Reasons to switch from Tysabri to Ocrevus

Question:
​I have 2 neurologists. A MS Specialist that is my primary prescriber for all meds located in another state, and a local neurologist affiliated with the local hospital which oversees my care in the event of a relapse and primarily needed because my MS neuro doesn't have privileges at the local hospital where I receive my Tysabri. My MS neuro is over the top excited about starting me on Ocrevus. My local neuro will accommodate the transition but she does not think there should be any rush to move to it just because it is "new".

She is so reluctant that she refuses to initiate the prescription, prior approval, etc and will only order the medication once he has done the "leg" work. His staff has informed me of this and has asked me to go to another facility where her accommodation is not needed. It is more of a drive but only twice a year. Also, the facility that I get the Tysabri is not infusing the Ocrevus today, but should be set up by the fall when I plan to make the transition.

​I have been on Tysabri since 2012 briefly got off to go on Tecfidera with poor results low WBC and returned to Tysabri. MRI no new lesions. JC negative (.18). No relapses. Planned to switch September. My rationale was that I've been playing with fire on Tysabri with the risk of PML, and that if this doesn't work, I can go back. Patients who have switched to Ocrevus from Tysabri, are they experiencing rebound effects? A general improvement in symptoms such as fatigue and cognition? And is it controlling the lesion load and relapse rate as well as the Tysabri? Certainly there are comparable studies since I am sure many Tysabri patients are making that leap.

Answer:
​The main reasons to switch from Natalizumab (brand name Tysabri) to Ocrelizumab (brand name Ocrevus) include the following:

• You are JCV antibody positive, especially those with index values greater than 1.5 and have been on Tysabri for more than 18 months
• You have developed antibodies against tysabri; this is usually but not always recognized by the development of infusion reactions early in therapy (between the 2nd and 6th infusion)
• You continue to get objectively worse on Tysabri
• You have primary progressive MS
• You develop non Hodgkins Lymphoma (NHL) or have a history of NHL
• You insurance company forces you to alter treatment

It doesn’t sound like any of those reasons apply to you so your local doctor may be correct for the wrong reason; that is, being newly approved by the FDA does not make Ocrelizumab a poor choice; the reasons I just mentioned make it a poor choice. Why change what is already working if you have an extremely low risk of developing PML (less than 1 in 10,000 risk) ? After all, you are JCV antibody negative.
​
And yes, there is evidence that Anti-CD20 monoclonal antibodies like Rituximab and Ocrelizumab prevent withdrawal relapses after stopping Tysabri, if you ever need to switch to Ocrelizumab in the future.

Revere (Rip) Kinkel MD
Professor of Clinical Neurosciences
Director of the Multiple Sclerosis Program
Clinical Neurosciences Director
University of California San Diego

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