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Latest MS research update - What are the best ways to reduce flu-like symptoms when using beta interferon? - 7 April 2014

The MS Trust runs a weekly search for interesting and relevant research articles relating to multiple sclerosis using Medline, a specialised search engine for medical journals. The original abstracts to each of the articles can be accessed via the links provided.

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This week's highlighted research...

What are the best ways to reduce flu-like symptoms when using beta interferon?

Research by topic areas...

Assessment tools
Disease modifying treatments
Paediatric MS
Physical activity
Quality of life
Rehabilitation
Symptoms and symptom management


What are the best ways to reduce flu-like symptoms when using beta interferon?

Summary

There are several beta interferon drugs that are approved for use as disease modifying therapies in MS. Beta interferon treatment has been shown to reduce the number and frequency of relapses, there is also evidence it can reduce the number of lesions and the severity of relapses. Post-injection reactions, causing flu-like symptoms, such as fever, muscle pain and headache are very common in people using beta interferon, especially in the first few months of treatment. It is known that experiencing these symptoms can affect how many people stay using treatment.

This study looked at the lifestyle and medication changes that can be made to manage and reduce the effects of flu-like symptoms (FLS). A panel of nine United States based MS nurses met and reviewed published information and studies as well as sharing their own experiences. The aim was to create a set of guidelines that could be used in the management of FLS in people with MS taking beta interferon treatment.

Based on clinical trial evidence and their own experience the panel recommended seven interventions that could be used to reduce the effects of FLS. These including, starting with a lower dose to allow the body to adjust, taking ibuprofen or paracetamol before an injection, timing the injection to sleep through the worst of the symptoms and to ensure you are well hydrated prior to injection.

The authors conclude that their guidelines can help health care providers to support beta interferon users in managing the effects of FLS and to continue using beta interferon.


Background

There are several beta interferon drugs that are approved for use as disease modifying therapies in MS. Beta interferon treatment has been shown to reduce the number and frequency of relapses, there is also evidence it can reduce the number of lesions and the severity of relapses. Post-injection reactions causing flu-like symptoms, such as fever, muscle pain and headache are very common in people using beta interferon, especially in the first few months of treatment. It is known that experiencing these symptoms can affect how many people stay using treatment. If side effects such as FLS can be effectively managed then it is likely more people will continue beta interferon treatment and benefit from its disease modifying effects.


How this study was carried out

This study looked at the lifestyle and medication changes that can be made to reduce and manage the effects of FLS. A panel of nine United States based MS nurses met and reviewed published information and studies as well as sharing their own experiences. The aim was to create a set of guidelines that could be used in the management of FLS in people with MS taking beta interferon treatment.

Five flu-like symptoms were examined: pyrexia (fever), chills, malaise (general discomfort), myalgia (muscle pain), and headache.

Possible interventions for reducing FLS were gathered and discussed. Each intervention was given an evidence level rating, based on the strength of the evidence that supported its effectiveness and use for limiting FLS.

  • Class 1 evidence - derived from clinical trials
  • Class 2 evidence - from clinical reports
  • Anecdotal evidence - based on the experience of the members of the panel

A list of proposed interventions was drawn up based on the consensus of the panel, these were listed as either highly effective, effective or probably effective and formed the basis of the guidelines.


What was found

The panel recommended seven interventions for limiting FLS during beta interferon treatment. These were listed, starting with the most effective down to the interventions that the nurses had tried but had not been trialed in a formal study.

Titration

  • This means that a lower dose is given when starting beta interferon treatment and the dose is then slowly increased over time to allow the body to adjust.
  • The recommendation was this was increased over a 4-6 week period to the full dose, but this can be customised to the individual person based on the severity of any side effects they experience.
  • This was rated as highly effective and supported by evidence from clinical trials (Class 1 evidence).

Analgesics

  • Taking ibuprofen or paracetamol before taking the dose of beta interferon was also shown to be effective in clinical trials in reducing the severity of FLS.
  • The panel recommended that one of these should be taken about an hour prior to injection.
  • This was rated as highly effective.

Interferon preparation

  • There was evidence that the FLS were reported more often in people using prefilled beta interferon syringes compared to those who mixed their preparation from a powder (lyophilized preparation) immediately before injection.
  • The panel recommended that if titration and analgesics did not reduce FLS in some people then switching to a lyophilized preparation could be tried.
  • This was rated as effective and supported by evidence from clinical reports (Class 2 evidence).

