Background: Clinical and/or neuroimaging evidence of disease reactivation has been described in MSers after a break from natalizumab.
Rigau et al. Lethal multiple sclerosis relapse after natalizumab withdrawal. Neurology. 2012 Oct 24. [Epub ahead of print]
Jander et al. Emerging tumefactive multiple sclerosis after switching therapy from natalizumab to fingolimod. Mult Scler. 2012;18:1650-2. doi: 10.1177/1352458512463768.
“These studies and case reports confirm mine and many other neurologists’ observations of rebound on natalizumab withdrawal. Most of us feel that this rebound is in excess of what activity MSers had before they started natalizumab. How to prevent it? It is difficult, because you want to make sure that JCV+ MSers who are switching from natalizumab (Tysabri) to fingolimod (Gilenya) are not in the pre-symptomatic phase of PML, which is why we advocate a 3 month washout period. The washout allows your own immune system to reconstitute the CNS and find any rogue virus. The problem with this strategy is that it allows your MS to comeback with a vengeance. Some of us have started prescribing pulsed monthly steroids to cover this period, but this does not appear to prevent the rebound entirely. There are several trials testing different washout periods and switching options that will hopefully allow us to make more evidence-based recommendations shortly. At present I am too concerned about carry-over PML on fingolimod to recommend anything less than a 3 month washout. If we can increase the diagnostic confidence of excluding early asymptomatic PML I will obviously change my recommendation. Please stay tuned to this blog; we will come back to you with more posts as data becomes available.”