Are you on an anti-CD20? To estimate your chances of mounting an antibody response to the COVID-19 vaccine you need to know the difference between primary and secondary or booster responses.
I had my COVID vaccines at 11months post AHSCT (12 weeks apart), I checked for antibodies 6 months later and thankfully I had some, though tither was not specified. I still went ahead and had my third shot last week, so I hope I have a good level of immunity against COVID at this time. I am due to start Ocrevus as I relapsed.
My VZV level is low and the other titters have just been checked, I assume they will be low to non existent too, redoing all my child hood vaccinations will be time consuming, and delay starting a dmt, I feel more concerned about my active MS right now, could I propose a middle ground, would the same principle apply? could I start the DMT and revaccinate as far away from the Infusion/ before the next as possible, say at 4.5/ 5 months for these other illnesses which thankfully are not so widespread in circulation?
I know you don’t give direct advice but I value your opinion
I am aware of some neurologists using natalizumab in this situation. Get on top of the MS, allow vaccinations to be done and to then revisit the issue of a switch to an anti-CD20. Natalizumab is the thinking neurologists DMT; it gives you time to think and make plans.
Not necessarily. It takes 12 months or more for the PML risk to emerge and with EID (extended interval dosing) this risk is mitigated by 90% or more. This is sufficient time to get your MS disease activity under control and have your vaccines. You could then consider switching to ocrelizumab when the COVID-19 pandemic is less of a problem, without rationing of anti-virals. We use natalizumab in this way all the time.
Thank you for your response and suggestions. Re tysabri, in addition to my Jc status, I had been concerned about rebound activity too, and had ruled tysabri out, but I am sure that could be planned for and managed. I will discuss this further with my neurologist, and hopefully get on a dmt asap 🤞
With ocrelizumab after B cell depletion, should the new lymphocytes function properly? Is the mechanism of action for this part of lymphocytes the same as for alemtuzumab?
Or do the new lymphocytes still have the MS habit? So once the therapy with ocrelizumab is interrupted after years (2-3 years) and the maintenance one is chosen, the problems continue to exist?
The new lymphocytes are the same as those that appear after alemtuzumab; they have a naive phenotype from the bone marrow. The difference is the counts are much lower post ocrelizumab than alemtuzumab, which explains the different vaccine data between these classes of therapy.
I suspect so, but don't know for sure. People on ocrelizumab have a deficit in B-cell antigen presentation that may be important for cancer immunosurveillance. Once you have immune reconstitution post-alemtuzumab tumour immune surveillance should be intact.
Hi Prof G, thank you for this post, which is very relevant (ish) to my circumstances. I'm on yr2 Ocrelizumab (last infusion beginning of July) I had my two covid jabs (last one at end of May). I'm due my 3rd covid jab tomorrow! Then I hope to have next infusion Jan 2022. I'm all good with treatment & jabs (lots of minor infections & mild flu symptoms with jabs). Could you confirm if the 3rd dose is a booster (lesser amount) or a full dose? I can't seem to get much info from the centre - they just said to ask when I'm there, which is a bit late to re-arrange or organise things! I don't mind either way - but it would be good to know. I also, feel that it would be good to understand if you have a good response or not? Is an antibody test and good thing to purse to find out?
The 3rd dose is for people who are immunocompromised and is a full dose. It does not preclude you from having a booster (fourth dose) 6 months after the 3rd dose. The 3rd dose can be given anytime 8 weeks after the 2nd vaccine dose and is part of the primary vaccine.
I had my COVID vaccines at 11months post AHSCT (12 weeks apart), I checked for antibodies 6 months later and thankfully I had some, though tither was not specified. I still went ahead and had my third shot last week, so I hope I have a good level of immunity against COVID at this time. I am due to start Ocrevus as I relapsed.
My VZV level is low and the other titters have just been checked, I assume they will be low to non existent too, redoing all my child hood vaccinations will be time consuming, and delay starting a dmt, I feel more concerned about my active MS right now, could I propose a middle ground, would the same principle apply? could I start the DMT and revaccinate as far away from the Infusion/ before the next as possible, say at 4.5/ 5 months for these other illnesses which thankfully are not so widespread in circulation?
I know you don’t give direct advice but I value your opinion
I am aware of some neurologists using natalizumab in this situation. Get on top of the MS, allow vaccinations to be done and to then revisit the issue of a switch to an anti-CD20. Natalizumab is the thinking neurologists DMT; it gives you time to think and make plans.
JC tither 3. Something so tysabri off table 🙈
Also thank you so much for taking time to reply
Not necessarily. It takes 12 months or more for the PML risk to emerge and with EID (extended interval dosing) this risk is mitigated by 90% or more. This is sufficient time to get your MS disease activity under control and have your vaccines. You could then consider switching to ocrelizumab when the COVID-19 pandemic is less of a problem, without rationing of anti-virals. We use natalizumab in this way all the time.
Thank you for your response and suggestions. Re tysabri, in addition to my Jc status, I had been concerned about rebound activity too, and had ruled tysabri out, but I am sure that could be planned for and managed. I will discuss this further with my neurologist, and hopefully get on a dmt asap 🤞
Anti-CD20 therapy started before natalizumab washes out prevents rebound. There is good data on this from Sweden and rituximab.
With ocrelizumab after B cell depletion, should the new lymphocytes function properly? Is the mechanism of action for this part of lymphocytes the same as for alemtuzumab?
Or do the new lymphocytes still have the MS habit? So once the therapy with ocrelizumab is interrupted after years (2-3 years) and the maintenance one is chosen, the problems continue to exist?
The new lymphocytes are the same as those that appear after alemtuzumab; they have a naive phenotype from the bone marrow. The difference is the counts are much lower post ocrelizumab than alemtuzumab, which explains the different vaccine data between these classes of therapy.
Thanks Prof! Ocrelizumab also has a higher incidence and risk of developing cancers than Alemtuzumab?
I suspect so, but don't know for sure. People on ocrelizumab have a deficit in B-cell antigen presentation that may be important for cancer immunosurveillance. Once you have immune reconstitution post-alemtuzumab tumour immune surveillance should be intact.
How can you have Covid-19 and be Sero negative? Sorry for my grammar I am using iPhone speech to text.
It is very common in immunosuppressed patients on anti-CD20 treatment and it even occurs in a minority of normal people.
Thank you. I definitely need to do more researching.
Thank you for coming back to me, much appreciate & I hope you're okay too!
Hi Prof G, thank you for this post, which is very relevant (ish) to my circumstances. I'm on yr2 Ocrelizumab (last infusion beginning of July) I had my two covid jabs (last one at end of May). I'm due my 3rd covid jab tomorrow! Then I hope to have next infusion Jan 2022. I'm all good with treatment & jabs (lots of minor infections & mild flu symptoms with jabs). Could you confirm if the 3rd dose is a booster (lesser amount) or a full dose? I can't seem to get much info from the centre - they just said to ask when I'm there, which is a bit late to re-arrange or organise things! I don't mind either way - but it would be good to know. I also, feel that it would be good to understand if you have a good response or not? Is an antibody test and good thing to purse to find out?
The 3rd dose is for people who are immunocompromised and is a full dose. It does not preclude you from having a booster (fourth dose) 6 months after the 3rd dose. The 3rd dose can be given anytime 8 weeks after the 2nd vaccine dose and is part of the primary vaccine.