Click here to watch Dr. Virender Bhan discuss the case and the responses to the survey.
J.T. is a 42-year-old woman previously well except for frequent urinary tract infections, which included an episode of pyelonephritis with no known anatomical abnormality. She initially presented with two relapses about six months apart, a mild optic neuritis and a mild sensory myelopathy with excellent spontaneous recovery. Her EDSS score was 1.0. She was started on dimethyl fumarate.
Seven months later she came to the emergency room with a severe relapse with multifocal findings including diplopia, severe ataxia, weakness, mixed ataxic and pyramidal gait disturbance. Her EDSS score was 6.0. MRI revealed multiple infra- and supratentorial enhancing lesions. She was treated with intravenous steroids with gradual improvement to an EDSS of 4.0.
Workup for treatment escalation revealed that she was non-immune to varicella, had a serum IgG level of 5.98 g/L (lab normal range 6-16 g/L), a lymphocyte count of 0.8 x 109/L, and a JCV index of 2.89.
The survey is now closed. There were 39 responses. See below for a summary of the answers you provided.
Question 1. How would you treat this patient?
A majority of respondents (51.3%) would switch to ofatumumab. Another 23.1% would switch to natalizumab, 17.9% to ocrelizumab, and 7.7% to oral cladribine. No respondent said they would maintain DMF.
Question 2. What is your key consideration for your choice of treatment?
The key consideration for most respondents was short-term efficacy (38.5%) or long-term efficacy (46.2%). Fewer respondents said their main concern was short-term safety (7.7%) or long-term safety (7.7%).
Question 3. What is your primary safety concern?
The largest proportion of respondents said PML was the main safety concern (35.8%). Other concerns were infections (including varicella) (28.2%), recurrent UTIs (12.8%), or low lymphocyte count or hypogammaglobulinemia (10.3% each).
Question 4. Would you vaccinate for varicella?
Most respondents were in favour of vaccination. A total of 33.3% said they would vaccinate before switching therapy, 38.5% said they vaccinate only if it did not delay the treatment switch, and 25.6% said they would switch immediately and revisit the issue of vaccination later on. Only 2.6% said they would not vaccinate.
Question 5. Would it be useful to obtain serum NfL at this juncture?
A majority (51.3%) were unsure because they said it would not affect the treatment decision-making. In addition, 25.6% said they would obtain sNfL since it would help in evaluating treatment response. Some (10.3%) said they would not order NfL testing because the results would not be meaningful without a level obtained at baseline, and 12.8% said that NfL testing was not easily accessible at their centre.
View the video commentary from Dr. Virender Bhan.