Switching-2-Fingolimod from .....
Interferon and glatiramer acetate: In general fingolimod can be started immediately after discontinuation of interferon or glatiramer acetate. It is important that all the recommended baseline screening tests and vaccination reviews are done before starting fingolimod.
Natalizumab: Due to risk of rebound activity on stopping natalizumab a prolonged wash-out period is not recommended before starting fingolimod. Most often the reason for switching from natalizumab to fingolimod 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 typically initiative fingolimod within 4 weeks of the last natalizumab infusion. A washout of 8 weeks are longer is associated with rebound disease activity. It is important that all the recommended baseline screening tests and vaccination reviews are done before starting fingolimod.
Teriflunomide: Because teriflunomide has such a long half-life some neurologists would recommend an accelerated washout using cholestyramine or activated charcoal. Rheumatologists rarely do this when switching patients with rheumatoid arthritis from leflunomide (teriflunomide prodrug) to other DMTs, so I am not sure this accelerated washout is necessary. It is important that all the recommended baseline screening tests and vaccination reviews are done before starting fingolimod. If the main reason for switching from teriflunomide is due to leukopaenia or lymphopaenia I would recommend waiting for the neutrophil and lymphocyte counts to go above 1,000/mm3 and 800/mm3 respectively. Similarly, if the switch is for abnormal LFTs on teriflunomide you would ideally want the liver enzymes to normalise or at least drop to below 3x the upper limit of normal.
Dimethyl fumarate: It is important that all the recommended baseline screening tests and vaccination reviews are done before starting fingolimod. If the main reason for switching from DMF is lymphopaenia I would recommend waiting for the lymphocyte counts to go above 800/mm3.
Alemtuzumab: It is important that all the recommended baseline screening tests and vaccination reviews are done before starting fingolimod. 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 fingolimod.
Cladribine: It is important that all the recommended baseline screening tests and vaccination reviews are done before starting fingolimod. 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 fingolimod.
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 fingolimod.