10 Comments
Jul 3, 2022Liked by Gavin Giovannoni

Thank you for this useful post.

Can we expect Cladribine to be as effective as anti-CD20? Or is it difficult to say?

Rituximab has been working well (12 courses in the last 10 years)

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author

Difficult to say, but cladribine has some long-term advantages.

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Nov 30, 2021Liked by Gavin Giovannoni

Would you need to wait some B cell recovery before moving from Ocrelizumab to Cladribine? Surprised this was not covered.

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Depends why you are switching. If it is because of poor efficacy you don't wait for B-cell reconstitution. If it is for safety best to wait. if it is for vaccine readiness then you best wait for a vaccine response. If it is because of a cancer, best to make sure the cancer is in remission. If it is for CNS penetration and perceived effects on the CNS B-cell compartment there is no need to wait for B-cell reconstitution.

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Thank you for this highly informative post. I understand the recommendation for waiting for some B cell recovery prior to starting cladribine. Do total lymphocyte counts need to be normal prior to switching? In realize this is part of the baseline assessment however I'm wondering about the risk of rebound activity in this interval. Also what if COVID vaccine boosters are not locally available yet at the time of a planned switch?

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founding

Fantastically well written. Thank you for the information...I have been planning a switch from OCR to Clad in the upcoming months myself. Any thoughts on any significant "upfront" BVL observations? Any thoughts on the relevancy of its effect on microglia or other CNS cells? Thanks again.

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When you read this, especially that clad takes out 85-90% of Bcells, you wonder why anyone is on ocrelizumab anyway?

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author

Clad takes out memory B-cells by much more, but it allows them to be replaced by naive cells from the bone marrow. It is the naive B-cells you need for vaccine responses, which explains why cladribine-treated patients make good antibody responses to the COVID-19 vaccines.

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Thanks Prof, understood. My comment was more focussed on what are the advantages of Ocrevus over Clad given that the latter is a potent b-cell killer and appears to have a number of other benefits that Ocrevus does not. Makes you wonder why Clad is not more well used

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One of the biggest problems with cladribine is that it is poorly understood as a DMT and it has a legacy that comes from oncology. If it was better understood and it can shake off its legacy it will be extensively used.

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