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Amanda, 31, a computer programmer was diagnosed with RRMS in 2014. She was initially treated with glatiramer acetate, but experienced ongoing disease activity. She was switched to fingolimod in 2016 and was clinically and radiologically stable for three years.

A brain MRI in 2019 revealed three new lesions, including one Gd+ lesion. Her EDSS score was 1.5 (vision 1, sensory 1). Amanda reported no relapses or worsening symptoms, so she opted to remain on fingolimod.

An MRI scheduled for 2020 was not obtained because of the COVID-19 pandemic. When an MRI brain was performed in November 2021, there were three new lesions. A change in treatment was discussed, but Amanda said she did not want to change her regimen because she was getting married in the spring.

In December 2022, Amanda complained of worsening symptoms despite adhering to her daily fingolimod treatment regimen. She said she was having difficulties walking, felt clumsy and uncoordinated. Her work performance had worsened over the past few months which she attributed to vision problems and difficulties concentrating. EDSS score was 2.5 (brainstem 2, cerebellar 2, vision 1, sensory 1, cerebral 1). An MRI brain showed two enhancing lesions.

Interactive survey

Question 1: What finding is most worrisome to you? (Pick one)

Question 2: What disease-modifying therapy would you recommend for Amanda?

Question 3: Amanda expresses concerns about her risk of developing severe COVID-19. Would this influence your preferred treatment choice? (Pick one)

Question 4: Amanda says she would like to become pregnant later this year. In this scenario, which treatments would you avoid initiating? (Pick any two)

Question 5: If Amanda were planning a pregnancy in 12-18 months from now, which DMT would you recommend? (Pick one)

Question 6: In your view, is Amanda at high risk of postpartum relapse?

Watch for a video case discussion by Dr. Virender Bhan, Burnaby, B.C., in an upcoming issue.

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