I went to 3 neurologists and they each gave me a different therapy recommendation

Here is My Question:
I was diagnosed with MS in 1991 (57 Yrs.) and have ben very fortunate to have remained stable with little progression. I have been on Tysabri since 2008 and am JCV Virus positive with a titer of 4.8. I have seen three neurologists and all three have given me a different answer to my therapy options. I do not have any enhancing lesions on MRIs. 

#! - stay on Tysabri says don't qualify for Lemtrada or Rituximab based on disease - no new lesions
#2 - start Lemtrada
#3 - start Rituximab

What is your opinion of my length of time on Tysabri? How does Lemtrada compare to Rituximab? Thank you. 

Answer:
Great questions; I assume you are now 57 years old and you were diagnosed 25 years (diagnosed 1991). Although you state that you are stable with little progressive, your level of disability and risk factors for further disease progression is unclear from your question. For instance, we see quite a few patients with very little disability and few risk factors for disease progression even after 25 years of disease. These patients would not want to experience the side effects and potential risks of the some of the treatments mentioned. In fact some may even consider discontinuing treatment.

I can tell you the following:
1. Your risk of PML on Tysabri is about 1 in 100 (high risk group). It is still unclear whether this risk significantly decreases or remains the same in patients like yourself on prolonged treatment
2. You can probably diminish the risk of PML by increasing the interval between infusions to 8 weeks. You would still require frequent monitoring.
3.  Rituximab is associated with fewer risks than Lemtrada. If you are a candidate for treatment based on level of disability and risk factors for disease progression (and based on your comments I am not sure you are a candidate), rituximab would be safer. 

Revere (Rip) Kinkel MD
Director of the Multiple Sclerosis Program
Professor of Clinical Neurosciences
University of California San Diego