Unexpected highly inflammatory ms activity uncharacteristic for prior disease course in patients treated with ocrelizumab
Author(s): ,
G. von Geldern
Neurology, University of Washington, Seattle, WA, United States
L. Jayagopal
Neurology, University of Washington, Seattle, WA, United States
M. Persenaire
Neurology, University of Washington, Seattle, WA, United States
A. Wundes
Neurology, University of Washington, Seattle, WA, United States
ECTRIMS Online Library. von Geldern G.
Oct 12, 2018; 229056
Gloria von Geldern
Gloria von Geldern
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Abstract: P1216

Type: Poster Sessions

Abstract Category: Therapy - Immunomodulation/Immunosuppression

Introduction: Ocrelizumab (OCR), a B-cell depleting agent, demonstrated significant reduction in clinical and MRI disease activity in relapsing remitting MS (RRMS) and a moderate effect on disability progression in primary progressive MS (PPMS) in clinical trials. Since its approval in spring 2017, real world experience contributes to our knowledge of efficacy and safety of this new medication.
Objective: To report unexpected highly inflammatory disease activity uncharacteristic for prior clinical course in 3 MS patients treated with OCR.
Results: 126 MS patients received OCR at our site since its approval. Among those, 3 patients experienced highly inflammatory clinical and MRI disease activity uncharacteristic for their disease. All had non-detectable B cells at that time. (1) A 50 y/o man with SPMS with no clinical relapses in many years experienced his life-time worst relapse with more than 20 enhancing lesions on brain and spine MRI 5 months after starting OCR (previously rituximab x1 year). Non-responsive to two 5-day courses of iv methylprednisolone, he was admitted for expedited infectious work up (non-yielding) and improved clinically after plasmapheresis while short-term repeat MRI remained highly inflammatory. Anti-OCR antibodies were negative. (2) A 48 y/o woman with PPMS experienced her first ever relapse 3 months after OCR initiation. She developed right sided weakness and ataxia; a large new enhancing cerebellar peduncle lesion was found on MRI. After iv methylprednisolone, her symptoms improved. A repeat MRI showed ongoing enhancement 3 months later. (3) A 55 y/o man with PPMS with no prior enhancing lesions on MRI underwent routine surveillance MRI 6 months after starting OCR. A new large enhancing lesion in the right cerebellar hemisphere was found. No new symptoms or exam findings were seen but enhancement continued for several months despite treatment with iv methylprednisolone.
Conclusions: While OCR is a potent treatment for RRMS and has demonstrated benefit in PPMS, we here report unusual and unexpected inflammatory disease activity in 3 patients, who had a progressive disease course prior to OCR. Due to the degree of immunosuppression associated with OCR and the amount of inflammation being uncharacteristic for these patients, infection or other complication of treatment mimicking acute MS disease activity had to be considered. Clinical experience with this new medication may help optimize patient selection and safety surveillance.
Disclosure: Dr. von Geldern has received research funding by Novartis. Dr. Wundes has received research funding by Biogen Idec and Alkermes. Others have nothing to declare.

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