ClinicSpeak & NeuroSpeak: sequencing DMTs switching from natalizumab to alemtuzumab

Can you switch from natalizumab to alemtuzumab safely? #ClinicSpeak #Neurospeak #MSBlog

"Finally, our algorithm for switching patients at high-risk of PML to other DMTs, in particular alemtuzumab, is in print. We originally published this algorithm on the blog way back in 2014 so why publish it in a journal now? Firstly, it is always good practice to get your work peer-reviewed and secondly it is not accepted practice to quote a blog."

"It is ironic that the day after the EMA announces a positive opinion on daclizumab as a treatment for relapsing forms of MS our paper comes out in print. Ironic in that I have being making the case for daclizumab being the agent of choice post-natalizumab. This means our recommendations will be out of date very soon. In anticipation of this I have already updated the recommendations by including both daclizumab and rituximab as potential switch agents. The daclizumab recommendation is based on scientific principles. Let's hope Biogen and Abbvie do a switch study to produce the necessary data to support this recommendation. In comparison the rituximab recommendation is based on real-life data from Sweden. Despite the latter, NHS England have already said no to rituximab off-label. However, the fact that we can't use rituximab in the NHS in England and Wales doesn't mean other neurologists reading this blog can't. So may be the blog is the best platform for keeping up-to-date with our thinking on this issue?"

Figure: adapted from Giovannoni et al. 

Giovannoni et al. Neurological dilemmas: Switching patients at high risk of PML from natalizumab to another disease-modifying therapy. Pract Neurol doi:10.1136/practneurol-2015-001355

There are several options for switching people with multiple sclerosis (MS) who are at high risk of developing progressive multifocal leukoencephalopathy (PML) from natalizumab to alemtuzumab. However, some of these have risks that need to be managed, for example, the risks of carrying over asymptomatic PML from natalizumab on to the new therapy, and the risk of rebound disease activity associated with a prolonged washout after starting natalizumab. We propose a pragmatic bridging strategy, using another disease-modifying therapy (DMT), to reduce the risk of switching from natalizumab to alemtuzumab. We also discuss the caveats and subtleties associated with sequencing DMTs in MS and the complex decision making involved.

CoI: multiple

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