Should I start Tysabri with JCV index of 2.21?

​Here is My Question:
Should I start Tysabri with JCV index of 2.21?

I am 30 yr old caucasian male, I was diagnosed sept 2016 with MS. I had JC index of 1.82 and declined to start Tysabri or any meds. Jan 2017 2 new T2 lesions on brain, 4 total T2, now a JC index of 2.21.

I am willing to start meds now, Tysabri for 12 months is what's being recommended by my nuero. Her argument against other meds are that they are not as effective and we need to stop new lesions.

Are there any other meds you could recommend that are effective but not as risky for PML??

Thank you!!

Answer:
I agree with the decision to treat your MS (there are multiple blog posts on this site that detail the benefits of treating and treating early for MS).

The choice of disease modifying therapy (DMT) can be a little complicated and comes down to how aggressive your MS really is (which you allude to in your question).  Other considerations depend on certain prognostic factors of your MS.  Male gender tends to have a more difficult disease course than women (on average).  Other considerations include a history of motor attacks (ie, weakness or clumsiness), frequent and recurrent attacks early on, presence of spinal cord or brainstem lesions, etc.  These are poorer prognostic factors which can argue for use of a highly effective therapy such as tysabri.  However, your risk for PML is higher than an individual with negative JC virus antibody titers.

Because I do not know you and haven't had the opportunity to examine your or review your imaging, I cannot realistically suggest a different course for your MS than what has been suggested by your neurologist.  If you are a candidate for a highly effective therapy, the off label use of rituximab 500mg would be an option for you.  This is very similar to the soon to be approved medication called ocrelizumab.  The estimated risk of PML is ~1:25,000 (based on treatment of rheumatoid arthritis patients on rituximab).  Your risk with Tysabri for PML is much higher than this.  I'd suggest reviewing options with your neurologist as there are 15+ FDA approved therapies now.

A. Scott Nielsen MD MMSc
Neurologist and MS Specialist at Kaiser Permanente
KP Fontana and Riverside Medical Centers