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Joseph is a 28-year-old shipping manager at a local warehouse. He is married and has a three-year-old daughter. He presents in April 2021 following an episode of right sided vision loss, with minimal pain. Exam showed visual acuity 20/400, loss of colour vision and an afferent pupillary defect. The rest of his neuro exam is normal. Brain MRI revealed MS-like white-matter abnormalities with a moderate burden of disease and evidence of right optic neuritis (T2 hyperintensity and contrast enhancement). He was treated with IVMP 1000 mg daily x 3 days, with minimal improvement. There is no history of comorbid conditions and no family history of demyelinating or autoimmune disorders. He has not received a COVID-19 vaccine. Extensive discussion does not change his mind and he says he has no plans to get vaccinated.


Question 1: What is your provisional diagnosis?

Question 2: What additional tests would you obtain? (max. 3 choices)

Question 3: Would you initiate treatment with a disease-modifying therapy (DMT) at this time?

Question 4: He develops interscapular pain, numbness/weakness in both legs, is unable to walk and has urinary urgency/incontinence.Moderate paraparesis, sensory level at T6, hyper-reflexia, bilateral Babinski sign.Hospitalized with thoracic myelopathy.MRI spine: 2.5-segment enhancing lesion at T4. CSF: 39 WBCs, mainly lymphocytes.OCB pattern atypical, 1 band (not in serum).Negative for NMO and MOG Ab. JCV index negative.Partial recovery with IVMP 1000 mg x5 d; able to walk but not run. How would you treat?

Question 5: How does Joseph’s COVID-19 vaccination status influence your treatment decision?

Bivalent boosters in development for COVID-19


The U.S. Food and Drug Administration will meet later this month to consider approval of two bivalent COVID-19 booster vaccines that are reportedly effective against the Omicron variant (B.1.1.529). Both boosters were developed by Moderna and are variations of the company’s original mRNA-1273 vaccine. Read More



Click here to watch Dr. Courtney Casserly discuss the case and the responses to the survey.

Alison, 31, is a lawyer, married with no children. She was diagnosed with RRMS in 2014. Her initial presentation was vertigo, diplopia and mild ataxia. EDSS score was 2.0. She was started on glatiramer acetate but was switched to fingolimod in 2016 after experiencing two relapses.

She has been clinically stable since 2016. Her EDSS score is unchanged. Her last MRI eight months ago revealed three new lesions, one enhancing, but she was happy on therapy and did not want to make a switch at that time.

The patient tells you she wants to get pregnant in the next 6-12 months.

The survey is now closed. We received 40 responses. See below for a summary of the answers you provided.

Question 1: Is Alison being adequately managed on her current treatment?
A majority of respondents (90%) said that Alison is experiencing breakthrough disease activity. Only 5% said she is clinically stable or that her MRI activity is not sufficient to warrant escalating therapy.

Question 2. How would you manage Alison’s transition off fingolimod prior to her pregnancy?
Most respondents (50%) said they would switch from fingolimod to natalizumab after an appropriate washout period, then continue natalizumab until the second trimester of pregnancy. However, many said they would switch to ocrelizumab (35%) or complete year 1 of cladribine dosing (15%).

3. Assuming all vaccines and TB skin testing are up-to-date, what testing is needed when transitioning from fingolimod to another higher efficacy agent (e.g. natalizumab, ocrelizumab, cladribine)?
A majority (55%) would obtain a CBC with differential, MR head, and serum JCV antibody testing with index. Some respondents opted for CBC with differential, MR head, CSF for JCV (15%); CBC with differential and MR head with gadolinium without CSF testing (15%); 10% would obtain a CBC with differential and MR head; and 5% thought a CBC with differential was sufficient without MRI (5%).

4. What would be your approach if Alison said she wanted to get pregnant in 12-24 months (rather than in 6-12 months)?
Respondents were somewhat evenly split. A total of 40% would switch from fingolimod to ocrelizumab, continue with 3-4 cycles (q6 months) then attempt conception four months post-ocrelizumab. About 30% said they would switch to natalizumab and continue treatment until the second trimester of pregnancy. Another 30% would wait until the lymphocyte count recovered and then complete a two-year course of cladribine, with the recommendation to wait 6 months post-cladribine before conception.

5. Alison opted to switch to ocrelizumab as her disease modifying therapy. She received three cycles of ocrelizumab, became pregnant, carried her baby to term, and had a healthy baby girl. Post-partum she is keen to restart treatment with a DMT. She plans to breastfeed. What is your advice regarding breastfeeding?
About one-third said they would immediately restart ocrelizumab while breastfeeding. Twenty percent would re-start ocrelizumab immediately but would advise Alison to “pump and dump”, i.e. discard the breast milk during the 10-day period after each infusion. About 15% said they would not re-start treatment until after Alison had completed exclusive breastfeeding. Another 15% said they would delay re-starting ocrelizumab for three months when the baby is weaned. Only 5% would counsel Alison not to breastfeed so she can start treatment as soon as possible.

View the video commentary by Dr. Courtney Casserly.