What should I do before starting Rituximab?

Here is My Question:
I am a 55 year old female and have had MS for 13 years. I was started on Rebif but stopped because of skin issues with injections, started on Tysabri which was stopped because I'm JCV positive and was on Tysabri for 2 years, and then started on Aubagio which I've been on for 3.5 years. I feel like my symptoms have slowly been getting worse so my Neurologist recommended we try Rituximab. I am concerned because I know Aubagio lasts in the body for a long time. Do I need to wait a certain time period before starting Rituximab or do one of those elimination protocols? Also, because of my age and the suppression of the immune system Rituximab causes, my Neurologist is also recommending the Shingles vaccine before I start Rituximab. Is that safe for me considering I'm still on Aubagio? 
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Answer:
Rituximab is an excellent option to treat underlying MS.  However, no disease modifying therapy will guarantee improvement in symptoms (they do cut down on inflammation occurring due to MS).  I'd suggest you speak with your neurologist about what he/she expects to gain from using rituximab and develop a plan together to make sure that you are responding to the medication.  This usually means semiannual clinic visits and occasional MRI scans.

I would recommend the cholestyramine elimination protocol and have your terifunomide level checked afterwards.  

I always check a chicken pox (VZV titer) before ordering rituximab.  If the titer is low, you should have the vaccine first and then wait at least a month before starting rituximab.

A. Scott Nielsen MD MMSc
Neurologist and MS Specialist at Kaiser Permanente