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In vitro studies are powerful for mechanistic precision, but they are simplified systems

The proposed mechanism of action of DMF (activation of the nuclear factor erythroid 2-related factor 2) would generally not foresee any issues with rapid transition to another therapy,Reference Spelman, Mekhael and Burke 134 although DMF has also been shown to have a lymphopenic effect in certain patient populations.Reference Willis, Pearson and Illes 136 Thus, similar to fingolimod, a washout period might be advisable when transitioning from DMF to alemtuzumab.Reference Fox, Kita and Cohan 137 , Reference Miller 138 For both drugs, however, the time period over which lymphocytes return to normal is variable and can take many months, during which time the patient is at risk of relapse.Reference Fox, Kita and Cohan 137 This is a significant challenge in sequencing from DMF

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