How does B cell therapy work in multiple sclerosis?

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After experiencing breakthrough multiple sclerosis symptoms while being treated with an interferon drug, Cherie Binns carefully considered her options.

In the end, her neurologist prescribed her rituximab. It’s a type of B-cell therapy that gets its name because it targets the B-cells that cause nerve damage in MS.

Binns, a 69-year-old nurse who works with MS patients in Wakefield, RI, says she has far fewer side effects than with the interferon drug. After a year and a half on rituximab, she noticed improvements in her left-sided weakness, trouble thinking, fatigue, and hand tremors. All are now minimal. The only side effect she had from rituximab was itching, which she controlled with an antihistamine.

“There’s a lot of debate in the MS community that people can live far more normal lives with a less intrusive therapeutic regimen,” she says.

Kelly Eichman, 40, had tried four other disease-modifying drugs since being diagnosed with relapsing-remitting MS in 2009. Then she started B-cell therapy with a B-cell therapy drug called ocrelizumab.

“Although I’ve only recently started semi-annual treatments, I’m tempted to call it my ‘miracle cure’ because I haven’t felt healthier in years before my MS diagnosis,” says Eichman, who is from southeast Minnesota originates.

How B cell therapies work

This therapy uses drugs called monoclonal antibodies to attack your body’s B cells. These white blood cells normally support your immune system. But when you have MS, they can damage nerves in your brain and spinal cord.

By destroying these cells, B cell therapy prevents your MS from getting worse. It is effective against relapsing remitting forms of MS, the type where you have flare-ups from time to time followed by periods without symptoms. It also works to slow primary progressive MS. This is the type that only gets worse over time.

B-cell therapies cannot cure MS. But by slowing it down and preventing recurrence, they can reduce disability and improve quality of life.

What B cell therapies are available?

To date, the FDA has approved two B-cell therapies for MS:

  • Ocrelizumab (Ocrevus) in 2017. You get this through an IV at a hospital or doctor’s office. It is used for both relapsing remitting MS and primary progressive MS.
  • Ofatumumab (Kesimpta) in 2020. You or someone else can give you an injection of this drug at home. It is used for relapsing remitting MS and secondary progressive MS (where you have relapses but your condition gets worse over time).

Doctors also use rituximab (Rituxan) to treat MS. It is mainly prescribed for blood cancers such as non-Hodgkin lymphoma. It is not yet FDA approved for the treatment of MS, but is often used “off-label” for this purpose. You take this medication through an IV at your doctor’s office.

Who Gets B Cell Therapy?

B cell therapy may not be the first MS treatment you try. Some doctors are starting out on more traditional MS therapies like interferon, says Dr. Ben Thrower, medical director of the Andrew C. Carlos MS Institute at the Shepherd Center in Atlanta. Interferons work with your immune system to reduce inflammation.

Thrower says he tends to favor more effective options like B-cell therapies for people who have just been diagnosed. “I think the most sensible thing to do is to be more aggressive in the beginning” to help people live their lives fully functionally for as long as possible, he says.

But, he says, you have to balance those benefits with a higher potential for side effects.

Possible side effects of B-cell drugs include:

  • Allergic reaction
  • Reactions where you get the shot or IV
  • An increased risk of infections such as colds and skin infections
  • headache

Some research has found that ocrelizumab may also increase your risk of certain types of cancer, including breast cancer. Ofatumumab has been linked to a rare and serious brain infection.

Neurologist Robert Bermel, MD, says he favors B-cell therapy for progressive primary MS. It’s the first treatment proven to prevent the disability in this type of MS from getting worse.

“B-cell therapies are great for reducing brain lesions and preventing recurrence,” says Bermel, associate of the Neurological Institute’s Mellen Center for Multiple Sclerosis at the Cleveland Clinic in Ohio.

What are the disadvantages?

However, B cell therapy is not for everyone. Your doctor will need to check your immunoglobulin levels, which measure how your immune system is working, before you start. People with chronic infections like hepatitis B and C or tuberculosis can’t receive B-cell therapy, Bermel says.

These drugs can also be very expensive. Before you start, check with your insurance company what is covered. In some situations, B cell therapy may cost less than interferon. That was the case for Binns when she switched from private insurance to Medicare.

However, prices for B-cell therapies could fall in the future. Researchers are developing biosimilars (a nearly identical copy of a drug) to rituximab. That’s the key to cutting costs, says Thrower.

patient perspective

Years after her diagnosis in 1994, Binns says, she became an advocate after hearing Thrower lecture about newer treatments like B-cell therapies.

She now has a port in her chest that gives her veins a break from needles. She gets an IV every 6 months, which takes a few hours. She can drive there and home herself instead of having to find someone to give her a ride.

For Eichman, the B-cell therapy meant MRI scans didn’t show any new lesions in her brain. Lesions affect how the brain works. They cause problems ranging from memory lapses to speech difficulties such as slurred words.

Binns advises that if you’re considering B-cell therapy, make sure you’re up to date on your vaccinations.

She has received three doses of the COVID-19 vaccine and her body is not yet producing protective antibodies against the coronavirus. So she wears a mask and encourages others to do so.

“Once you’ve had B-cell therapy, it can potentially take 6 months to a year for your blood cells to repopulate and for you to be able to make antibodies,” she says. Before starting treatment, ask your doctor what vaccinations you should have and how long before starting treatment you should have them.

If you’re curious about B-cell therapies, ask your neurologist at your next visit. Your doctor can help you decide if any of these treatments are right for you.

Thrower says his practice encourages patients to participate in treatment decisions.

“We put all the information and our preferences on the table and then see how that aligns with what the person wants,” he says.

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