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Fingolimod – First-Dose Bradycardia Mechanism — SCE Neurology MCQ

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ModerateMultiple Sclerosis & CNS InflammationFingolimod – First-Dose Bradycardia MechanismSCE Neurology

A 55-year-old woman with known MS on fingolimod develops a first dose bradycardia. Her heart rate drops to 42 bpm during the 6-hour first-dose observation period. She is asymptomatic. What is the mechanism and management?

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Correct answer: A — Fingolimod causes transient bradycardia by acting on S1P1 receptors on atrial myocytes — asymptomatic first-dose bradycardia is expected in some patients and usually resolves spontaneously; extend the observation period and monitor until HR normalises

Fingolimod (a S1P receptor modulator) causes transient first-dose bradycardia and AV conduction delay due to its action on S1P1 receptors on cardiac myocytes (which modulate sinoatrial node function). This is a pharmacological effect, not an adverse reaction. NICE TA254 requires: (1) ECG before the first dose, (2) continuous heart rate and BP monitoring for ≥6 hours after the first dose, (3) extended monitoring if HR is lowest at hour 6 or <45 bpm or new AV block. If asymptomatic, observe and await spontaneous resolution. If symptomatic (chest pain, dyspnoea, syncope), treat with atropine and consider prolonged monitoring. A: Not allergic — pharmacological effect. C: Only if symptomatic. D: Not indicated. E: Directly caused by fingolimod.

Reference: NICE TA254 Fingolimod; Fingolimod SmPC; ABN MS Guidelines