TeachNeuro: fingolimod rebound

Question 1We know that some patients rebound when they discontinue fingolimod. When patients have clinical or radiological evidence of disease activity, and a clinical decision is made to escalate treatment, we wait until the patients have recovered from the lymphopenia. The patients don’t seem to relapse during this period of bridging? Is this correct?Question 2If the patient develops shingles or cryptococcus whilst on fingolimod, one would stop the fingolimod. However, this would put the patient at risk of relapse, is there a recommendation for bridging treatment? With shingles, when would you restart treatment or would you switch to a different DMT? With Cryptococcus, what would be the recommended treatment the patient switches to?Question 3Is it common to see a patient who has been on Fingolimoid relapse when the medication is stopped during pregnancy? Would you advise giving glatiramer acetate if there is a risk of relapse during pregnancy?Novi et al. Dramatic rebounds of MS during pregnancy following fingolimod withdrawal. Neurol Neuroimmunol Neuroinflamm. 2017 Jul 27;4(5):e377.Canibaño et al. Severe rebound disease activity after fingolimod withdrawal in a pregnant woman with multiple sclerosis managed with rituximab: A case study. Case Rep Womens Health. 2019 Nov 20;25:e00162. Please let me know if you these kinds of episodes are appropriate for MS-Selfie. However, I firmly believe that there should be no boundaries to knowledge, i.e. what trainee MSologists learn is what pwMS have the right to hear about. SubscriptionsAll newsletters, such as this one, are free. If you subscribe you will get access to the MS-Selfie Case Studies. The MS-Selfie case study from the 6th of November is about a patient with cervical intraepithelial neoplasia (CIN) who is ocrelizumab. Please note, subscriptions are being used to employ someone to curate the contents of this and other Newsletters onto an MS-Selfie microsite that I hope will become a living self-help guide for pwMS. If you have MS and can’t afford the subscription please drop me an email and I will arrange a complimentary subscription.MS-SelfieConflicts of InterestTwitterLinkedInMediumGeneral Disclaimer: Please note that the opinions expressed here are those of Professor Giovannoni and do not necessarily reflect the positions of Barts and The London School of Medicine and Dentistry nor Barts Health NHS Trust. The advice is intended as general advice and should not be interpreted as being personal clinical advice. If you have problems please tell your own healthcare professional who will be able to help you. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit gavingiovannoni.substack.com/subscribe