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Switching patients at high risk of PML from natalizumab to another disease-modifying therapy
  1. Gavin Giovannoni1,2,
  2. Monica Marta1,2,
  3. Angharad Davis1,2,
  4. Benjamin Turner1,2,
  5. Sharmilee Gnanapavan1,2,
  6. Klaus Schmierer1,2
  1. 1Department of Neurosciences, Blizard Institute, Barts and The London School of Medicine and Dentistry, London, UK
  2. 2Department of Neurology, Royal London Hospital, Barts Health NHS Trust, London, UK
  1. Correspondence to Professor Gavin Giovannoni, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University London, 4 Newark Street, London E1 2AT, UK; g.giovannoni{at}


There are several options for switching people with multiple sclerosis (MS) who are at high risk of developing progressive multifocal leukoencephalopathy (PML) from natalizumab to alemtuzumab. However, some of these have risks that need to be managed, for example, the risks of carrying over asymptomatic PML from natalizumab on to the new therapy, and the risk of rebound disease activity associated with a prolonged washout after starting natalizumab. We propose a pragmatic bridging strategy, using another disease-modifying therapy (DMT), to reduce the risk of switching from natalizumab to alemtuzumab. We also discuss the caveats and subtleties associated with sequencing DMTs in MS and the complex decision making involved.

  • Alemtuzumab
  • Natalizumab
  • PML
  • progressive multifocal leukoencephalopathy

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