One intriguing side effect of the medication I'm taking (Tecfidera) is something called "flushing." This is more or less the same side effect I would get from taking Niaspan, a high-dose version of niacin (vitamin B3) often prescribed as an "old school" treatment for high cholesterol.
Flushing consists of an intense itching that takes place just under the skin (very similar to allergic itching) and a companion reddening of the face and/or neck and/or chest. For me, the flushing mostly impacted me at the ears; the insides of my ears would get extremely itchy and my ear lobes and pinna would turn a deep red and feel warm to the touch.
I took Niaspan for years and it was extremely helpful in lowering my cholesterol. I also took an extremely high dose (2000mg) which did not seem to bother my liver. At bedtime, I would take this dose with four baby low-dose aspirin, which help to attenuate some of the discomfort of flushing. I learned to ignore the side effect mostly and to simply tolerate it. Apparently I'm more tolerant than most, as I've heard horror stories from people who have tried Niaspan; interestingly, their tales of misery correspond almost too neatly with the same horror stories spun from others who are taking (or had to stop taking) Tecfidera due to intolerance issues.
Tecfidera, it turns out, does pretty much the same thing to me in terms of flushing, except that it makes my whole face red (actually, from the chin up, I turn magenta; from my chin down, I'm my normal sallow olive-skinned self) and the itching tends to spread to other extremities. Still, it's not usually too bad and maybe just once a month do I actually notice it. Since I take this medication not only at night (when I can sleep through this side effect) but also in the morning, I am always concerned I will be struck with flushing at an inopportune time. By and large, that hasn't happened. Once in a while, I might feel it coming on, but in the last six or so months, I think I've really only noticed it a total of six times (maybe more, but it wasn't extreme enough to be memorable).
I had an afternoon of flushing the other night, which surprised me with its severity. Luckily I was in a movie theater where nobody could see me. Then, the next night, it happened again and I even thought about taking Benadryl to counter the effect (which eventually I did when I went to bed as I was also having some congestion issues).
I decided the next day to look into the mechanics of flushing. Is it a bad thing for someone with MS? A good thing? What exactly do Niaspan and Tecfidera have in common that leads them both to achieve this similar side effect? But first things first: What is actually happening to the body during "flushing?"
Biology 101
Remember, there are arteries and capillaries. Arteries are the large vessels which carry lots of blood away from the heart at a very fast rate to all major sectors of the body, while capillaries distribute the blood (in smaller amounts, more slowly) from these main arteries to the body's nooks and crannies. Sometimes, the bottleneck of blood supply transferring from the arteries to the capillaries leads to inadequate blood flow, leaving some toxins to remain in the cells rather than be washed away by blood factors necessary for healing.
However, if you dilate the blood vessels (technically, vasodilation), they relax and expand to allow more blood to stream through and bring healing blood products to the cells. The cells can then flush out any resident toxins. The itchy warmth that occurs is caused by newly oxygenated blood flushing into the capillaries close to the skin as well as by the actual process of dilation that occurs in the blood vessels.
Dilating the capillaries can happen as a natural occurrence (as in an immune system response where histamines are released into the blood stream to deal with inflammation), or it can happen with some pharmacological help. Niacin's signatory impact on the body is through vasodilation. By opening up blood vessels, cholesterol in the body can be processed and moved without sticking to the walls of the vascular system and creating plaques that lead to chronic disease later.
It appears that Tecfidera activates a similar kind of flushing response in either the vascular system or fibers of the autonomic nervous system (or maybe both?), though researchers really can't explain how or why as of yet. I did learn that these ANS nerve fibers serve the sweat glands, which can lead to an effect called "wet flushing" (much like a hot flash, but not related to the female hormone, FSH), which is not the same as the "dry flushing" that occurs via vasodilation from products like niacin (see Nasr, Cleveland Clinic).
What's interesting to me is that I learned in my research that, between 1946 and 1959, thousands of MS patients were treated with a central nervous system vasodilator in a kind of therapy called "relief by flush." Apparently, histamine vasodilation proved to offer many MS sufferers relief from acute "flares" and virtually every kind of symptom (see Ganesh & Stahnisch, 2013). Inconsistency in research, the death of the leading researcher, Hinton Jonez, and the distraction of new drug research seemed to pull attention away from these findings.
Lately, however, there has been a return to the notion of niacin as a potential remedy for MS after controversial treatments for chronic cerebrospinal venous insufficiency (CCSVI) began to make headlines in the mid 2000s. Though the jury is still out on the efficacy of "liberation therapy" for CCSVI, vitamin B3 has been resurrected as a potential helper and even shown in separate studies to offer "dramatic protection" against early stages of multiple sclerosis (Rhodes, Haacke & Moore, 2011).
