Immunosuppression with chronic active Hepatitis

Here is My Question:
I was diagnosed with MS four years ago. The first medication I took was dimethyl fumarate and after two years I still had disease progression. So I did one round of almetuzumab/Lemtrada afterwards.
then I suddenly had ITP so I didn't do round 2. I took IVIG for ITP 3 times and then took rituximab because my platelets would go as low as 0. While on rituximab turned out that I had hep B virus antibodies from an old injury so I started taking antivirals (Vemlidy). What do you think is the most suitable medication would be? Would I be able to take mavenclad?

Answer:
You pose a very important question for which we currently have incomplete answers. Immunosuppression in patients with chronic active Hepatitis based on serology and the presence or absence of viral DNA replication is associated with Hepatitis B viral reactivation. This can be quite serious. While anti-CD20 therapies (rituximab, Ocrelizumab and Ofatumumab) are most strongly associated with Hep B viral reactivation, this can also theoretically happen in people on other forms of immunosuppression including alemtuzumab, or even Mavenclad. This is particularly true of an individual, such as yourself, who has received multiple therapies associated with this risk. 

There are studies currently planned or underway to determine if co-treatment with Vemlidy reduces this risk but no definite answers yet.

Given this information, it could be appropriate to remain on both Rituximab and Vemlidy, if the rituximab is effective at treating your MS and your risk of Hep B viral reactivation is relatively low (defined as only Hep B core antibody positive). You should definitely see a hepatitis specialist (ID doctor or hepatologist) to determine your overall risk of Hep B viral reactivation. If there is no evidence of DNA replication (Hep B DNA negative and Hep B Surface Ag negative), your risk is lower. However, they will need to monitor your labs for viral reactivation, if you continue treatment with Rituximab and vemlidy.

Hope this helps.

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Revere P (Rip) Kinkel, MDProfessor of Clinical Neurosciences
Director of the Multiple Sclerosis Program
Clinical Neurosciences Director
University of California San Diego
#Vemlidy #hepatitis #multiplesclerosis