Switching from Fingo

S

You asked about switching from fingolimod to another imod or anti-CD20. I am sorry I can’t give advice and maybe profK can tell us about the BartsMS standard, but it is important that the switch occurs to stop rebound occurring. Some people repopulate slowly after fingolimod but here is one persons view. It is open access so you can have a read.

Barry B, Erwin AA, Stevens J, Tornatore C. Fingolimod Rebound: A Review of the Clinical Experience and Management Considerations. Neurol Ther. 2019; 8:241-250

Because the treatment of multiple sclerosis (MS) may span decades, the need often arises to make changes to the treatment plan in order to accommodate changing circumstances. Switching drugs, or the discontinuation of immunomodulatory agents altogether, may leave patients vulnerable to relapse or disease progression. In some cases, severe MS disease activity is noted clinically and on MRI after treatment withdrawal. When this disease activity is disproportionate to the pattern observed prior to treatment initiation, patients are said to have experienced rebound. Of the US Food and Drug Administration (FDA)-approved agents to treat MS, the drugs most commonly implicated in rebound are natalizumab and fingolimod. In this review based on the reported cases and data from clinical trials, we characterize disease rebound after fingolimod cessation. We also outline fingolimod rebound management considerations, summarizing what evidence is available to help clinicians mitigate the risk of rebound, switch therapies, and treat rebound events when they occur. The commonly encountered situation of fingolimod discontinuation prior to pregnancy is also discussed.

Malpas CB, Roos I, Sharmin S, Buzzard K, Skibina O, Butzkueven H, Kappos L, Patti F, Alroughani R, Horakova D, Havrdova EK, Izquierdo G, Eichau S, Hodgkinson S, Grammond P, Lechner-Scott J, Kalincik T; MSBase Study Group. Multiple Sclerosis Relapses Following Cessation of Fingolimod. Clin Drug Investig. 2022 Apr;42(4):355-364.

Background: There is growing interest in the issue of disease reactivation in multiple sclerosis following fingolimod cessation. Relatively little is known about modifiers of the risk of post-cessation relapse, including the delay to commencement of new therapy and prior disease activity.

Objective: We aimed to determine the rate of relapse following cessation of fingolimod and to identify predictors of relapse following cessation.

Methods: Data were extracted from the MSBase registry in March 2019. Inclusion criteria were (a) clinically definite relapsing multiple sclerosis, (b) treatment with fingolimod for ≥ 12 months, (c) follow-up after cessation for ≥ 12 months, and (d) at least one Expanded Disability Status Scale score recorded in the 12 months before cessation.

Results: A total of 685 patients were identified who met criteria. The mean annualised relapse rate was 1.71 (95% CI 1.59, 1.85) in the year prior to fingolimod, 0.50 (95% CI 0.44, 0.55) on fingolimod and 0.43 (95% CI 0.38, 0.49) after fingolimod. Of these, 218 (32%) patients experienced a relapse in the first 12 months. Predictors of a higher relapse rate in the first year were: younger age at fingolimod cessation, higher relapse rate in the year prior to cessation, delaying commencement of new therapy and switching to low-efficacy therapy.

Conclusions: Disease reactivation following fingolimod cessation is more common in younger patients, those with greater disease activity prior to cessation and in those who switch to a low-efficacy therapy.

COI: None relevant

Disclaimer there are the views of te author and no one else

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MouseDoctor

7 comments

  • Be interesting to get profK’s thoughts on washout period. I’m switching from 10 years of being on fingo to sipo as now SPMS. Have read 4-6 weeks so lymphocyte count and immune system can improve. Hoping to get next Covid booster before I start it whilst not so immuno suppressed……..plus flu and shingles or is that asking too much! I’m 55, female and on wonderful HRT 🙂

    • Linda – I believe the shingles vaccine is a two shot regimen, separated by 6 months. So it is really hard to plan for when switching DMTs. If you can’t get the shingles shots, they should be able to prescribe antivirals as an alternative, this is what I have been doing.

      Plus, if you worship at the church of Prof. G, then there might be added benefit of taking antivirals 😉

      Good luck with the transfer, I know how scary it can be, but with proper planning the risk of rebound can be managed.

      • Thanks Tommy.
        I had a really severe shingles attack in April and was very poorly for 5 weeks. Folk that say it’s like chicken pox, oh no, big red welts all across lower back and down right leg. Poor husband had to take daily photos! GP was very good and I was on anti virals for 2 weeks. Friends over 70 had just the one injection so I was hopeful for the same but would appreciate my next Covid booster more if I could have it whilst immune system has a little recovery between imods.

        As for Prof. G, who doesn’t worship at his church 😁
        My poor consultant must be so fed up of me quoting him, ‘I’m NEIDA’😉
        I do subscribe to his MS Selfie, follow on Twitter etc, not quite a stalker …..yet!

        Thanks very much for m you kind words.

    • Linda,

      Thanks for your post. I wasn’t on Fingo, but had a highly effective induction therapy c.15 years ago. This stopped all relapses, but a year ago (age 55) I was ‘upgraded’ to SPMS. Our cases show that addressing relapses isn’t enough. I like Prof G’s take that relapses are just the immune system’s response and are not the real MS. There’s something else causing the damage and our two cases (I expect there are many more) point to this. This disease is progressive from the start.

      • Thanks for responding VI.
        I agree with your points, and of course Prof. G too. I have used his terms and facts many times with my consultant. Fortunately he knows him so he knows I’m not playing around on Mr Google and coming up with random information!

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