Staying With Rituxan Rather Than Switching to Ocrevus

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.

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Why I Am Not Considering Ocrevus?

Fear of Change: A Relapsing MS Moment

There is nothing predictable or constant with multiple sclerosis. People living with the disease may have periods of time where not much seems to be going on. Other times, there may be relentless relapses that leave neurological debris in their wake. The high degree of adaptability required to mentally and physically handle these changes is tremendous.

Stability is a welcome blessing when it comes to living with MS or any other chronic disease. With stability comes some level of predictability. However, it doesn’t prevent the potential rollercoaster that changes, of any sort, may cause.

I’ve enjoyed a sense of stability for years now. In fact, I’ve only had one major relapse since December 2011 that occurred in February 2016. One reason for this streak of “luck” is a treatment that has proven to be effective for me. I’m what you would call a “responder” to the medication rituximab.


Recently I’ve encountered a threat to access of that same medication. Since I’ve been sick so many times during the past year, my doctor has ordered laboratory tests to check for levels of specific immune system components, called immunoglobulins. I don’t have the results yet; but based on concern for a potential immunodeficiency, my doctor has delayed my next round of infusions until we know more.

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MS Moment: The Recurring Fear of Change

Personalized Treatment for MS or Herd Mentality: What Does Your Neurologist Do?

People diagnosed with multiple sclerosis (MS) and their neurologists must make many decisions when it comes to treating the disease. With FDA-approved disease-modifying therapies, it can be challenging to know which one to use, if any.

How do doctors and patients choose? To make an informed decision, neurologists are expected to follow clinical practice guidelines that frequently summarize the available medical evidence. Meanwhile, patients are expected to do their own research and consider lifestyle factors and personal preference, as well as doctor recommendations.

It’s clearly unwise for neurologists to follow outdated clinical guidelines; consider that when the American Academy of Neurology (AAN) published its guidelines in 2002, only four treatment options were available. A less obvious concern is when neurologists ignore current clinical guidelines and instead follow the recommendations of other neurologists they know or experts in the field, a behavior called “herding.”

Herding can be detrimental to patient care, suggests a study published in January 2017 in the journal Patient Preference and Adherence.

What is herding in medicine?

Herding is a phenomenon in which individuals follow the behavior of others rather than making a decision independently. Herding occurs in MS care when one neurologist follows the therapeutic recommendation of a colleague even when this advice is not supported by clinical guidelines.

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Does Your Multiple Sclerosis Specialist Follow the Herd?

When is It Time to Change RA Treatments?

Common considerations for altering treatmentAs near remission or low disease activity are common goals of RA treatment plans, signs of disease activity would indicate that your plan may need adjustment. However, minor flare-up of symptoms, such as sudden and temporary increases in painful, swollen, tender or red joints, may indicate the need for corticosteroids to reduce and control inflammation or an increase in the dosage of your current medication. If you have many flare-ups, consider talking to your doctor about adding or changing to a more effective DMARD or biologic.

The early symptoms of RA are also signs that your disease has become more active or that treatment is no longer working. Symptoms such as pain, fatigue, swollen or tender joints, and morning stiffness that lasts longer than 45 minutes, warrant a discussion with your rheumatologist. The return of symptoms may be subtle and not reach the same intensity you experienced before diagnosis, so you may not think to bring this up to your doctor, but you should.

New symptoms often indicate increased disease activity. Definitely tell your doctor when you’ve noticed that RA symptoms seem to have spread to other parts of your body or are behaving differently than they have in the past. If RA previously only affected your hands and now you notice new problems with your shoulders or knees, or you experience painful breathing or heart arrhythmias, or anything else unusual, call your doctor without delay.

Other signs of disease activity, such as laboratory results that indicate high levels of inflammation (such as increased SED rate or C-reactive protein levels) or x-rays showing additional joint damage, may also indicate that your current treatment plan is no longer effective. Your doctor should periodically measure you for signs of disease activity and document them in your medical record for future reference.

Increased risk of infection is a potential side-effect of a number of RA medications. If you are experiencing more infections or changes in white blood cell counts, your doctor may suggest a change in medication. Complications of infection can quickly become rather serious. In addition, there are some drugs, such as methotrexate, which your doctor may want you to skip while you use antibiotics and until an infection has cleared up.

A number of RA medications can have an impact on liver or kidney functions. If your laboratory results indicate increased liver enzymes or other abnormal results, your doctor may want you to change therapies.

RA is a disease that attacks primarily during child-bearing years for many patients. If you are pregnant or planning to become pregnant, you need to talk to your doctor about what you should do to protect an unborn fetus against birth defects or miscarriage. If you plan to breastfeed, your doctor may suggest an altered treatment plan to keep your RA under control while you are breastfeeding and until you are able to return to your previous therapy.

Effectively talk to your doctor When you visit your doctor, be sure to describe any symptoms you are experiencing or have experienced since your last visit. Make special note of any new symptoms or difficulties. Be sure to mention how RA is effecting your ability to engage in everyday activities, such as bathing or dressing yourself, turning knobs, holding a cup, getting up out of a chair or the car, or walking for a short distance. If RA is keeping you from doing the things you want to do, don’t be afraid to discuss options with your rheumatologist.


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Signs You May Need to Change RA Treatments