Q&A 84: rituximab, rituximab, rituximab: is this the only option for treating breakthrough MS disease activity?

Why not alemtuzumab or AHSCT? These two therapies are the most effective treatments in network analyses and have the best results in reducing MS-related accelerated brain volume loss.

Case

I am a woman in my early 40s who was diagnosed with RRMS in 2018 after a relapse where I experienced numbness in my right leg. Back in 2015, I suddenly lost the ability to walk normally on my left leg, which was unfortunately misdiagnosed as a hip injury. I still have residual symptoms from that relapse and can only walk a maximum of 3 km.

In my family, we are three siblings, all of whom have MS. When my diagnosis was made, I had numerous lesions and significant damage, particularly in the spinal cord. I started oral cladribine (Mavenclad) as my first treatment in 2018/2019. Since completing the course, I have had two clinical relapses without new findings on MRI—until now. A new lesion, measured at 10 mm, has been found in the right hemisphere (I have not received more details from my neurologist). I have now been offered Rituximab as my only treatment option.

Where I live, HSCT is not a standard treatment, but I am considering traveling abroad and paying for the treatment myself.

Question 1: Is Rituximab the best option, or should I pursue AHSCT before becoming too old or transitioning to SPMS? What will give me the best prognosis?

Question 2: Should genetic testing be performed given the significant prevalence of MS and other neurological diseases in my family, and would this have any implications for the choice of treatment?

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Answers

Question 1: Is Rituximab the best option, or should I pursue AHSCT before becoming too old or transitioning to SPMS? What will give me the best prognosis?

Alemtuzumab or AHSCT, but the answer is much more nuanced than that ….