Fingolimod for Multiple Sclerosis

A 37-year-old man with multiple sclerosis was evaluated for consideration of oral immunotherapy. Six years earlier, he had reported acute monocular visual disturbance. The diagnosis of multiple sclerosis was subsequently confirmed by means of examination of cerebrospinal fluid, which revealed an increased IgG index and oligoclonal banding, and by abnormal results on magnetic resonance imaging (MRI). There was no family history of multiple sclerosis. Daily injections of glatiramer acetate were initiated at the time of diagnosis, but two consecutive annual brain MRI scans revealed substantial disease activity. He was then switched to interferon beta therapy, but this treatment was discontinued after the patient had two episodes of acute neurologic worsening. Monthly natalizumab therapy was then considered, but a test for JC virus antibodies was positive. Neurologic examination showed disk pallor and visual acuity of 20/40 in the right eye, partial internuclear ophthalmoplegia, wide-based gait, and posterior column deficits in both legs. The patient was referred to a specialist in multiple sclerosis for consideration of oral fingolimod therapy.