Should I switch from Tysabri to Ocrevus?

Here is My Question:
I do not tolerate my Tysabri infusions well, I have been on it for 21 months. My neurologist has talked to me about switching to Ocrevus but I am not sure. I have only been on Tysabri, it took 6 months to get my MS under control and stop having relapses after starting it, so he does not want to put me on anything less potent. My main concern is the increased risk of cancer, specifically breast cancer which due to family history I am already in a high risk category. I also am concerned that in the time between stopping the Tysabri and starting the Ocrevus I may relapse. I should also mention I am JC virus negative at this time. 


Answer:
My usual preference is to continue with Tysabri unless one of the following occurs:

1. It is not working: This does not appear to be the case with you
2. It is too risky: Again, this doesn’t appear to be the case with you. Too risky would mean you are high titer positive for JC virus antibodies and on therapy for more than 2 year or you have a history of immunosuppression
3. It is not tolerated despite efforts to lessen side effects. You mention not being able to tolerate Tysabri but do not mention the specific problem(s) you are experiencing. Problems with infusions can often be handled with premedication and problems between infusion can often be handled by increasing the interval between infusions to 8 weeks. 

If you really can not tolerate Tysabri despite best efforts to lessen side effects (persistent side effects are very uncommon with this treatment), Ocrevus and Rituximab  are great options, if your MS Specialist believes you have a high risk of relapsing in the first 6 months after stopping Tysabri. If you are not in a high risk for relapse group, then Gilenya and tecfidera are also options.

The potential risk of breast cancer on Ocrevus can be mitigated by frequent breast cancer screening starting before you start treatment. We really do not  know at present how to interpret the higher risk of breast cancer observed in the Ocrevus clinical trials. It was unexpected and not observed previously with Rituximab treatment, a therapy very similar to Ocrevus and used since the mid 1990s. The FDA also did not determine that the risk of breast cancer was higher in  Ocrevus treated patients than in the general population, although it would take many more people on this treatment followed for a longer period to time to make this determination.

Please discuss these issues further with you MS Specialist and I am sure you can both make a comfortable decision that meets your needs and addresses your concerns.


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