5 Tips to Improve Flu-like Symptoms

Most people with multiple sclerosis who take one of the interferon therapies (Avonex, Betaseron/Extavia, Rebif) experience flu-like symptoms – fever, chills, headache and muscle aches and pains. These symptoms are so common that it’s maybe more accurate to think of them as an effect of the drug rather than a side effect. Flu-like symptoms are at their worst in the first 24 hours after injecting an interferon.

It’s often said that flu-like symptoms diminish if you keep taking the interferon, and this may be true in some cases. But many people find that the problem drags on and never really goes away (Visser and colleagues. Eur J Neurol 2011;18:1343-1349). The persistent feeling that you’re coming down with the flu can certainly wear away well-being, and so it’s not surprising that flu-like symptoms are a common reason why people stop taking their MS medication.

A group of MS nurses in the U.S. have examined the problem and have come up with practical tips to minimize flu-like symptoms (Filipi and colleagues. Int J MS Care 2014;16:55-60). The following is their list of suggestions.

1. When you start taking an interferon, slowly increase the dose.

This strategy is called dose titration – starting with a low dose (e.g. one-quarter of the usual dose), then increasing the dose gradually over the first month of treatment. This is considered to be the most effective way of minimizing flu-like symptoms, although there is actually little evidence to support it.

One early study found a trend to reduced flu-like symptoms when the interferon dose was slowly increased but the difference was not statistically significant (Wroe SJ. J Int Med Res 2005;33:309-318). A second study also found no difference in flu-like symptoms even when dose titration was combined with a pain reliever (Tylenol or Advil/Motrin) (Brandes and colleagues. Curr Med Res Opin 2007;23:1667-1672).

In the START study of Betaseron, about 1 in 3 people continued to experience flu-like symptoms despite titrating their interferon dose and taking a pain reliever (Dhib-Jalbut and colleagues. Int J MS Care 2012;14:198-208). During the one-year study, one-third interrupted taking their medication and about 1 in 4 people stopped treatment altogether – often because of side effects.

In a more practical vein, dose titration can be tricky (and wasteful since it involves throwing away what you don’t use) if you’re mixing the drug yourself, and not all countries have approved this approach for individual interferon products.

2. Take a pain reliever before injecting yourself.

Several studies have found that taking a pain reliever (Tylenol, Advil/Motrin, Aleve) before self-injecting can reduce flu-like symptoms to some extent. Tylenol was shown to be as effective as Advil/Motrin in one study (Reess and colleagues. Mult Scler 2002;8:15-18). A second study found that Advil/Motrin was slightly better than Tylenol when taken both before and 6-12 hours after the injection (Rio and colleagues. Neurology 2004;63:525-528).

However, pain relievers aren’t a cure-all. One study found that most people continued to suffer from muscle pain and fatigue despite taking Tylenol, Advil/Motrin or Aleve (Leuschen and colleagues. Mult Scler 2004;10:636-642). Taking a pain reliever is a short-term strategy and shouldn’t be continued for more than a month because of the risk of side effects, such as stomach or liver problems.

3. Try injecting yourself at different times of the day.

Injecting yourself just before bedtime is often the preferred approach since you’ll be asleep when flu-like symptoms are at their worst. However, changing the timing of the injections can be helpful. One study tried this approach in people with persistent flu-like symptoms (Nadjar and colleagues. Clin Neurol Neurosurg 2011;113:316-322). After switching to morning injections, about 60% said their symptoms improved, 18% said they got worse and 24% said there was no difference. So it seems that a person’s response to the timing of the injection is a very individual thing.

4. Ensure the drug is close to body temperature before injecting.

The nurses suggest warming the interferon before injecting it. The goal is to get it to body temperature – either by warming it in your hands or under your armpit, or putting the vial in your pocket for a few minutes. DO NOT heat the solution in a microwave or oven.

5. If you have a fever – stay hydrated.

A low-grade fever is common as part of the flu-like symptoms. So it’s important that you drink enough water to remain adequately hydrated. This can be a bit of a challenge if you suffer from bladder problems, such as incontinence. The temptation is to cut back on your fluid intake if you are having bladder problems – but inadequate water intake may worsen your flu-like symptoms. So you’ll need to find the right balance. One approach may be to ensure enough fluids during the day, then cut back on your fluid intake before you go to bed.

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