With so many disease-modifying therapies (DMTs) available to treat multiple sclerosis (MS), deciding which one is right for you can be challenging. As of July 2018, there are 15 DMTs approved for MS by the U.S. Food and Drug Administration (FDA). Among these therapies, four are given by intravenous (IV) infusion in a doctor’s office, infusion clinic, or hospital: Ocrevus (ocrelizumab), Lemtrada (alemtuzumab), Tysabri (natalizumab), and Novantrone (mitoxantrone). No matter which infusion therapy you receive, be sure to check out my tips for infusion day at the end of this article.
The four main infusion therapies for MS
Approved in March 2017, Ocrevus (ocrelizumab) became the first FDA-approved therapy for primary progressive MS (PPMS) as well as all forms of relapsing MS (RMS). Ocrevus is a humanized monoclonal antibody that targets and depletes CD20 positive B lymphocytes (or B-cells), which contribute to nerve damage in MS. It is marketed by Genentech and given by infusion every six months with the first dose split into two infusions given two weeks apart. Pre-medications, such as corticosteroids and an antihistamine, are given prior to each infusion to reduce potential infusion reactions.
Ocrevus is very closely related to Rituxan (rituximab), a monoclonal antibody therapy approved for use in rheumatoid arthritis, non-Hodgkin’s lymphoma, and four other conditions. It is not approved for use in MS. However, Rituxan is frequently used off-label to treat MS and other autoimmune diseases, including neuromyelitis optica (NMO) and neuromyelitis optica spectrum disorder (NMOSD).
Since November 2014, Lemtrada (alemtuzumab) is an FDA-approved therapy for the treatment of relapsing forms of MS. Lemtrada is a monoclonal antibody that targets and depletes CD52, a protein found on both T- and B-cells. It is marketed by Sanofi-Genzyme and given by infusion in two rounds. Lemtrada is administered in two annual treatment courses. The first course is administered by IV infusion on five consecutive days, and the second course is administered on three consecutive days, one year later. Lemtrada is generally reserved for patients who have not responded sufficiently to other MS disease-modifying therapies.
Marketed by Biogen, Tysabri (natalizumab) was approved for the treatment of relapsing forms of MS in 2004 and for Crohn’s disease in 2008. Tysabri is a monoclonal antibody that targets the cell adhesion molecule alpha-4 integrin. It is given by IV infusion every 28 days. Tysabri is associated with increased risk of progressive multifocal leukoencephalopathy (PML) in patients who test positive for antibodies to the John Cunningham (JC) virus and who have used Tysabri for more than two years. Any new neurological symptoms suggestive of PML should be reported immediately to your neurologist for evaluation.
Novantrone (mitoxantrone) is an anticancer medication that became the first infusion therapy approved for worsening MS in 2000. Novantrone works by suppressing activity of T-cells and B-cells. It is administered by IV infusion once every three months for a lifetime maximum of 12 doses due to risk of heart damage. After EMD Serono obtained the rights to distribute Novantrone from Amgen, EMD Serono withdrew it from market. The FDA since determined that Novantrone was not withdrawn from sale for reasons of safety or effectiveness. The drug is still available under the generic name mitoxantrone hydrochloride.
Get ready for infusion day
Each infusion therapy takes a different amount of time to be administered — a time that might be adjusted due to infusion reactions. Tysabri infusions are the quickest, at one hour in duration with a one-hour observation period afterward. Each Lemtrada infusion is administered over four hours with a two-hour post-infusion observation period. Full-dose Ocrevus infusions are administered over 3.5 hours, preceded by a one-hour premedication period and followed by a one-hour post-infusion observation period.
No matter how long or short your infusion may be, having a pleasant experience at the infusion clinic takes some preparation. One of the most important things I do in advance of treatment is to make sure I am fully hydrated and that my veins are plumped up. I begin by drinking plenty of water several days before an anticipated infusion. I will also avoid caffeinated beverages the day before treatment to avoid the dehydrating effects of caffeine.
Since some therapies are associated with potential infusion-related reactions during treatment, it is important to feel comfortable during treatment. On the morning of the infusion, I make sure that I shower thoroughly, wash my hair, and wear clean, loose clothing. I do these things to reduce the chance of feeling grimy and itchy because itchiness has been an infusion reaction I’ve experienced previously.
No matter which treatment you are receiving, always alert the medical staff if you begin to feel something even just a bit odd. Itchiness, redness, flushing, swelling, coughing, difficulty breathing — each of these can be potential reactions that require immediate attention. Reactions can be managed under most circumstances, but only if you report them promptly.
Comfort can be important when you are sitting in an infusion chair for up to seven hours. You may want to bring a neck pillow or your favorite travel blanket. If you receive IV Benadryl as a pre-med, you may become very sleepy. I always bring my computer, phone, and a book to keep myself entertained and to be able to complete some work while I’m hanging out. Don’t forget the charging cords! And finally, consider bringing food. Snacks, lunch, and drinks become very important during long infusions. My favorites are carrots and hummus, pears, sandwiches, grapes, and a bottle of flavored sparkling water.