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Natalizumab – New JCV Low Index — SCE Neurology MCQ

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HardMultiple Sclerosis & CNS InflammationNatalizumab – New JCV Low IndexSCE Neurology

A 40-year-old woman with MS has been on natalizumab for 5 years with excellent disease control. Her JCV antibody index has been negative throughout. She now seroconverts to JCV positive with an index of 0.4. What management is appropriate?

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Correct answer: E — Continue natalizumab after updated PML-risk discussion with enhanced JCV and MRI surveillance

The best answer is “Continue natalizumab after updated PML-risk discussion with enhanced JCV and MRI surveillance”. MS care requires phenotype confirmation, relapse assessment, symptom management and specialist disease-modifying therapy; ocrelizumab is an NHS option for eligible early inflammatory primary progressive disease. The alternatives “Stop natalizumab and begin an immediate unbridged treatment washout, within the relevant UK pathway”, “Continue using the historic JCV-negative monitoring schedule, after excluding important mimics”, “Use prophylactic plasma exchange while natalizumab continues, after specialist assessment”, “Add antiviral prophylaxis and replace surveillance MRI with CT, when the phenotype supports it” are clinically adjacent possibilities, but they do not match the defining chronology, localisation, physiology, investigation result or UK management sequence in this stem.

Reference: NICE NG220 multiple sclerosis recommendations: https://www.nice.org.uk/guidance/ng220/chapter/Recommendations