Aaron E. Miller, MD


October 15, 2013

In This Article

The Switch to Fingolimod

I want to particularly address the first oral agent that was introduced, fingolimod, which has now been on the market for approximately 3 years in the United States. This agent is now at a stage where we are learning much more about its risks and benefits. We have other, newer oral agents -- teriflunomide and dimethyl fumarate -- which have been approved in the past year in the United States, although dimethyl fumarate is not yet approved in Europe. We don't have enough maturity in the marketplace yet to assess the best utilization of those agents, but we do have information about fingolimod, in particular its relationship to natalizumab. Since its reintroduction in 2006, natalizumab has been on the market for about 7 years. During that time, we have learned that a major risk concern with natalizumab is the development of progressive multifocal leukoencephalopathy (PML), and we have learned that the major risk factor for the development of PML with natalizumab is the presence of antibodies to the JC virus, the virus that causes PML. It turns out that many of the patients who have been treated with natalizumab and are positive for these antibodies are switched to fingolimod, so one thing that has been addressed is how long one should wait before putting a patient on fingolimod after natalizumab. This congress has shown us that, clearly, a shorter time is preferred -- definitely within 2 months rather than 3 or 4 months after you discontinue natalizumab, otherwise the risk for relapses and MRI activity is increased.


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