ClinicSpeak: natalizumab or alemtuzumab?

Wow, MS DMT counselling just got very complicated. Natalizumab vs. Alemtuzumab #ClinicSpeak #MSBlog #MSResearch

"In clinic on Tuesday I saw two  patients with rapidly-evolving severe MS who were eligible for natalizumab under the current NHS England's guidelines. One patient was a young man naive to first-line treatment with a poor prognostic profile (high lesion load on MRI, including posterior fossa lesions, and early disability in motor and cerebellar systems). The second patient is a young woman failing fingolinod (two disabling relapses in the last 6 months) having previously failed interferon-beta. Up until now the discussion for both of these patients would have been simple and I would have offered them natalizumab. I have a well-oiled summary of the risks and benefits of natalizumab and how we manage and de-risk the PML problem if they happen to be JCV-seropositive. But things have changed, we now have alemtuzumab as a therapeutic option for these patients. When I started discussing alemtuzumab next to natalizumab with these two patients things got very complicated."

"How do you compare a maintenance and an induction strategy with each other? When I mentioned the rates of long-term remission on alemtuzumab, and the potential an induction therapy offers regarding a cure, things got messy. I now realise that I can't mention the C-word without defining it. When I tried to define the C-word and discussed the potential of a cure, both patients were lost. Despite this it was clear that a potential cure is the alemtuzumab trump card. The promise of long-term remission, and a potential cure, is what outweighs the risks of being treated with alemtuzumab."

"The MS nurse who did the clinic with me, and I, have now decided to work on a better way of comparing the merits of these two drugs; we need to avoid mentioning the C-word. However, without the C-word, natalizumab, particularity if you are JCV-seronegative, would win hands down based on a risk-benefit analysis. The exception being for patients who are planning to have children, particularity if they want to fall pregnant in the next few years. An induction therapy is very appealing for young woman wanting to have children."

"At the end of the clinic I realised that if I am going to compare natalizumab with alemtuzumab I will need at least 60 minutes to go through the pros and cons of each therapy and their relative merits. Then each patient will also need a follow-up session to ask further questions. Counselling regarding DMTs just go a whole lot harder and more complicated. The following table tries to capture the issues that will need to be discussed when comparing these two agents. This is why true patient-decision making may also be an unrealistic expectation."

"Do you have any questions or comments? Please note this table is my first attempt at a very difficult task and will need some thought, in fact some very deep thought."

CoI: multiple

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