Switching-2-Teriflunomide from ......
Interferon and glatiramer acetate: In general teriflunomide 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 teriflunomide.
Natalizumab: Due to risk of rebound activity on stopping natalizumab a prolonged wash-out period is not recommended before starting teriflunomide. Most often the reason for switching from natalizumab to teriflunomide, or another DMT, 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 teriflunomide as soon as possible after the last natalizumab infusion. We, however, tend not to use teriflunomide post-natalizumab as the data demonstrating that teriflunomide 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 vaccination reviews are done before starting teriflunomide.
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 vaccination reviews are done before starting teriflunomide. 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 teriflunomide.
Dimethyl fumarate: It is important that all the recommended baseline screening tests and vaccination reviews are done before starting teriflunomide. 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 teriflunomide. 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 teriflunomide.
Cladribine: It is important that all the recommended baseline screening tests and vaccination reviews are done before starting teriflunomide. 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 teriflunomide.
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 teriflunomide.