Switching from Tecfidera to Ocrevus

Here is My Question:
I'm interested in switching from Tecfidera to Ocrevus and have some questions about making the switch. 

How should I transition off Tecfidera as far as preparation and time frame? Which immunizations need to up to date? If I need to update immunizations such as MMR when is the best time to do this? What other tests and images should be done prior to starting Ocrevus? What factors would make me a poor candidate for the new medication? What premedication is recommended with the Ocrevus infusions to decrease infusion reaction? What is the risk for PML with Ocrevus if I am JC negative and how often should this be rechecked? What tests and follow up imaging should be done to determine whether Ocrevus is working for me? If well tolerated, is Ocrevus something I could use exclusively and long term as a DMT? 

Thank you for the information. 

Answer:
All very good questions. let’s see if I can handle them in order

1. Transitioning from Tecfidera to Ocrevus should be simple since Tecfidera is short acting. As long as your lymphocyte counts and subsets are near normal, I am not recommending a wash out period between cessation of Tecfidera and starting Ocrevus. If your lymphocytes counts are low, I would recommend waiting until they normalize off of tecfidera before starting Ocrevus

2.  No specific immunizations are required before starting Ocrevus. You should be tested for latent or active Hepatitis B and Hepatitis C before starting treatment. Depending on risk factors it is probably important to check for HIV and TB before starting Ocrevus. Lastly older individuals should probably get a shingles vaccine before starting Ocrevus, if their immunity is waning

3.  Imaging may help determine if you are a good candidate for Ocrevus; Ideal candidates for Ocrevus include patients with active relapsing MS  (relapses and new MRI activity in the past year) with significant risk factors for disease progression or progressive MS patients under the age of 55 who are still ambulating, particularly if their rate of worsening is rapid and there has been evidence of active inflammation on MR imaging.
People over the age of 55 with very slowly progressive MS or and patients with severe disability from MS (wheelchair bound with significant loss of independence or worse), especially if at risk for pulmonary infections or other frequent infections, may not be the best candidates. Therapeutic decisions in these patients require individual evaluation.

4. Pre-medications and infusion instructions are in the package insert and known by the infusion center personnel who administer infusions

5. It is always best to monitor responses to treatment with quantitative performance measures and serial quantitative MRI imaging

6. Ocrevus is infused only as a mono-therapy (stand alone treatment ) every 6 months. Some physicians administer at different intervals depending on the circumstances. Some physicians will use Ocrevus as an induction therapy (2 treatments at onset separated by 2 weeks) followed by maintenance therapy with another disease modifying therapy. You would need to discuss your particular circumstances with an MS specialist and possibly seek several opinions

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