Rituxinavia in the Real World experience

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Rituximab in multiple sclerosis at general hospital level. Hellgren J, Risedal A, Källén K. Acta Neurol Scand. 2020 Jan 28. doi: 10.1111/ane.13225. [Epub ahead of print].

OBJECTIVES: The use of Rituximab (RTX) in multiple sclerosis (MS) is a rapidly increasing choice of disease modifying therapy. Efficacy outside specialized university hospital-based care is not yet systematically investigated. Our aim was to evaluate off-label RTX treatment for MS at a general hospital in Sweden.

MATERIALS AND METHODS:Subjects with definite MS with at least one rituximab infusion were eligible for inclusion in this retrospective, observational study. Effect was evaluated by monitoring clinical disability, annual relapse rate, new lesions on MRI, and safety by the incidence and severity of adverse events.

RESULTS:Among the 83 included subjects, 15 had clinical worsening of disease during the median 23.5 (1-76) months of follow-up after RTX initiation: 7/66 with relapsing-remitting multiple sclerosis (RRMS) and 8/17 with progressive subtypes (PMS). Cumulative survival without worsening was 86% in RRMS and 30% in PMS. The annual relapse rate before RTX versus follow-up dropped from 0.38 to 0.05 (p <0.00001). Subjects with new enhancing lesions on MRI during the first year before RTX initiation versus the year after dropped from 0.94 to 0.024 (p <0.00001) and was only seen in RRMS (1.05 to 0.31, p=0.00003). Adverse events were mainly mild. Thirty-six out of 53 non-infusion-related adverse events were infections, of which four were serious, including a case of pneumonia with concomitant late-onset neutropenia.

CONCLUSIONS:Rituximab was as effective and safe when given at a general hospital out-patient clinic compared to results from previous university hospital-based studies. Vigilance is required concerning severe adverse events.

Rituximab is a CD20 B cell depleting antibody and is commonly used in Sweden. It is slightly less potent than ocrelizumab. In this study 18% worsened during the observation period. This occurred in 11% of people with RRMS and 47% with progressive MS, showing that people with RRMS respond the best. The relapse rate dropped to 0.05 so one relapse every twenty years, but this comes with the price of severe infections in some people. Is this reproducible?

Rituximab in the treatment of multiple sclerosis in the Hospital District of Southwest Finland Laura Airas, Marjo Nylund, Iina Mannonen, Markus Matilainen,  Marcus Sucksdorff, Eero Rissanen doi: https://doi.org/10.1101/2020.01.15.20017533

Background: There are already numerous B-cell depleting monoclonal anti-CD20 antibodies which have been used to reduce the inflammatory burden associated with multiple sclerosis (MS). We describe here our experience of treating MS-patients with B-cell depleting rituximab. Patients and methods: All MS-patients (n=72) who had received rituximab treatment for at least six months by January 2019 were identified from the patient charts at the Turku University Hospital. Information about MS disease subtype, disease severity, MR-imaging outcomes and B-cell counts were collected from the charts. Results: Rituximab was well received and well tolerated by the patients. There were no serious infusion-related side effects. The most serious adverse event that led to treatment discontinuation was neutropenia. Our study confirms the usability of rituximab treatment for MS in the Finnish health care environment. Conclusions: Off-label rituximab-treatment can be successfully used to reduce MS disease burden for the benefit of MS patients.

So yep is the answer

COI multiples

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MouseDoctor

20 comments

  • A doctor told me that Rituximab and Ocrevus can make neurodegeneration worse in people without active lesions. Is this true? Is there any data to support this?

  • Rituximab is a really good drug and cheaper now off patent. It should be available in this country for all MS patients that need it. Instead of some of the other substandard drugs like interferons and copaxone.

    • We should have moved on from the CRABS, but their use is perpetuated by lazy risk averse neurologists.

      Many neurologists do not have the infractructutre to monitor some of the high efficacy drugs also some systems only reimburse a few visits each year. However time is your brain

  • Hi
    I’ve been following this whole Rituximab story for the last year since the Basel report was published last year. I have SPMS and am within the range of the average age and EDSS of this study. As it is off label and not available on the NHS I thought I had struck gold when I eventually found a neurologist who would prescribe it and provide the necessary dosing protocols but didn’t have the facilities to administer. My NHS neurologist is happy deal with post infusion monitoring. Sadly I am having no luck finding a facility or neurologist to oversee/ supervise the infusions. I am fully aware that at best it may slow progression and at worse do nothing with potential risk of side effects. I would be very grateful to know if there is anyone who can, or knows of anyone that can help with this in the UK.

    • Do either of your neuros know an oncologist or even a rheumatologist who may be able to help out?
      Maybe try searching for UK rituximab infusion units and getting your neuro to contact one of the doctors involved with that unit (if you haven’t already).

      • This was my first approach. I must add that I’m getting many conflicting opinions. It is a deeply laborious process, first finding a private facility that administers the drug, contacting the pharmacy is the quickest way. Then finding every neurologist that practices privately out of that facility, studying their biog to see if they have MS as a specialism then contacting their secretaries. I either get get a reply, often not. So far no one willing! Thank heavens for cut and paste! There appears to be no way of expediting this crazy process!

    • A neurologist without the facilities to do infusions…A sad state of affairs as it mean no access to a number of treatments. It is a standard oncology procedure.

      • Yes how crazy it all appears to be. Hence reaching out to a legitimate knowledge data base. I’ve spent a lot of time in Sweden over the years it might be simpler to go there every six months mad as it sounds Jonatan Salzer had a plenary at ecrims i do believe. I might contact him and see if he knows any private facilities over there.

      • Sorry I re-read my original post and did omit to mention that the neurologist that is willing to prescribe was seen in a privately

          • If so can this be arranged at Barts? I have a private neuro willing to provide a prescription and dosing protocol etc. My NHS neuro is happy to deal with post infusion monitoring. So infusion facilities and supervision every 6 months is all I require.

          • I dont know, you would have to ask ProfG/K but as this would be personal advice they probably can’t respond and as ProfG was saying the trust is in special measures but you have to get referred in somehow which I guess is the job of the NHS neuro to find out.

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