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Conclusion
Multiple sclerosis is a heterogeneous disease with widely varying clinical manifestations and rates of progression. Natalizumab is an effective treatment to reduce multiple sclerosis relapses and decrease progression of disability. Prompt recognition and treatment of natalizumab-associated PML is important in preventing significant mortality and neurologic disability. A combination approach for diagnosing PML can be used that includes: clinical examination, MRI, and CSF JCV PCR.
Clinicians can utilize known risk factors for PML such as antibody status, length of natalizumab therapy, and prior immunosuppression to individualize patient care. Factors such as multiple sclerosis severity, rate of progression, patient preference, and therapy efficacy all must be factors when determining a treatment plan. Discussion among the patient, family, and clinician is important in determining the best course of therapy. For example, a patient on an effective first-line agent like interferon without progression would likely not warrant change to natalizumab. If disease progression and relapses occur on a first-line therapy, then changing to a second-line therapy like natalizumab may be warranted. The efficacy of natalizumab must be carefully weighed with the potential complication of PML.
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