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Fingolimod to Ocrelizumab – Rebound Risk — SCE Neurology MCQ

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HardMultiple Sclerosis & CNS InflammationFingolimod to Ocrelizumab – Rebound RiskSCE Neurology

A woman with relapsing multiple sclerosis has a disabling relapse while taking fingolimod. MRI shows four new enhancing lesions and the multidisciplinary team recommends switching to ocrelizumab. Her lymphocyte count is 0.35 × 10⁹/L, with no active infection. Which switching plan best reflects current UK specialist guidance?

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Correct answer: C — Start ocrelizumab within 4–6 weeks of stopping fingolimod, modified by infection and haematological review

Stopping an S1P modulator can be followed by rebound inflammatory activity, so an arbitrary prolonged washout is hazardous in a patient with active disease. ABN guidance advises careful switching and generally limiting the treatment gap to a maximum of about 4–6 weeks. The exact timing still requires an individual infection and haematological assessment; prolonged lymphopenia may justify delay and a bridging strategy rather than simply leaving the patient untreated. Continuing fingolimod through the anti-CD20 infusion creates unnecessary overlap, whereas waiting for a normal lymphocyte count regardless of disease activity may expose the patient to avoidable rebound.

Reference: Association of British Neurologists 2024 guidance on multiple-sclerosis disease-modifying treatments: https://pn.bmj.com/content/25/1/18