What would you recommend for a patient with MS on dimethyl fumarate with recent exacerbations including optic neuritis and new enhancing brain lesions who wishes to go on more intensive therapy such as a B-cell depletion but recently required treatment for shingles?

While live vaccines are still generally discouraged for patients with MS, there is ample evidence that most vaccines are unlikely to trigger new MS lesions.

One option then would be to vaccinate with Shingrix, a recombinant vaccine, before starting B-cell therapy. Generally, I would wait at least 2...