) virus vaccine. While it’s true that in some years the flu vaccine is more or less effective against the flu strain that is predicted to be dominant that year, overall, for people with MS, the flu vaccine has proven to be a helpful tool for staying fl u-free.  The profile of high effectiveness and good safety is very helpful and important, and it is strongly recommended for all MS patients.

It is especially recommended for those who take medications that may reduce the normal immune response (see below), as they are at greatest risk of developing secondary and potentially serious infectious complications from the f u, such as pneumonia. Also, for MS patients, being vaccinated decreases the risk they will transmit this potentially deadly infection to their loved ones and others. For these reasons, MS specialty doctors and the Center for Disease Control and Prevention (CDC) encourage MS patients to get the flu vaccine.  The Rocky Mountain MS Center and the National MS Society do not recommend the live attenuated vaccine for those with MS, and instead suggest use of the inactivated flu shot vaccine and not the nasal flu vaccine.

Can Flu Shots Cause Exacerbations? Although there were some initial concerns that the flu vaccine might provoke MS exacerbations, research does not support this. A 1993 study, headed by Dr. Aaron Miller of the National MS Society, found that among the 104 study participants there was no difference in the number of exacerbations experienced by those who received the flu vaccine and those who didn’t. Other studies and extensive data collection have been undertaken as well, and these have consistently found no link between relapses and the inactivated flu vaccine. Again, we suggest the use of the inactivated flu shot vaccine and not the nasal flu vaccine.

Other Immunization Guidelines

People with MS should generally avoid live virus immunizations unless the risk of exposure to a serious infection outweighs the risk of the vaccine, such as travel to a high risk location. Th e live virus vaccine with the greatest known association with increased MS relapses is Yellow Fever vaccine. Below is a partial list of immunizations to discuss with your physician.

  • Tetanus-Diptheria: Boosters every 10 years.
  • Hepatitis B Immunization: For health care or public safety workers who have exposure to blood in workplace. Household contacts and sex partners of those infected with hepatitis. Sexually active men and women with more than 1 partner in the last 6 months or with sexually transmitted diseases. Intravenous drug abusers.
  • Pneumococcal Immunization: Once at age 65 or older or anyone with additional risk factors. If received before age 65, need booster aft er 5 years.
  • Human Papilloma Virus (HPV) Immunization: Once up to age 26 years.
  • Varicella Immunization (chicken pox): Once if there is no clinical history of Varicella.
  • Varicella Zoster (shingles) Vaccine: There are two available. Th e original (Zostavax) is a live attenuated vaccine with moderate eff ectiveness, especially in older individuals. Recently, a vaccine, Shingrix, was approved. Shingrix is more eff ective than Zostavax overall, and is taken as two injections two months apart. As Shingrix is so much more eff ective than Zostavax, Shingrix is the recommended shingles vaccine in the general population, even for those who already had shingles, or for those who already had Zostavax. Th ere is little to no data, however, on the use of Shingrix in MS patients. It does employ a highly eff ective adjuvant (a substance added to the vaccine to enhance the body’s immune response to the vaccine), which in theory could increase the immune dysfunction we see in MS. Patients should talk to their doctor about this issue, but, for many, the known risk of shingles may well outweigh the theoretical risk of enhanced relapses due to MS.

Therapies that suppress the immune system

As a person living with MS, you will have important discussions with your neurologist about disease modifying therapies (DMTs) to treat your MS.  Some of these DMTs may suppress or alter normal immune responses. Thus, these immunosuppressive DMTs may reduce the effectiveness of vaccines, or increase risk of live, attenuated vaccines, ie increase the risk the vaccine will actually cause a variation of the viral disease itself. The CDC recommends against the use of all live virus vaccines in those who take immunosuppressive medications, including the MS DMTs that are immunosuppressive (natalizumab, rituximab, ocrelizumab, alemtuzumab, gilenya and possibly teriflunomide).   Given that treatment with immunosuppressive therapy can be anticipated for many people with MS, your health care team may recommend some vaccines on the basis of planned, future immunosuppression.  For example, your doctor may recommend a Pneumovax shot, which protects against pneumonia, based

on the fact that you are planning immunosuppression with a medication like ocrelizumab or rituximab.  Generally it is recommended to wait one month after the vaccine is given (to allow it to completely take hold) before using an immunosuppressive DMT. It is a good idea to make sure your primary care physician and your neurologist are both involved in these decisions before using immunosuppressive therapy. For more information on immunizations and immunosuppression, please refer to the following article published in the journal of Clinical Infectious Diseases: http://cid.oxfordjournals.org/content/58/3/e44.full#sec-6

Conclusion

Preventive care is an important component of health, but when you’re living with MS it’s absolutely critical. Adding a few simple steps to your routine PCP visits, or making some changes in your usual habits, can help stave off serious complications in the future. Playing defense now can set you on the right path to avoid everything from minor annoyances to serious complications in the future.

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