Warts after Fingo

I had the pleasure of meeting Dr Reddel last week at recent “At the Limits meeting”. He is following in his Father’s footsteps and likes doing risk assessments.

His dad as a test pilot in Australia and Dr Reddel, a Neuro with a real sense of humour. He gave a neuro from the shires a bit of a ticking off for not testing their pwMS for tuberculosis prior to giving certain DMT. As surely they are not too snobbby to travel or have visitors and catch something that remains undiagnosed.

Dr Reddel has developed Apps to monitor alemtuzumab risks but today he has commented on fingolimod 

Triplett J, Kermode AG, Corbett A, Reddel SW. Warts and all: Fingolimod and unusual HPV-associated lesions.Mult Scler. 2018 Nov 14:1352458518807088

BACKGROUND:Fingolimod is used to reduce relapse rates in relapsing-remitting multiple sclerosis (MS). It is a sphingosine 1-phosphate (S1P) analogue having antagonistic effects on S1P receptors. Its immunosuppressive effect is due to reduced circulating lymphocyte numbers, and it may also be associated with impaired intrinsic cancer surveillance. Fingolimod side effects include increased rates and severity of viral infections particularly varicella zoster.
METHODS:We present five cases of chronic and treatment refractory warts associated with fingolimod therapy.
RESULTS:Each of the five cases presenting with chronic warts while receiving fingolimod therapy had prolonged periods of lymphopenia and improvements were seen following dose reduction or cessation of fingolimod.
CONCLUSION:Cutaneous warts are associated with human papilloma virus (HPV) infection, suggesting an increased risk of other HPV-driven conditions such as cervical cancer following fingolimod administration. HPV viruses are responsible for approximately 90% of cervical cancers as well as a significant portion of anogenital cancers and have a high prevalence in sexually active adults. Given the reduced immune response to viral infections and potential impaired cancer surveillance in those receiving fingolimod, HPV vaccination and frequent assessment for the development of HPV-associated malignancies are recommended.

I am not a clinician and so am not making any recommenedations however it is something you should be aware of . Where is ProfG? 

Other docs commented “Although chronic warts have not previously been reported, it is conceivable they have escaped collection, and by publishing this series we may draw attention to the HPV associated risks of fingolimod. While further data is collected, clinicians should consider obtaining a history of HPV infections and vaccination history in females arranging a gynaecological exam and Pap smear to assess for dysplastic lesions and/or direct cervical screening for HPV. The newly available nine-strain HPV vaccination is effective against the most commonly oncogenic genital HPV strains and should be considered in unvaccinated patients prior to commencing fingolimod”. 

“It is not clear if increased frequency of cervical cancer screening would be useful or even cost-effective in female patients on fingolimod, but clinician awareness around these cases is important”.

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