Fingolimod

How it works

It is phosphorylated in vivo and sequesters lymphocytes within lymph nodes by down-regulating S1P receptors, reducing infiltration of autoreactive T cells into the central nervous system.

Prescribing in practice

• First-dose bradycardia and atrioventricular block can occur, so initiation requires baseline ECG and a period of monitored cardiac observation after the first dose.
• Screen for varicella-zoster immunity, baseline liver function and a recent dermatological and macular assessment before starting.
• Contraindicated in significant cardiac disease, recent cardiovascular events and during pregnancy because of teratogenicity.

Monitoring

Monitor full blood count, liver function, blood pressure, ophthalmic review for macular oedema and remain alert for infection throughout treatment.

Counselling the patient

• Report any breathlessness, dizziness or palpitations, particularly in the first hours after the initial dose.
• Use effective contraception during and for a defined period after stopping, and tell your team promptly if pregnancy is possible.
• Seek urgent advice for fever, persistent infection or visual disturbance.

Evidence & guidelines

NICE recommends fingolimod within its marketing authorisation for highly active relapsing-remitting multiple sclerosis.