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Friday, 15 August 2014
ClinicSpeak: natalizumab or alemtuzumab?
"In clinic on Tuesday I saw two patients with rapidly-evolving severe MS who were eligible for natalizumab under the current NHS England's guidelines. One patient was a young man naive to first-line treatment with a poor prognostic profile (high lesion load on MRI, including posterior fossa lesions, and early disability in motor and cerebellar systems). The second patient is a young woman failing fingolinod (two disabling relapses in the last 6 months) having previously failed interferon-beta. Up until now the discussion for both of these patients would have been simple and I would have offered them natalizumab. I have a well-oiled summary of the risks and benefits of natalizumab and how we manage and de-risk the PML problem if they happen to be JCV-seropositive. But things have changed, we now have alemtuzumab as a therapeutic option for these patients. When I started discussing alemtuzumab next to natalizumab with these two patients things got very complicated."
"How do you compare a maintenance and an induction strategy with each other? When I mentioned the rates of long-term remission on alemtuzumab, and the potential an induction therapy offers regarding a cure, things got messy. I now realise that I can't mention the C-word without defining it. When I tried to define the C-word and discussed the potential of a cure, both patients were lost. Despite this it was clear that a potential cure is the alemtuzumab trump card. The promise of long-term remission, and a potential cure, is what outweighs the risks of being treated with alemtuzumab."
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