How does B-cell therapy for multiple sclerosis work?

After Sherry Beans developed symptoms of MS while being treated with an antiviral drug, she carefully weighed her options.

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

Bynes, a 69-year-old nurse who works with multiple sclerosis patients in Wakefield, Rhode Island, says her side effects are much fewer than they would with the interferon medication. After a year and a half of taking rituximab, I noticed improvement in left-sided weakness, thinking problems, fatigue, and hand tremors. Everything is minimal now. The only side effect she experienced from rituximab was itching, which she controls with antihistamines.

“There is a lot of discussion in the MS community about the fact that people can live more normal lives with a less invasive treatment regimen,” she says.

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

“Although I recently started the bi-annual treatment, I tend to call it my ‘miracle drug,’ as I hadn’t felt better in years before my multiple sclerosis diagnosis,” says Eichmann, who is from southeastern Minnesota.

How do B cell treatments work

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

By destroying these cells, B-cell therapy prevents MS from getting worse. It is effective against relapsing forms of MS, the kind where you have episodes from time to time, followed by periods when you have no symptoms. It also works to slow primary progressive MS. This is the type that gets worse over time.

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

What B cell treatments are available?

So far, the US Food and Drug Administration has approved two B-cell treatments for MS:

• Ocrelizumab (Ocrevus) in 2017. You can get this through an IV in a hospital or doctor’s office. It is used to reverse types of MS as well as primary progressive MS.
• Ofatumumab (Kesimpta) in 2020. You or someone else can give you a dose of this medicine at home. It is used to reverse MS and secondary progressive multiple sclerosis (where you have had relapses, but your condition continues to get worse over time).

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

Who gets B-cell therapy?

B-cell therapy may not be the first treatment for multiple sclerosis you try. Some doctors start with traditional MS treatments, such as interferon, says Ben Thoreau, MD, medical director of the Andrew C. Carlos Multiple Sclerosis Institute at Shepherd Center in Atlanta. Interferons work with the immune system to reduce inflammation.

Thrower says he tends to favor more effective options, such as B-cell treatments, for people who have just been diagnosed. “I think being more aggressive in the beginning makes the most sense” to help people live their lives fully for as long as possible, he says.

But, he says, you must balance these benefits with a greater potential for side effects.

Possible side effects of B-cell therapy drugs include:

• Allergic reactions
• Feedback where you get the shot or IV
• Increased risk of infections, such as colds and skin infections
• headache

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

What are the disadvantages?

However, B-cell therapy is not appropriate for everyone. Your doctor will need to check your immunoglobulin levels, which measure how your immune system is working, before starting it. Permell says that people with chronic infections like hepatitis B and C or tuberculosis can’t get B-cell therapy.

These medications can also be expensive. Before starting one, check with your insurance company to see what it covers. In some cases, the cost of B-cell therapy may be less than the cost of interferon. That was the case for Bynes when she switched from private insurance to Medicare.

However, prices for B-cell therapy may drop in the future. Researchers are developing biological alternatives (a nearly identical version of a drug) to rituximab. Thrower says this is the key to lowering the cost.

Patients’ point of view

Years after her diagnosis in 1994, Bynes says she became an advocate when she heard Thrower talk about new treatments like B-cell therapies.

She now has a port in her chest, which gives her veins a respite from the needles. She has an intravenous injection every 6 months, and it takes a few hours. She is able to drive herself there and back home, rather than having to find someone to take her.

For Eichmann, the B-cell therapy meant the MRI scans showed no new lesions in her brain. The lesions affect how the brain works. They cause problems ranging from memory lapses to speech difficulties, such as inflamed words.

Binns points out that if you’re considering B-cell therapy, you should make sure your vaccinations are up to date.

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

“Once you get B-cell therapy, it can take six months to a year before your blood cells multiply and you can build up the antibodies,” she says. Before starting treatment, ask your doctors which vaccinations you should have and how far you should get them before starting treatment.

If you are interested in B-cell therapies, ask your neurologist at your next visit. Your doctor can help you decide if one of these treatments is 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 fits into what the person wants,” he says.