Q&A 73: Ocrelizumab vs. Ofatumumab vs. Ublituximab

The other choice is to stay on fingolimod and see what happens over the next 6-12 months.

Case study:

I am currently 42 years old and have been on fingolimod (Gilenya) as my first-ever medication for the past eight years with stable RRMS, no new lesions, and only one relapse following COVID last year.

I suffer from extreme MS-related fatigue and brain fog and no other disability progression. I have recently been given the option to transition to an anti-CD20 therapy (Ocrevus, Kesimpta, or Briumvi).

I know you would have preferred Alemtuzumab or stem cells, yet this is not an option, and also I am risk-averse to these treatments. Please provide a specific drug recommendation for each of the available choices. I would greatly appreciate your insights and guidance on a few related questions:

Fingolimod Transition

I came across your previous recommendation on waiting for total peripheral lymphocyte counts to exceed 800/mm³ before initiating a new DMT, typically around weeks 3-4 post-Gilenya. Has this guidance changed, or do you still follow this protocol?

Are there any specific vaccination/treatment recommendations during the fingolimod washout period? After stopping Gilenya and starting the new treatment, when would be the optimal time to take these vaccines/treatments?

Ocrelizumab vs. Ofatumumab

In your 2021 and 2023 blog articles, you mentioned that there wasn’t enough significant clinical evidence to compare Ocrelizumab and Ofatumumab in terms of smouldering MS symptoms, brain volume loss, and disability progression. Has there been any new research or updates regarding these comparisons?

When discussing these two options, I noticed that you rarely reference the Ocrelizumab cancer risk or the “crap gap” (the weeks before infusion when you feel weak, which affects my quality of life). Is there a reason for this omission? Given my family history of breast cancer on both sides, I wanted to understand if there is an incremental risk with Ocrelizumab compared to Ofatumumab.

Ublituximab (Briumvi)

I don't see you often include ublituximab (Briumvi) in your comparison of DMT efficacy. Is there a reason for that?

NOTE: General substack newsletters and the microsite are free; only Q&A sessions are restricted to paying subscribers. I can't run and maintain the MS-Selfie microsite, so I must pay people to help me do the work. If people want to ask medical questions unrelated to the Newsletters or Podcasts, they either need to become paying subscribers or email (ms-selfie@giovannoni.net) to request a complimentary subscription.

Prof G’s answer

Fingolimod Transition

Q1: I came across your previous recommendation on waiting for total peripheral lymphocyte counts to exceed 800/mm³ before initiating a new DMT, typically around weeks 3-4 post-Gilenya. Has this guidance changed, or do you still follow this protocol?