Cardiac ultrasound and electrocardiography (ECG) should be performed accordingly, as late-onset cardiotoxicity is described [143]. Thorough monitoring and vigilance is especially relevant for TRAL, as secondary leukaemia is potentially curable if diagnosed early and treated adequately [144], but is associated with potentially fatal complications [145-147] if overlooked. Discussions about SADR incidence, especially TRAL and cardiotoxicity [36, 37, 137, 138, 142, 148-152],

have led to reassessment of the proper risk–benefit profile of MX. TRAL incidences H 89 vary from 0·07% [149] to 2·82% [138] and are subject to methodological difficulties (e.g. reporting bias especially for meta-analyses [36, 149] and largely lacking prospective data). Interestingly, there seem to be regional differences of TRAL incidence with similar German and French estimates [37, 142], but higher Italian and Spanish rates [137, 138]. Estimates of the incidence

of cardiotoxicity are complicated by different definitions of an adverse cardiac event [reporting of clinical events versus paraclinical abnormalities in ECG, transthoracal echocardiography (TTE) [153] and radionuclide ventriculography [143, 150, 154]]. Subclinical decrease of left ventricular ejection fraction (LVEF) in TTE may be a dose-dependent effect [153]; however, this has not been confirmed by a study with 14% incidence of LVEF decrease in radionuclide ventriculography without dose-dependency [150]. Data on recovery and prognosis of cardiac events are inconsistent [143, 150, 151, 153, 155, 156]. Clinical and paraclinical parameters AZD2014 for the prediction of MX response have been

established [157]. SADR development might be associated with pronounced or lasting leucopenia before TRAL onset [37] and increased brain natriuretic peptide (BNP) in subclinical myocardial injury [158]. In addition to treatment-related factors, genetic factors (genes involved in detoxification: CYP3A4; cellular drug efflux: ABCB1, ABCG2; DNA repair: BRCA2, XRCC5) may influence susceptibility for SADRs [139, 155, 159]. Pharmacogenetic CYTH4 approaches may help early identification of patients at higher risk for side effects or even individualized treatment schemes. The growing spectrum of treatment options for neuroimmunological diseases confronts us with complex risk–benefit considerations and treatment decisions. Whereas established first-line DMDs such as interferon-beta formulations and glatirameracetate are generally safe, newly emerging DMDs with higher efficacy often carry a higher potential of adverse effects with thorough therapy monitoring requirements. Long monitoring intervals, even after cessation of therapy, also pose new challenges for adherence to respective protocols. If not in the clinical trial setting (FTY, alemtuzumab), post-marketing experience (NAT) has revealed relevant or even completely new safety issues not anticipated previously.