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

Craig is a 36-year-old salesperson with no prior medical history. In 2012, he presented with optic neuritis. Six months later he experienced a myelopathic episode. MRI-brain and -C-spine revealed a moderate disease burden of seven T2 lesions and one Gd+ lesion.  He was started on interferon-beta-1a s.c. in 2013.

He was clinically stable for two years but showed some ongoing MRI activity. EDSS was 2.5 (vision 2, motor 2, sensory 1). In 2016, he experienced another myelopathic episode. EDSS post-recovery was 3.0 (vision 2, motor 2, sensory 2, bladder 2). MRI revealed multiple new brain lesions.

He was started on natalizumab in 2017. His anti-JCV antibody index was negative. For the next five years he was clinically and radiologically stable. JCV index was 0.3 in 2018 and 2019, then increased to 0.68 in 2020, 0.91 in 2021 and 1.61 in August 2022. When repeated one month later, the JCV index was 1.69.

The survey is now closed. We received 25 responses. See below for a summary of the answers you provided.

Question 1: Would you switch Craig to another DMT?
The largest number of respondents said they would switch due to the JCV index >1.5 (36%); one-third (32%) would have switched when the JCV index was >0.9. Sixteen percent of respondents would not switch treatments.

Question 2: At what JCV index cut-off value would you consider switching a natalizumab-treated patient?
Most respondents would switch with a JCV index >1.5 (36%), 0.9-1.5 (20%) or at 0.9 (12%) Twenty percent would switch based on other criteria.

Question 3: What would be your treatment approach?
A majority (72%) would stop natalizumab in this patient and switch to another high-efficacy DMT. However, some (28%) would opt for extended-interval dosing of natalizumab.

 Question 4: Craig tells you he would like to switch treatments. What would be your preferred therapy?
A majority said the preferred therapy would be an anti-CD20 agent, either ocrelizumab (56%) or ofatumumab (28%). Twelve percent selected an S1PR agonist and 4% preferred cladribine. No respondent chose a platform therapy.

Question 5: Craig experiences a relapse during the one-month washout period. What would you do?
A majority (56%) would administer steroids and continue with the treatment plan. Some respondents said they would immediately obtain an MRI with Gd+ (24%) or test for JCV DNA in CSF (12%). Eight percent would start the next DMT immediately.

View the video commentary from Dr. Daniel Selchen.