Click here to watch Dr. Daniel Selchen discuss the case and the responses to the survey.

D.C. is a 41-year-old woman diagnosed with multiple sclerosis 14 years ago. She was treated initially with a beta interferon. She experienced ongoing disease activity and was transitioned to natalizumab 10 years ago. She was completely stable for six years. She was switched to fingolimod after a significant change in JCV index. She had no MRI changes on natalizumab and a few new MRI lesions on fingolimod. She had no new lesions while on natalizumab and few MRI changes on fingolimod. Her EDSS score a year ago was 1.5 (vision 1, sensory 1, bladder 1).

At her present visit, D.C. describes worsening fatigue with associated cognitive and gait fatigability. She tells you that her left leg feels weak, and she has noticed a left foot drop after walking about a kilometer. She previously had no mobility limitations. Her current neurological examination is unchanged. A recent MRI showed one small new non-enhancing periventricular lesion. Serum NfL is twice the upper limit of normal for age. 

The survey is now closed. There were 35 responses. See below for a summary of the answers you provided.

Question 1. What is her current EDSS score?
Two-thirds of respondents thought her EDSS score had worsened to 2.0 or 2.5. Another 20% said it was unchanged at 1.5, and 14% were unsure.

Question 2. How would you characterize her current situation?
The highest proportion of respondents (46%) characterized D.C. as having progression independent of relapse activity (PIRA). A total of 9% said she had treatment-refractory RMS, 26% said RMS with worsening symptoms, 9% with SPMS and 11% said PIRA and SPMS.

Question 3. Is the MRI change actionable?
A majority of respondents said that some action was required. A total of 69% said they would change treatment because of breakthrough disease and 6% said they would switch because the MRI and NfL findings suggest SPMS onset. One-quarter would not intervene since one lesion is insufficient to justify a change in treatment (11%) and 14% said they would wait 6-12 months and reassess.

Question 4. Is the NfL level actionable?
Opinion was divided. Overall, 46% said an elevated NfL is an indication of treatment failure and would change therapy, 26% noted that there is no baseline sNfL so it is unclear if the patient is responding to treatment, 26% said they would not treat a biomarker, and 8% said they would need more information before acting.

Question 5. How would you treat this patient?
A majority of respondents (69%) said they would switch to an anti-CD20 agent. Twenty percent said they would switch to oral cladribine, and 6% would switch to natalizumab or siponimod. No respondent would maintain fingolimod in this patient.

View the video commentary from Dr. Daniel Selchen.