Click here to watch Dr. Kristen Krysko discuss the case and the responses to the survey.

RJ, age 38 years, has a 15-year history of relapsing-remitting multiple sclerosis. She initially presented with highly-active MS and was started on beta-interferon-1a 44µg. She continued to have significant clinical disease activity and ongoing MRI lesions in both brain and spine. She was transitioned to fingolimod in 2012.

Her MS was generally well-controlled for many years. She was relapse-free with no definite progression although there were occasional breakthrough MRI lesions over the next six years. RJ reported worsening symptoms and difficulty concentrating. Her MRI at that time showed three new lesions. She opted to switch to an anti-CD20 agent three and a half years ago.

She has had no relapses on anti-CD20 therapy. Her neurological examination has been stable for years. Positive findings are: visual acuity 20/30 on the right and 20/25 on the left with optic disc pallor; asymptomatic left INO; moderate limb dysmetria; mild bilateral hip flexor weakness with no other motor abnormalities except minimal spasticity; bilateral extensor plantars; absent vibration at the great toes; normal gait except for some minimal difficulty with tandem; normal bladder function; and no cognitive impairment. Her disability score is EDSS 3.5.

RJ tried to get pregnant for a year prior to her diagnosis without success. There was no fertility assessment or treatment at that time. She stopped pregnancy planning when the relationship ended and has consistently stated over the years that she had no plans to get pregnant. However, at her last visit, RJ said she is in a new relationship and she and her new partner would like to have a child.

The survey is now closed. There were 36 responses. See below for a summary of the answers you provided.

Question 1: Would you advise her to undergo fertility evaluation?
Two-thirds of respondents (69.2%) thought that RJ should undergo fertility evaluation.

Question 2: In your opinion, do the potential benefits of treatment with an anti-CD20 agent in this case outweigh the potential risks of treatment exposure to the fetus?
A total of 69.2% responded that treatment with an anti-CD20 agent outweighed any potential risks to the fetus, 11.5% said the benefits did not outweigh the risks, and 19.2% were unsure.

Question 3: What advice would you give RJ about her current disease-modifying therapy?
Most respondents (69.2%) thought RJ should continue with her usual dosing regimen, timing the last dose of anti-CD20 agent according to the half-life, then suspend treatment if she becomes pregnant. A total of 23.1% said she should continue the usual dosing but suspend treatment once she becomes aware that she is pregnant. Few respondents (3.85%) said she should stop treatment immediately or switch to a lower-efficacy DMT.

Question 4: When would you advise RJ to re-start anti-CD20 therapy postpartum?
A majority of respondents (76.9%) said she should re-start treatment two weeks post-partum even if she is still breastfeeding. A total of 11.5% said she should re-start as soon as possible, 3.9% said she should re-start as soon as she stops breastfeeding, and 7.7% advised re-starting >2-4 weeks after she has stopped breastfeeding.

Question 5: When would you advise RJ to have her infant vaccinated?
Most respondents (61.5%) recommended staying with the usual vaccination schedule advised by her pediatrician. A total of 30.8% said they would test B cell counts before vaccinating, 3.9% said they would delay the usual vaccination schedule by 2-4 months, and 3.9% were unsure.

View the video commentary from Dr. Kristen Krysko.