Timing

  • Changing the time of day that the injection is done may help some people deal with the FLS.
  • The panel recommended that beta interferon injection should be done in the evening so the worst of the symptoms would be experienced during sleep.
  • However some people find they suffer less FLS when they inject in the morning. So timing is a very individual thing and people should determine when their symptoms are at their worst and work out when it would be best for them to inject to best deal with them.
  • This was rated as effective and supported by evidence from clinical reports (Class 2 evidence).

Temperature

  • Although there were no formal studies on the temperature of the injection fluid, the panel had found in their experience that the severity and duration of FLS were reduced when the solution was closer to body temperature when injected.
  • Artificially warming the drug will damage it, so the panel recommended gently warming the vial between the hands to warm the solution up closer to body temperature.
  • This was rated as probably effective, as it was based on anecdotal evidence only.

Hydration

  • Fever can cause dehydration and dehydration before injection can make FLS worse.
  • The panel recommended that people ensure they have had enough to drink prior to injecting. Although this was not based on formal clinical trial data, the nurses on the panel had found that in their experience well hydrated people had suffered less discomfort from FLS.
  • This was rated as probably effective, as it was based on anecdotal evidence.

Diet

  • As with hydration there were no formal clinical trials, but the panel had seen better resistance to FLS in people who had a good level of nutrition, so recommend a balanced diet.
  • This was rated as probably effective, as it was based on anecdotal evidence.

What does it mean?

The panel recommended that MS Nurses should discuss beta interferon treatment and potential side effects with people with MS prior to treatment starting. They suggested that early access to information, warning that FLS side effects are likely and giving advice on the practical methods that can be used to limit these effects, helped prepare people and be informed as to what to expect during treatment. Many studies have shown if people know what to expect and know of ways to manage side effects then they are more likely to stay on that treatment.

The authors conclude that their guidelines can help MS Nurses and other health care providers to support beta interferon users in managing the effects of FLS and to continue using beta interferon treatment and benefit from its disease modifying effects.


Comment

The full text of the paper provides much more information, including references supporting the recommendations made. Although this is the work of a group of US based MS nurses, the advice provided is relevant to MS nurses and people with MS in the UK.

A few of the recommendations given by this panel are already well known and are included in the drug information leaflets, due to the strength of the evidence for their use. Other suggestions may not be familiar and may offer alternative methods for some people with MS to try.

Filipi ML, Beavin J, Brillante RT , et al.
Nurses' perspective on approaches to limit flu-like symptoms during interferon therapy for multiple sclerosis..
Int J MS Care. 2014 Spring;16(1):55-60.
abstract
Read the full text of this paper

More about managing side effects

Side effects are unwanted symptoms caused by a medical treatment and can happen with any drug, even something as everyday as aspirin can cause side effects in some people.

Some effects can pass by and be barely noticed and others can be more serious and make a noticeable difference to your wellbeing or ability to go about your day normally. No one wants to take a drug that they think will make them feel better and find that it can actually make them feel worse. For most people the side effects of beta interferon treatment are relatively mild and manageable, and probably just a bit of an irritation or inconvenience, although for some people they can be more intrusive and cannot be tolerated.

Due to the way that beta interferon affects the body, flu-like symptoms are common. This study suggests a number of lifestyle and treatment modifications you could try yourself to reduce the effect of these.

  • To help reduce body temperature, paracetamol or ibuprofen can be taken before the injection and at four to six hour intervals after the injection, if required to reduce the physical effects of the FLS.
  • If you experience FLS, keep a diary and record when you experience the worst symptoms. You can then try taking your injections at a different time, such as before bed, so you sleep through the worst of the symptoms and their effect on your day is less.
  • Ensure you drink enough. As well as reducing the severity of FLS, drinking enough fluid can also help with bladder problems.
  • Eat a balanced diet, which not only may make your body better able to deal with FLS but can also make you feel better overall.

If you are experiencing side effects that you are finding particularly difficult to deal with, discuss this with your health professionals. There may be an alternative drug or dose that may be better for you.

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Agius M, Meng X, Chin P, et al.
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Charvet L, O'Donnell E, Belman A, et al.
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Physical activity

Pilutti LA, Dlugonski D, Sandroff BM, et al.
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Quality of life

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Symptoms and symptom management

Alvarenga-Filho H, Papais-Alvarenga RM, Carvalho SR, et al.
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