17 Comments

Thank you doctor, that is exactly what we (patients) need. Even go deeper and get more details should be basic knowledge if we care about our health.

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Dr. Giovanni,

I am a nurse practitioner and MS certified nurse. This blog post puts into layman's terms what I have been struggling to learn and remember for YEARS. Thank you!

Katy Clark, FNP-BC, MSCN

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Dr. Giovannoni! I'm sorry for the typo.

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Thanks for the explanation. Very clear and I really learned a lot reading it, specifically about some concepts that I did not understand well about B and T lymphocytes

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I appreciate the level of detail. I only get lab work just prior to my infusion with Ocrevus so maybe once or twice a year. My GP does not believe in routine lab work so the Neuro is the only one that orders any lab work. I have no idea if my counts drop after my infusion. So clearly there is no standard which is why, I feel, we don’t like uncertainty. For example, I have never heard from my neurologist anything about maybe the Covid vaccine won’t work nor that maybe I should get an antibody test to see if it worked or not. Maybe I should not be seeking outside sources of information as this leads to said uncertainty.

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There was no mention of dimethyl fumarate in your list of DMT’s. Dimethyl fumarate gave me lymphopaenia, <0.4 so I was moved to teriflunomide. My lymphopaenia now cycles between 0.5 and 0.9, but is usually 0.6 or 0.7 which is giving cause for concern. Currently had teriflunomide suspended for 8 weeks to see what happens. I’ll be pleased but very surprised if I make it to 1.0 or higher in 8 weeks. Not sure what the future holds, as I hate the idea of injectables, but GA seems the only thing that will not give me lymphopaenia.

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author

Apologies, an oversight. Now added.

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Hi Dr. Giovannoni. Hope you are doing well.

I’m a pwMS and I’d like to know how does Ocrevus compares to Kesimpta in terms of safety and immunology? I read a few weeks ago a study that said that Kesimpta had a better safety profile than Ocrevus because B-Cell Repopulation was faster, but they never went into details to explain really why is safer because of that. I appreciate if you could explain it to me a little bit better.

P.S: I’ve been taking Kesimpta for 3 months including loading doses. All good so far.

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Dear prof. G, could you help clarify something for me?

After 2 months of teriflunomide, my CD19 B cells have dropped from 120 to 73 (so about 40%).

After horrible experiences with DMF and chronic lymphopenia, and infections, I wonder how this drop in CD19 B cells can affect my infection risk.

Also in the long run. With DMF, chronic lymphopenia seemed to increase infections over time, even if ALC stayed 'stable' around 0.6.

I know DMF, teri, etc. are not depleting therapies, but I can't help wonder whether depleting en repopulating is sometimes less risky for infections, than years of continous significant suppression.

Any thoughts would be very helpfull!

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author

Short-term lymphopaenia is on average not that serious. It is long-term persistent lymphopaenia that increases your risks of secondary and opportunistic infections and secondary malignancies.

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thank you - I realize that, and I have experienced that first hand with DMF.

I was lymphopaenic for 6 years with DMF, then was almost to normal for a few months (no DMT), and now I'm lymphopaenic again since I started a new DMT.

I'm not sure if that's to be considered as - overall - one long-term lymphopaenia of 7 years now, or one long-term + 1 short-term lymphopeania.

My question is maybe if it is known whether specifically CD19 B cell reduction is problematic for increased infection risks.

With DMF, I found there is a plausible link between low ALC and (opportunistic) infections, with probable mechanism of action being the severe reduction of CD8+ T cells (e.g. Ghadiri et al, Dimethyl fumarate-induced lymphopenia in MS due to differential T-cell subset apoptosis, Longbrake et al, Dimethyl fumarate selectively reduces memory T cells in multiple sclerosis patients, Fleischer et al, Treatment response to Dimethyl fumarate is characterized by disproportionate CD8+ T cell reduction in MS; Dello Russo et al, Dimethyl fumarate induced lymphopenia in multiple sclerosis: A review of the literature), even leading to recent proposals to monitor specific subsets of lymphocytes for DMF-safety vigilance, rather than just ALC (e.g. Anagnostouli et al., Agressive Herpes Zoster in Young Patients with Multiple Sclerosis under Dimethyl Fumarate).

With the history of infections I have been through (and want to avoid in the future), I would be very interested to know if a similar link has been found between reduced B cells and (opportunistic) infections.

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Thanks for the thorough explanation. I had my first Ocrevus 1 month after I had my second COVID vaccine. I had never been on an anti-CD20 before that date. Now I'm trying to figure out if that 1 Ocrevus treatment impacted my response to the vaccine. I am assuming not really, since I had all of my normal B cells when I got the vax. My next Ocrevus is in late October, and that would presumably impact my response to any boosters (I think).

I keep trying to do a risk assessment on myself - in my 40s with no other health concerns and vaccinated, I finally stopped masking in mid-June when my state dropped the mandate. Now trying to figure out if I'm a bit too lax.

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Hello Dr. Giovanni,

I am due to start my 2nd course of Cladribine treatment and my lymphocytes have been stubbornly stuck at 0.6 for the last six months. I just hope to reach .8 in the next 1-2 months.

Any natural way to boost these, or is it just a waiting game?

I am fully cov vaccinated.

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According to the Maveclad SmPc if it takes longer than 6 months for your ALC to get above 800/mm3 from the time you are due for your 2nd course you shouldn't have the 2nd course. This however is a soft call and should be left up to your HCP to decide. The reason is that this advice is not evidence-based.

Yes, there are treatments that can be given to boost lymphocyte counts, but they are only used if there is a major safety concern. Just having a count of 0.6 is not a major safety concern.

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hi there. Just wanted to feed back how clear this article was. Really landed the B cell T cell thing for me which after 9 years post diagnosis and avid reading of the Barts blog was still a bit woolly concept for me. Very timely as well as just stopped fingolimod to start cladribine (hooray). Waiting for those pesky lymphocytes to increase and fingers crossed for no rebound. Thanks for all the great info Prof you have been a massive boon in my quest to stay well and walking the Yorkshire hills xx

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Wonderful x10. Thank you Prof GG

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Dear Prof. G,

When you have completed the MS-Selfie Newsletters on each of the DMTs would ther be any possibility you could create an algorithm (diagram) for the best treatment at this point in time with the research we have, eg

1. start on ocrelizumab, ofatumumab or natalizumab (if alemtuzumab is not offered)

2. what next for those at risk of PML or failing, would you have different recommendations depending on age, activity level prior to starting treatment, MRI, risk of SPMS, likely benign course, ie how would you decide between cladribine, ocrelizumab, fingolimod, interferon etc for a patient

3. when would you stop treatment, if a patient doesn't turn progressive should they remain on a high efficacy DMD for life of drop to a lower with age.

I know this could be a large diagram with lots of parameters but I think it would be really useful for patients to have your view on this and understand what would give them the best chance!

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