Disease-modifying therapy (DMT) is an important part of fighting back against multiple sclerosis. With varying degrees of effectiveness, DMTs have been shown to slow down and reduce disease activity in people diagnosed with MS. The majority of the available DMTs are approved for relapsing forms of MS, while some are also approved for clinically isolated syndrome.
The MS community becomes excited as each new DMT for MS is approved. When I was diagnosed in 2005, we had four options. Now we have 15 DMTs from which to choose — and choices mean additional decisions to make.
Hottest new MS treatment
The latest disease-modifying therapy, called Ocrevus (ocrelizumab), was approved in March 2017 for relapsing and primary progressive forms of MS. Ocrelizumab works differently than other DMTs for MS in that it selectively depletes B-cells. B-cells are a type of white blood cell that develops antibodies in response to specific antigens, a process which helps the immune system to fight invaders. However, abnormal B-cells may mistakenly produce autoantibodies that contribute to autoimmune diseases such as multiple sclerosis, rheumatoid arthritis (RA), lupus, or scleroderma.
Ocrevus is very closely related to the drug Rituxan (rituximab) which is used to treat certain autoimmune diseases, such as rheumatoid arthritis and myasthenia gravis, as well as cancers like non-Hodgkin’s lymphoma and chronic lymphocytic leukemia. Both therapies work in the same way to alter the immune system. Rituxan is also commonly used off-label to treat MS, and I have personally used it since 2009.
Ocrelizumab specifically targets and destroys CD20+ B-cells in a way that serves to lower the immune system. Studies of ocrelizumab demonstrated that it could reduce relapses by 46 to 47 percent in people with relapsing MS compared to treatment with subcutaneous interferon beta-1a. People with primary progressive MS (PPMS) who received ocrelizumab were 24 percent less likely to experience disability progression than those who received placebo in a clinical study.
Ocrelizumab is an intravenous infusion therapy which is delivered twice a year in an infusion center or doctor’s office. The first dose is divided in half and given as two separate infusions, two weeks apart. Pre-medications, such as corticosteroids and an antihistamine, are given in advance to reduce the risk of infusion-related reactions that may include itchy skin, hives, coughing or wheezing, throat irritation, flushing, shortness of breath, dizziness, or fatigue. Since ocrelizumab weakens the immune system, patients are at greater risk of developing infections. Additional risks include reactivation of the hepatitis B virus and progressive multifocal leukoencephalopathy.
The decision to switch treatment or not
The MS community has received ocrelizumab with excitement and open arms. I personally know several people who have either switched to Ocrevus already or are considering it. Several factors come into play when making treatment decisions, including comparing efficacy, side effects, impact on lifestyle, and insurance coverage. Twelve years ago, MS patients would choose a treatment and stick with it, even if their disease remained active. Now, patients have options and may switch DMTs when their disease fails to reach NEDA (no evidence of disease activity).
Like many people living with multiple sclerosis, I am determined to do all I can to slow down the disease. Although I might not always exercise as much as I should or I might indulge in rich food on occasion, I still try to focus on healthy lifestyle habits and reduce stress. An important part of fighting this disease for me is to consistently use a disease-modifying therapy.
Shortly after my own diagnosis, I chose a treatment (Copaxone) which worked for a few years. But when my disease began to progress, I looked for other options with the intent to switch treatments. Research indicated that a drug used for RA, called Rituxan, might be effective against MS. After consultation with my doctors, we made the switch and I’ve been successfully using this monoclonal antibody therapy ever since. My disease has become stable and I’ve achieved NEDA.
“If it ain’t broke...”
As I mentioned, there are several people living with MS who use Rituxan off-label. Some of these patients report that their neurologists and/or insurance companies want them to switch to Ocrevus which is officially approved for MS. Some of these patients, like myself, have decided to stick with Rituxan. My personal success with Rituxan has fueled my own excitement for the MS community that now has access to Ocrevus.
Comparing the two agents — which is difficult because there are no published studies that directly compare each treatment — is limited by information that is available. Ocrevus is expected to be associated with fewer infusion-related reactions because it is a humanized antibody. Studies of Ocrevus have revealed an increased risk of breast cancer, while the limited studies of Rituxan in MS did not reveal a similar risk. An ongoing study (NCT02980042) in Colorado is comparing the tolerability and safety of switching from rituximab to ocrelizumab in people with RRMS.
Regardless of which DMT people choose to use, I’m excited that folks with relapsing or primary progressive forms of the disease have access to this new and effective DMT. At this time, I don’t see any strong reason to switch treatment, but if new research shows that Ocrevus is more effective and/or less risky, or is associated with reduced risk of developing neutralizing antibodies, I might reconsider. For right now the saying — if it ain't broke, don’t fix it — sums up my decision.
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