- How are expectations have shifted since we have licensed high-efficacy DMTs; we are not only expecting MSers to flatline (no increase in disability), but expect a significant proportion of MSers to have a sustained improvement in disability.
- Your baseline disability level predicts worsening. In other words if you have lost time, or brain, you are more likely to progress when coming off natalizumab. This makes sense biologically. What protects from developing progressive MS is reserve capacity; if your nervous system has not lost too many neurons and axons the surviving cells have the ability to compensate.
- Natalizumab is not an induction therapy; it is a maintenance therapy. In other words when you stop natalizumab MS comes back with a vengeance. Some observations suggest the rebound with natalizumab is much worse than you would expect from natural history studies. Natalizumab is an interesting observation.
Should we accept these results? No. I think there are now several strategies that we can adopt to prevent rebound and worsening post natalizumab. This study was done in the era when we did wash-outs and allowed rebound to occur post-natalizumab. I think most of us will not simply stop natalizumab without transitioning MSers onto other high-efficacy therapies. I have posted on this before."