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Fingolimod in active multiple sclerosis: an impressive decrease in Gd-enhancing lesions
© Muris et al.; licensee BioMed Central Ltd. 2014
Received: 24 June 2014
Accepted: 8 August 2014
Published: 20 August 2014
Fingolimod is a disease modifying therapy (DMT) in highly active relapsing remitting multiple sclerosis (RRMS), as is natalizumab. Fingolimod decreases annual relapse rates and gadolinium enhancing lesions on MRI as compared to either interferon beta (IFNβ) or placebo. The effect of fingolimod on MRI outcomes compared to natalizumab treatment has not been investigated in (head to head) clinical trials. Clinical experience with natalizumab is much more extended and in general practice often preferred.
This case describes a 31-year old woman with RRMS, who experienced severe side effects on natalizumab. After a voluntary four months treatment free period, a severe relapse appeared which was treated with prednisone and plasmapheresis; thereafter fingolimod was initiated. In the following months MRI signs improved spectacularly.
This case suggests that fingolimod might be a good alternative for natalizumab, especially for use in RRMS patients, with highly active, advanced disease, when natalizumab treatment is stopped due to side effects or even after a severe relapse.
Fingolimod (FTY720, Gilenya®, Novartis Pharma AG, Basel, Switzerland) is like natalizumab (Tysabri®, Biogen Idec Inc, Weston, MA, USA) a single disease modifying therapy (DMT) in highly active relapsing remitting multiple sclerosis (RRMS) patients. Fingolimod is registered in 80 countries across the world. In some countries, like the USA, Switzerland, Australia and Russia, fingolimod is approved as a first line treatment while in Europe and Canada fingolimod is a second line therapy especially for those patients who are non-respondent to at least one other DMT like interferon beta (IFNβ) or glatiramer acetate (GA) or who have rapidly evolving MS –.
Fingolimod is an oral sphingosine 1-phosphate receptor modulator and acts as a functional antagonist reducing the amount of circulating pathogenic lymphocytes by inhibiting mainly naïve T cells and central memory T cells to egress from the lymph nodes. It might also play a role in the neuroprotection of the central nervous system (CNS) . Phase II and phase III studies with fingolimod have shown a decrease in annual relapse rate, as well as a reasonable decline in gadolinium (Gd) enhancing lesions on MRI, both in number and volume, after up to 36 months of fingolimod treatment compared to either first line treatment with IFNβ or placebo –.
The effect of fingolimod compared to natalizumab treatment has never been investigated in a head-to-head clinical trial. However, natalizumab was approved approximately five years before fingolimod and therefore the clinical experience with natalizumab is much more extended and in general practice often preferred ,,. When natalizumab is discontinued, because of various reasons, a switch to fingolimod is an obvious next step. However, reactivation of disease in patients switching from natalizumab to fingolimod is reported in a considerable proportion of patients –.
Here we describe a case of a patient who suffered from highly active RRMS which was treated with fingolimod following a severe relapse after discontinuation of natalizumab and a treatment free interval of four months. We consider this case as a striking example of the positive effect that fingolimod treatment may have especially on MRI outcome, even after successful natalizumab treatment.
A 31-year old woman was diagnosed with RRMS at the age of 25. Three years before diagnosis she presented with a first event of one-sided optic neuritis. She did not have any further medical history.
Natalizumab and fingolimod both are registered immunomodulatory therapies in RRMS, currently known to have comparable effectiveness. Natalizumab, in general practice frequently used, results in clinical and MRI stabilization, or even improvement . However, in the long term, natalizumab treatment has some shortcomings. Side effects like frequent urinary tract infections or herpes infections can occur. Also the increasing risk of getting PML in anti-JC virus antibody positive patients can lead to discontinuation of treatment. Fingolimod, with a different mechanism of action but shown to be also highly effective in reducing relapse rate in RRMS, might therefore be a good alternative for natalizumab ,.
A potential risk of natalizumab discontinuation is the risk of reactivation of disease, as is also described in our case presentation. Radiological and clinical rebound, in which disease activity increases to levels even higher than baseline, has been described between 1 and 6 months after discontinuation of natalizumab . However, in most cases disease activity returns to baseline with a peak four months after withdrawal . Fingolimod has been described to potentially mitigate the reactivation of disease after withdrawal of natalizumab . However, severe relapses in the first months after switching from natalizumab to fingolimod have also been reported –. These differences in outcome of fingolimod treatment used to overcome disease reactivation might be due to differences in duration of the wash out period of natalizumab. The wash out period between natalizumab and fingolimod is considered not to exceed two or three months ,. On the other hand, recently an observational study showed that relapses after switching from natalizumab to fingolimod occurred independently of the wash-out period .
In this case presentation, fingolimod was not used to prevent a rebound effect or reactivation of disease after discontinuation of natalizumab. Instead, after natalizumab withdrawal initially the patient did not receive any immunomodulatory medication. Only after the severe relapse, four months later, fingolimod was started. Afterwards, the patient stabilized clinically and T1 Gd enhancing lesions decreased spectacularly with only one persistent Gd lesion and no new Gd enhancing lesions after 8 months (Figure 1B). Although, Gd enhancing lesions may become inactive after 2–3 months, this decrease from 54 T1 Gd enhancing lesions to only one persistent is conspicuous and a treatment effect of fingolimod therefore almost undeniably.
This case shows and confirms that fingolimod might be radiologically and clinically as effective as and a good alternative for natalizumab in highly active advanced RRMS or possibly even in patients developing relapsing progressive MS. Based on this case report one might speculate fingolimod to be a good alternative for natalizumab in anti JC virus positive patients. Moreover, it might even be useful in the treatment regime of a MS patient after a severe relapse.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.
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