What should I do to best manage my MS?

Here is My Question:
RRMS diagnosed age 14 immediately following onset. Treated with Rituxan x 3.5 yrs, full health, then switched to Ocrevus age 18 yrs in 8/21. Soon began chronic infections for months, advanced severe bacterial and COVID pneumonia. Now completing IVIG and recovering. 1) How now to manage MS? 2) lower dose/Rituxan/Kemsimpta, other DMT? 3) can I consider no DMT for at least a period of time to restore my immune system? 4) any suggested dietary plan- Best Bet? Thank you!

Answer:
Not knowing the details of your case, let me provide some information so you can ask your neurologist (MS specialist) some important questions.

1. You are very young and already immunosuppressed. But because you are young, your immune system will be restored over time. After prolonged repeated rituximab and ocrelizumab treatments, this repletion of your immune system can take several years. 
   Your physicians can monitor your B cell subsets to determine when they are repleted. It will be important to know when central memory B cells and Plasmablasts begin to return. ARUP (a commercial lab) has a nice B cell subset analysis panel that can be used for this purpose
2. Ask your physicians to consider continued immunoglobulin replacement therapy until your IgG levels remain normal; 
3. One option for treatment that may help control viral infections and benefit your MS is  Beta-Interferon. There are many brands available including long acting Pegylated Interferon. These are all administered by subcutaneous injection. The Beta Interferons are still quite useful treatments for MS but may cause flu like side effects when started. The side effects can usually be controlled with acetaminophen and ibuprofen. If you do start a Beta Interferon therapy, make sure your physicians monitor you closely with repeated MRI scans beginning 3 and 9 months after starting treatment. If your MRI scans are stable at 9 months, you can lengthen the interval between scans.
4. Most of the other treatment options may lower lymphocyte counts to an unacceptable level, which is to be avoided in your immunosuppressed state. You can reconsider these options with your physicians after your B cells subsets and immunoglobulin levels are both repleted.

Good luck . See what your doctors think and work with them to find a good solution.

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

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