Contributions
Abstract: EP1794
Type: ePoster
Abstract Category: Therapy - disease modifying - 32 Others
Background: Switching between disease modifying treatments in Multiple Sclerosis (MS) is becoming increasingly complex. In patients failing Fingolimod therapy, treatment can be escalated to Alemtuzumab to achieve disease suppression. Potential difficulties with this treatment strategy include rebound disease activity, as there have been reports of treatment failure in up to 25% of patients who have switched from Fingolimod to Alemtuzumab. This process is thought to be mediated by prolonged sequestration of auto-reactive lymphocytes due to Fingolimod, which are then released following discontinuation. These cells (whilst sequestered) can also avoid the activity of Alemtuzumab, later causing ongoing disease activity despite Alemtuzumab treatment.
Methods: Patients with relapsing remitting MS who switched to Alemtuzumab from Fingolimod were reviewed from a South West Wales cohort.
Results
Case 1: A 31-year old female with relapsing remitting MS was escalated to Alemtuzumab from Fingolimod due to clinical relapse activity. Following the first course of Alemtuzumab treatment she suffered 2 further relapses and her MRI demonstrated multiple new T2 lesions and 6 Gadolinium-enhancing lesions. Her second course of treatment has been successful, achieving current disease stability.
Case 2: A 43-year old female with relapsing remitting MS was escalated from Interferon beta to Fingolimod and had been stable for 3 years. She subsequently developed clinical and radiological disease activity and was switched to Alemtuzumab. In view of the risk of treatment failure, a 12-week washout period was instituted, with a pulse of Methylprednisolone at 8 weeks to reduce the chance of rebound disease. On cessation of Fingolimod, MRI disease activity was noted at 8 weeks and clinical disease activity at 12 weeks. The first course of Alemtuzumab however was successful with no clinical or radiological disease activity.
Conclusion: The complexity of managing MS patients with disease modifying treatments, and especially of managing the complications of switching between treatments is rapidly evolving. We present an example of treatment failure following escalation from Fingolimod to Alemtuzumab. We discuss a treatment strategy that includes an extended washout period with corticosteroid cover, to balance the risk of potential Alemtuzumab treatment failure against Fingolimod withdrawal rebound disease activity.
Disclosure:
M Hu: nothing to disclose.
G Ingram: has received travel funding and/or speaker honoraria from Biogen, Roche, Merck Serono, Novartis, Teva, Genzyme Sanofi.
O R Pearson: served on the scientific advisory board for Biogen, Novartis, Roche, UK MS Register and has received travel funding and/or speaker honoraria from Biogen, Roche, Merck Serono, Novartis, Teva, Genzyme Sanofi.
Abstract: EP1794
Type: ePoster
Abstract Category: Therapy - disease modifying - 32 Others
Background: Switching between disease modifying treatments in Multiple Sclerosis (MS) is becoming increasingly complex. In patients failing Fingolimod therapy, treatment can be escalated to Alemtuzumab to achieve disease suppression. Potential difficulties with this treatment strategy include rebound disease activity, as there have been reports of treatment failure in up to 25% of patients who have switched from Fingolimod to Alemtuzumab. This process is thought to be mediated by prolonged sequestration of auto-reactive lymphocytes due to Fingolimod, which are then released following discontinuation. These cells (whilst sequestered) can also avoid the activity of Alemtuzumab, later causing ongoing disease activity despite Alemtuzumab treatment.
Methods: Patients with relapsing remitting MS who switched to Alemtuzumab from Fingolimod were reviewed from a South West Wales cohort.
Results
Case 1: A 31-year old female with relapsing remitting MS was escalated to Alemtuzumab from Fingolimod due to clinical relapse activity. Following the first course of Alemtuzumab treatment she suffered 2 further relapses and her MRI demonstrated multiple new T2 lesions and 6 Gadolinium-enhancing lesions. Her second course of treatment has been successful, achieving current disease stability.
Case 2: A 43-year old female with relapsing remitting MS was escalated from Interferon beta to Fingolimod and had been stable for 3 years. She subsequently developed clinical and radiological disease activity and was switched to Alemtuzumab. In view of the risk of treatment failure, a 12-week washout period was instituted, with a pulse of Methylprednisolone at 8 weeks to reduce the chance of rebound disease. On cessation of Fingolimod, MRI disease activity was noted at 8 weeks and clinical disease activity at 12 weeks. The first course of Alemtuzumab however was successful with no clinical or radiological disease activity.
Conclusion: The complexity of managing MS patients with disease modifying treatments, and especially of managing the complications of switching between treatments is rapidly evolving. We present an example of treatment failure following escalation from Fingolimod to Alemtuzumab. We discuss a treatment strategy that includes an extended washout period with corticosteroid cover, to balance the risk of potential Alemtuzumab treatment failure against Fingolimod withdrawal rebound disease activity.
Disclosure:
M Hu: nothing to disclose.
G Ingram: has received travel funding and/or speaker honoraria from Biogen, Roche, Merck Serono, Novartis, Teva, Genzyme Sanofi.
O R Pearson: served on the scientific advisory board for Biogen, Novartis, Roche, UK MS Register and has received travel funding and/or speaker honoraria from Biogen, Roche, Merck Serono, Novartis, Teva, Genzyme Sanofi.