Table 2.
Risk mitigation strategies available for commonly used disease-modifying therapies
| Key modifiable infectious risks | Screening and patient selection | Vaccination | Prophylaxis | On therapy monitoring | DMT dose and frequency adjustment | Behavioral modifications | Disease-modifying therapy at risk |
|---|---|---|---|---|---|---|---|
| Hepatitis B | Hep B Core Ab, Hep B S Ag; avoid use in very disabled patients | Hepatitis B vaccination | Concomitant antiviral therapy in those infected with hepatitis B | None, unless there is suspicion for exposure | None | Minimizing risk factors for hepatitis B exposure | Anti-CD20*, cladribine. Reasonable to check with S1Ps**, natalizumab, and alemtuzumab. |
| Hepatitis C | Hep C Ab | None | No established guidelines—recommend expert consultation | None | None | Minimizing risk factors for hepatitis C exposure | Cladribine. Reasonable to check with alemtuzumab |
| Herpes Viruses | Varicella immunity | Varicella, shingles vaccines are available | None for S1Ps. Acyclovir with use of alemtuzumab and cladribine | None | May decrease dose frequency to lessen lymphopenia | None | S1P **, cladribine, alemtuzumab |
| JC Virus | JC virus antibody titer | None | None | JCV titer monitoring, MRI brain every 6 months | May extend dosing interval, especially in JC seropositive patients | None | Natalizumab |
| Tuberculosis | Quantiferon Gold | Not required | anti-Tb therapy | None | None | Minimizing exposures to tuberculosis (e.g., travel to endemic regions) | Alemtuzumab, teriflunomide, cladribine |
| HIV | HIV serologic testing | None available | Anti-retroviral medications, recommend expert consultation. consider use of pre-exposure prophylaxis in those at high risk of HIV infection | None | None | Minimize behavioral risks of HIV exposure | Cladribine, alemtuzumab |
| Listeria | None | None | Listeria diet, consider cotrimoxazole | None | None | Listeria diet | Alemtuzumab |
| HPV | Ensure age-appropriate cervical cancer screening. | HPV vaccination available | None | Age-appropriate cervical cancer screening | None | Use of condoms, minimizing number of sexual partners | Alemtuzumab |
* includes rituximab, ocrelizumab, and ofatumumab. **includes fingolimod, siponimod, and ozanimod. DMT disease-modifying therapy, HIV human immunodeficiency virus, HPV human papilloma virus