Why this is relevant to MSers
Well... last fall, I stopped taking Niaspan. I was having some pretty serious "wet flushing" and, at age 48, I asked my PCP if he could check to see if I was in early menopause. I had a blood test, stopped taking my birth control pill for a month to see what would happen. Nothing changed, I still had the sweats, and the blood test came back negative. Then I stopped taking Niaspan to rule it out as the source behind my nighttime flushing. I continued to have it (and still do, though not all the time). Clearly the culprit is Tecfidera.
But what about the Niaspan? I completely forgot until recently that I wasn't taking it (with its companion baby aspirin) and now I wonder if my cholesterol has grown elevated without it. Hmm. One of my worst symptoms of MS has to be this underattention to detail that is not typical for me. I hate forgetting, making careless omissions. I think this oversight is one of them, and I hope I won't regret it later.
But what about the Niaspan? I completely forgot until recently that I wasn't taking it (with its companion baby aspirin) and now I wonder if my cholesterol has grown elevated without it. Hmm. One of my worst symptoms of MS has to be this underattention to detail that is not typical for me. I hate forgetting, making careless omissions. I think this oversight is one of them, and I hope I won't regret it later.
I'll be seeing my doc again later this month for annual tests and will be curious to get back my cholesterol results. But in the meantime, I think it's safe for me to go ahead and reintroduce the Niaspan, 1000mg at a time this week, bumping it back up to 2000mg next week. It seemed to be working for me before, and by the looks of things, all that flushing action it contributes to might end up being the perfect companion to my Tecfidera treatment.
And now, when I hear others complaining about the flushing side effect of Tec, I can offer them a glimmer of hope, that maybe the itching and redness and internal flushing is just proof it's doing its job, that there really might be some legitimate "relief by flush."
And now, when I hear others complaining about the flushing side effect of Tec, I can offer them a glimmer of hope, that maybe the itching and redness and internal flushing is just proof it's doing its job, that there really might be some legitimate "relief by flush."
(Or maybe not. The jaded GenXer in me has discovered that many of my MS contemporaries seem more happy to wallow in their discomfort and complain rather than find a solution. Positive spirits like me just come in and ruin their day! LOL).
All I can say is that I feel very lucky to be able to tolerate the flushing I get from either drug.
At any rate, stay tuned...
Citations & further reading
Brickner, RM. "Phenomenon of relief by flush in multiple sclerosis; its use as a foundation for therapy." AMA Arch Neurol Psychiatry. 1955 Feb;73(2):232-40. DOI:10.1001/archneurpsyc.1955.02330080110020
Denoon, DJ. "Vitamin B3 May Help MS." 2006. WebMD Health News. See: http://www.webmd.com/multiple-sclerosis/news/20060919/vitamin-b3-may-help-ms
Nasr, C. "Flushing." (n.d.) Cleveland Clinic Center for Continued Education. See: http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/endocrinology/flushing/
Ganesh & Stahnisch. "On the Historical Succession of Vessel-Based Therapies in the Treatment of Multiple Sclerosis." 2013. Eur Neuro 2013;70:48–58. DOI:10.1159/000348780
Rhodes, MA; Haacke EM, Moore EA. CCSVI as the Cause of Multiple Sclerosis: The Science Behind the Controversial Theory. McFarland Health Topics: 2011. ISBN-13: 978-0786460380. Amazon link
Stimson, D. "Vitamin B3 Points Toward New Strategy for Treating MS" 2007. National Institute of Neurological Disorders and Stroke. See: http://www.ninds.nih.gov/news_and_events/news_articles/news_article_MS_B3.htm
Denoon, DJ. "Vitamin B3 May Help MS." 2006. WebMD Health News. See: http://www.webmd.com/multiple-sclerosis/news/20060919/vitamin-b3-may-help-ms
Nasr, C. "Flushing." (n.d.) Cleveland Clinic Center for Continued Education. See: http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/endocrinology/flushing/
Ganesh & Stahnisch. "On the Historical Succession of Vessel-Based Therapies in the Treatment of Multiple Sclerosis." 2013. Eur Neuro 2013;70:48–58. DOI:10.1159/000348780
Rhodes, MA; Haacke EM, Moore EA. CCSVI as the Cause of Multiple Sclerosis: The Science Behind the Controversial Theory. McFarland Health Topics: 2011. ISBN-13: 978-0786460380. Amazon link
Stimson, D. "Vitamin B3 Points Toward New Strategy for Treating MS" 2007. National Institute of Neurological Disorders and Stroke. See: http://www.ninds.nih.gov/news_and_events/news_articles/news_article_MS_B3.htm
