Table 2.

Adverse effect or risk mitigation strategies for the disease modifying therapies

Disease Modifying Agent	Adverse effect or risk	Mitigation
Interferon-beta	Flu-like symptoms Injection site reactions Depression	NSAIDs or acetaminophen, hydration. Applying ice to the site prior to injection, site rotation, and proper injection techniques. Screen and monitor for depression, suicidal ideation
Glatiramer acetate	Injection site reactions Immediate post-injection systemic reaction	Applying ice to the site prior to injection, site rotation, and proper injection techniques
Mitoxantrone	Congestive heart failure, Secondary AML, Amenorrhea	Limit dosing to a cumulative 140 mg/m2 (approximatei 10 courses). Monitor blood counts after 60 mg/m2
Natalizumab	PML Hypersensitivity reactions Infusion reactions	Stratify PML risk by JCV Ab status, prior immune suppression, and duration of therapy Pretreat with loratadine and acetaminophen Routine anti-natalizumab antibody testing and MRI brain especially if neurologic symptoms arise or worsen
Fingolimod	First-dose cardiac events (bradycardia, AV block, cardiac arrest, arrhythmias) Herpes infection Macular edema PML Headaches	First-dose observation for 6 hours with hourly heart rate and blood pressure measurements. Vaccination with varicella vaccine if VZV IgG negative. Acyclovir for herpetic infections. Eye exams or OCT for edema. Patients to monitor for metamorphopsia. No current guidelines for PML. Patients however should be aware of PML symptoms
Teriflunomide	Teratogenesis Liver toxicity Reactivation of latent tuberculosis	Ensure proper contraception for both male and female patients Contraindication for existing liver disease or TB exposure. Accelerated elimination via cholestyramine (8 g three times daily for 11 days) or activated charcoal (50 g twice daily for 11 days)
Dimethyl fumarate	Flushing GI: Abdominal pain, diarrhea, nausea PML	Aspirin 325 mg 30 minutes prior. Intake with full stomach, may also consider food with fat content peanut butter, chocolate milk, olive oil, almonds, cashews, potato chips, or avocados. Monitor lymphocyte counts routinely, check JVC Ab if <500
Alemtuzumab	Infusion reactions Infections Autoantibody disorders (thyroid, ITP, anti-GBM disease) Cancers (thyroid, melanoma)	Pretreatment with methylprednisolone 1000 mg antipyretics, and antihistamines Clinical monitoring for UTI, URI Acyclovir prophylaxis for herpetic infection

Ab = antibodies; AML = acute myelogenous leukemia; AV = atrioventricular; GBM = glomerular basement membrane; GI = gastrointestinal; ITP = idiopathic thrombocytopenic purpura; JCV = John Cunningham virus; NSAIDs = nonsteroidal anti-inflammatory drugs; OCT = optical coherence tomography; TB = tuberculosis; URI = upper respiratory tract infections; UTI = urinary tract infections; VZV = varicella zoster virus.