Improving risk-stratification of natalizumab-associated PML

Based on publicly available data, we reevaluated current algorithms for stratifying the risk of progressive multifocal leukoencephalopathy (PML) in natalizumab-treated patients with multiple sclerosis, and found that there are a number of issues. First and foremost, our analysis highlights the necessity of separate PML incidence assessments for the U.S. versus Europe, and indicates that the risk in John Cunningham virus (JCV) antibody-negative patients may be higher than previously communicated. Additionally, we advocate introducing a low-risk JCV index threshold of 0.45 for individuals with prior exposure to an immunosuppressant, and setting the low-risk threshold at 0.6 instead of 0.9 for those without such pretherapies. On the other hand, the risk of PML on natalizumab, in general, appears to not only plateau but to actually decrease after about 5 years of continuous dosing.

Automated summary

The study reevaluated algorithms for stratifying PML risk in natalizumab-treated multiple sclerosis patients and identified issues, including the separate assessment of PML incidence in the U.S. and Europe and the potential higher risk in JCV antibody-negative patients. The study also suggested introducing a low-risk JCV index threshold for individuals with prior immunosuppressant exposure and adjusting the low-risk threshold based on pretherapy history. Additionally, the study observed a plateau and decrease in PML risk after approximately 5 years of natalizumab treatment.