Fingolimod

How it works

It is a sphingosine 1-phosphate receptor modulator that traps lymphocytes within lymph nodes, reducing the number of circulating lymphocytes available to enter the central nervous system.

Prescribing in practice

• First-dose bradycardia and atrioventricular block can occur, so first-dose cardiac monitoring is required and it is contraindicated in patients with significant cardiac disease.
• It increases the risk of serious infections and macular oedema, and varicella immunity should be checked with vaccination of seronegative patients before starting.
• It is contraindicated in pregnancy and effective contraception is required; discontinuation may rarely be followed by severe rebound disease activity.

Monitoring

Monitor full blood count, liver function, blood pressure, ophthalmic review for macular oedema, and perform first-dose cardiac observation, with varicella serology before initiation.

Counselling the patient

• Use reliable contraception, as this medicine can harm an unborn baby.
• Report fever, signs of infection or any visual disturbance promptly.
• Do not stop the medicine without discussing it with your neurologist, as relapses can return strongly.

Evidence & guidelines

Fingolimod reduced relapse rates compared with placebo and interferon in pivotal trials, and is used within NICE-defined criteria for highly active disease.