A 32-year-old woman with relapsing-remitting MS (RRMS) has had 2 relapses in 12 months and 2 new T2 lesions on MRI despite interferon-beta therapy for 18 months. She is otherwise healthy, planning pregnancy in 2 years. Which disease-modifying therapy best balances high efficacy and safety during future pregnancy planning?
- A Natalizumab
- B Alemtuzumab
- C Cladribine ✓
- D Ocrelizumab
Explanation
Cladribine (an oral immune reconstitution therapy) is given as 2 short annual treatment courses over 2 years, then provides sustained remission. After the 2-year treatment period, conception can safely proceed (recommended 6-month washout after last dose), making it favorable for women planning pregnancy. Alemtuzumab also provides immune reconstitution but has significant infusion reactions and secondary autoimmunity risk. Natalizumab requires continuous dosing and has PML risk (JC virus antibody positive). Ocrelizumab (anti-CD20) requires ongoing dosing and post-dose washout for pregnancy. ECTRIMS/EAN 2024 guidelines discuss cladribine as compatible with pregnancy planning.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.