I am 43 and have just been diagnosed with MS

Here is My Question:
I am a 43 year-old female and was recently diagnosed with MS just last month. Late December 2015, I suffered from an attack of optic neuritis and spent three days in the hospital for IV steroid treatment and other diagnostic tests. Other than the IV steroids and a three week taper of oral prednisone, I have never been on any other DMTs or immunosuppresants. The ON has been my only symptom, as well as some minor facial tingling. My MRIs showed approximately 3-4 active lesions and 3-4 inactive lesions. None on C or T spine. I take medication for hypertension and hypothyroidism.

My MS specialist neurologist is recommending Rutixan as my first form of treatment for MS. I am JC positive, not sure of exact level. I know there have been no reported cases of PML in MS patients treated with Rituxan, and that the risk is about 1 in 25,000. Is Rituxan normally used as a front line treatment for MS? It seems very aggressive to me, but my neuro said that he wants to treat it aggressively, as I am so young and have so little disability at this point. He wants to keep it that way. Do the benefits of this treatment outweigh the risks of PML?

​How long could I safely take Rituxan before having to consider switching to another DMT? I've read that patients can only take Rituxan for 2 years max.? I have ruled out Tysabri, Tecfidera, and Gilenya due to PML risk. How small or large is the PML risk in Gilenya as compared to Rituxan? Is Aubagio more effective than the interferon drugs in regards to delaying disease progression, number of relapses, and number of MRI lesions? Not looking for recommendations, just a little guidance. =) 

Answer:
Being JC Ab positive has only been shown to a significant predictor of risk for PML in patients taking natalizumab (Tysabri) and it has not been shown to be a valid predictor of PML in patients on other MS therapies.

Because there are only a handful of cases of PML in patients taking Gilenya (five patients) or Tecfidera (three patients), there are no recommendations for screening patients with the JC Ab test to guide therapy choices. 

No one knows the actual risk of PML with the oral medications but it appears to be significantly lower when compared to natalizumab.  While Aubagio has not had any reported cases of PML yet, I would not be surprised if a case or two is eventually reported over the next several years.

As you mentioned, the risk of PML with rituximab is also very low.  Rituximab is sometimes used as an option for treating relapsing MS patients but it is not commonly used as the first medication.
You will need to discuss with your neurologist how much “risk” you are willing to take in being aggressive in the treatment of your MS for the future potential benefits (decreased disability, decreased relapses, decreased MRI lesions).  Once you decide how much risk you are willing to take you will be better prepared to choose which medication to start. 

Please type in "PML" or "JC" in the search box in the upper right hand corner of this page and you will find many questions and answers about these topics.

Benjamin J. Osborne, MD
Department of Neurology
MedStar Georgetown University Hospital

PLEASE NOTE:  The information/opinions on this site should be used as an information resource only.  This information does not create any patient-HCP relationship, and should not be used as a substitute for professional diagnosis and treatment.  Please consult your health care provider before making any healthcare decisions or for guidance about a specific medical condition.