Real Life Use of CD20 depletion

Warning: this post contains an unpleasant image of a skin condition
Yamout BI, El-Ayoubi NK, Nicolas J, El Kouzi Y, Khoury SJ, Zeineddine MM. J. Immunol Res 2018:9084759
OBJECTIVE: To evaluate the efficacy and safety of rituximab in multiple sclerosis in a clinical practice setting.


Clinical data for all adult patients with multiple sclerosis (MS) treated with off-label rituximab at a single MS center in Lebanon between March 2008 and April 2017 were retrospectively collected from medical charts. The main efficacy outcomes assessed were annualized relapse rate (ARR) and proportion of patients free from relapses, disability progression, or magnetic resonance imaging (MRI) activity.


A total of 89 rituximab-treated patients were included: 59 relapsing-remitting MS (RRMS) and 30 progressive MS (PMS). Patients were treated with 1000 or 2000 mg rituximab IV every 6-12 months for a mean duration of 22.2 ± 24.8 months. The subjects were 65.2% females with a mean age of 40.5 ± 12.3 years and a mean disease duration of 7.9 ± 6.2 years. During treatment, the ARR decreased from 1.07 at baseline to 0.11 in RRMS (p < 0.0001) and from 0.25 to 0.16 in PMS patients (p = 0.593). The mean Expanded Disability Status Scale (EDSS) remained unchanged in both RRMS and PMS patients. Between baseline and the last follow-up, the percent of patients free from any new MRI lesions increased from 18.6% to 92.6% in the RRMS group and from 43.3% to 82% in the PMS group. No evidence of disease activity (NEDA) was achieved in 74% of patients at 1 year of treatment. A total of 64 adverse events (AEs) (71.9%) were recorded with the most common being infusion-related reactions in 25.8% of patients, all mild in nature. Two of our rituximab-treated patients experienced serious AEs requiring surgical interventions: pyoderma gangrenosum vaginalis and an increase in the size of a meningioma. No case of progressive multifocal leukoencephalopathy (PML) was detected.


In our real-world cohort, rituximab was well-tolerated and effective in reducing relapse rate and disability progression in relapsing-remitting and progressive MS patients.
This is real-life use of rituximab, a B cell depleting drug, which is like ocrelizumab, only cheaper…OK it is what we call chimeric, part animal (mouse) and a large part human. Ocelizumab is humanised, a tiny part animal and vast majority human and ofatumumab which is human.
Ocrelizumab binds to CD20 better than rituximab and it is a more effective B cell killer than rituximab.
The main side effect is infusion reactions which was similar to the about 30% infusion reactions in people treated with ocrelizumab.
The main adverse events was a meningioma a type of slow growing brain cancer  and a form of Pyroderma gangrenosum . This is an unpleasent ulcering condtion thought to a problem with neutrophils, which are the most common type of white blood cell type.
WARNING: Dont view this whilst you are having your breakfast! 
It looks unpleasent and it is not even the vaginalis variant.


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  • Can we have this? It sounds good (not the ulcer, obvs). Also, I am very happy that the researchers didn't have the useless EDSS as one of the main outcomes.

  • Why are we going on about Rituximab when we have Ocrelizumab licensed by NHS? Regardless of whether it's cheaper or not. Heres a novel idea why don't barts use this blog for posting their own research conclusions? Do we have anything to report? Or even the research u guys are doing? MD u once mentioned if u had ms you'd take meds in the fridge being researched. Which meds?

    • Not if you are PPMS, it is not considered cost effective until the deal is done. However it shows you what ocrelizumab will at least achieve. If you pick alemtuzumab you have years of real life data, if you go for ocrelizumab this is not the case.

      Now Mr. Angry
      To you next point. I am not sure any lab publishes a paper every day. So should I drop the the block down to once a fortnight or once a month, it would be alot less effort for me. So be careful what you wish for.

      Next up maybe my research is understanding what rituximab and other B cell therapies do or maybe it is examing the side-effect problems of alemtuzumab, after all we did expose the fact that neutralizing antibodies existed and this prompted the change in the Euopean Label in early 2018. Maybe I post on what is published that day/week and if the posts seem boring, its because there is nothing to comment on,

      Yes we do have stuff to report? Yes but there are only so many hours in a day and we have: teaching to teach, pwMS to see, research to undertaken, grants to get and other things to do.

      Which Meds…that's between ne and the fridge. Until proven the should stay in the fridge. How many people have taken prozac because it was being tried in MS-SMART, howmany people hae taken over the counter biotin as a result of the High dose biotin study.

  • Thanks for the warning about the photo.

    I am very happy on Rituxan, one infusion every six months – just get on with life and more or less forget about the MS.

    • Eww!!! The warning isn't much use if the pic is on the page
      You could have included a link to the picture rather than the picture itself
      Totally set off my tryphophobia

    • Now just imagine that you only need a few courses you could them forget about rituxan. This is why the Roche need to follow up on their phase III data given the results of the phase II extension study

  • MD is there a direct comparison of rituximab vs ocrezulimab vs ofatumumab re: relapses and progression?

    My guess that if blinded their results would be near identical in progressive AND RRMS for all three. The only winner is Pharma and its shareholders and associated neurologists who continue their profitable ways by re-designing the identical drug. How is this furthering MS research and treatment?

    • I agree… they may be the same except ofatumumab is designed to be given monthly a pain in the bum I suspect. Maybe where greed shoots oe in the foot
      Time will tell

  • About rituximab and the 4 causes of progression from Prof G's post-
    It is obviously very good at stopping the shredder
    Does it do anything for the slow burn and the energy problems?

    Also, can rituximab use continue indefinely? 5 years, 10 years, 15 years, …
    Does it stay effective?

    • So burn and energy problemms…Not directly I suspect as it does not get in the brain to any signficiant level but may get at a root problem.

      As for treatment indefinately, I suspect the infection time bomb will be the problem and the question we should address is do we need to treat for ever. Maybe not

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