Ocrevus for MS
by Dr. Landis September 2018
Multiple sclerosis (MS) is a demyelinating disease in which the insulating covers of nerve cells in the brain and spinal cord are damaged. This damage disrupts the ability of parts of the nervous system to communicate. A person with MS can have multiple neurological signs and symptoms depending on the locations of the lesions within the nervous system. These may include loss of of changes in sensation, muscle spasms and weakness, pronounced reflexes, difficulties with coordination and balance, problems with speech or swallowing, and visual problems. Difficulties thinking and emotional problems such as depression or mood changes are also common. Symptoms may worsen with exposure to higher than usual temperatures.
When MS first starts 45% will have motor or sensory problems, 20% will have optic neuritis, and 10% will have symptoms related to brainstem dysfunction, while the remaining 25% have a combination of these. 85% of patients will have disease flares followed by improvement while 15% gradual worsening over time without periods of recovery. A combination of these two patterns may also occur. Relapses are usually not predictable, occurring without warning. Exacerbation rarely occurs more frequently than twice per year. Some relapses, however, are preceded by common triggers like stress, viral infection, and warm weather.
The McDonald Criteria are used for diagnosis of MS. These are based on the clinical presentation, MRI results of the brain and spinal cord, and CSF findings. Once the diagnosis is made treatment initiated. For acute flares IV steroids are initiated followed by a prednisone taper.
Ocrevus has been approved for Relapsing-Remitting MS and Primary Progressing MS. It was initially approved in March 2017. Ocrevus is an IV infusion that takes about 3 hours. Initial infusions are the starting infusion, an infusion 2 weeks later and then every 6 months. During the Relapsing-Remitting studies, the patients getting Ocrevus were 83% relapse free annually vs 71% for placebo. There were also improvements in disability decline and improvement in number of enhancing MRI lesions. For the PPMS studies the proportion of patients with disability decline was also reduced from 39.3% to 32.9%. The MRI lesions were also reduced in size with the Ocrevus. Side effects to the Ocrevus include infections, malignancy (breast cancer), PML, hepatic failure, infusion reactions, myelosuppression, depression, and shingles. The most common side effects were infusion reactions and upper respiratory tract infections. It is recommended that patients getting Ocrevus get their pneumonia vaccines and shingles vaccines prior to starting Ocrevus. There should be no live virus vaccines 6 weeks prior to getting Ocrevus or after getting Ocrevus.