Switching-2-DMF from ......
Please note that DMF is not recommended as a 2nd-line therapy on the NHS. The following advice is for MSers moving onto DMF for tolerance or safety issues on other DMTs.
Interferon and glatiramer acetate: In general DMF can be started immediately after discontinuation of interferon or glatiramer acetate. It is important that all the recommended baseline screening tests and reviews are done before starting DMF.
Natalizumab: Due to risk of rebound activity on stopping natalizumab a prolonged wash-out period is not recommended before starting DMF. Most often the reason for switching from natalizumab to DMF, or other DMTs, is to reduce the risk of carry-over PML from natalizumab. In our centre we do an MRI and a LP for CSF analysis to exclude JCV-DNA on PCR. Provided these two tests are clear we would typically initiate DMF as soon as possible after the last natalizumab infusion. We, however, tend not to use DMF post-natalizumab as the data demonstrating that DMF can prevent rebound activity is not as strong as for fingolimod and anti-CD20 therapies. It is important that all the recommended baseline screening tests and reviews are done before starting DMF.
Fingolimod: Because fingolimod has quite a long half-life some neurologists recommend a short washout period, i.e. 4-6 weeks, which may be appropriate depending on the reason for switching. I would recommend waiting for the total peripheral lymphocyte counts to go above 800/mm3 to exclude the uncommon occurrence of a persistent lymphopaenia post-fingolimod. It is important that all the recommended baseline screening tests and necessary reviews are done before starting DMF. If the switch is for abnormal LFTs on fingolimod you would ideally want the liver enzymes to normalise or at least drop to below 3x the upper limit of normal before starting DMF.
Teriflunomide: It is important that all the recommended baseline screening tests and necessary reviews are done before starting DMF. If the main reason for switching from DMF is lymphopaenia or abnormal LFTs I would recommend waiting for the lymphocyte counts to go above 800/mm3 and for the liver enzymes to normalise or at least drop to below 3x the upper limit of normal before starting DMF
Alemtuzumab: It is important that all the recommended baseline screening tests and vaccination reviews are done before starting DMF. I would recommend waiting for the total peripheral lymphocyte counts to go above 800/mm3.
Ocrelizumab (anti-CD20): It is important that all the recommended baseline screening tests and vaccination reviews are done before starting DMF.
Cladribine: It is important that all the recommended baseline screening tests and vaccination reviews are done before starting DMF. I would recommend waiting for the total peripheral lymphocyte counts to go above 800/mm3.
Mitoxantrone: I would recommend waiting for the neutrophil and lymphocyte counts to go above 1,000/mm3 and 800/mm3 respectively. It is important that all the recommended baseline screening tests and vaccination reviews are done before starting DMF.
HSCT: I would recommend waiting for the neutrophil and lymphocyte counts to go above 1,000/mm3 and 800/mm3 respectively. It is important that all the recommended baseline screening tests are done before starting DMF.