MS – Ocrelizumab Breast Cancer Signal — SCE Neurology MCQ

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HardMultiple Sclerosis & CNS InflammationMS – Ocrelizumab Breast Cancer SignalSCE Neurology

A patient receiving six-monthly ocrelizumab for relapsing multiple sclerosis has had two pneumonias in eight months. Before the next infusion, IgG is 3.4 g/L and there is no current MS activity. What is the most appropriate next step?

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Correct answer: A — Defer ocrelizumab for immune and infection review

The best answer is “Defer ocrelizumab for immune and infection review”. Ocrelizumab can cause secondary hypogammaglobulinaemia and serious infection; recurrent infection with markedly low IgG warrants treatment-delay and specialist assessment rather than automatic redosing. “Give the infusion unchanged because B-cell depletion cannot lower immunoglobulins” is less appropriate because anti-CD20 treatment can reduce immunoglobulin concentrations over time “Double the ocrelizumab dose to prevent inflammatory rebound” is less appropriate because greater B-cell depletion would intensify rather than correct the infection risk “Start live attenuated vaccination immediately before the infusion” is less appropriate because live vaccines are not given during immunosuppressive treatment and would not correct the low IgG “Diagnose primary immunodeficiency before full assessment treatment exposure” is less appropriate because the temporal treatment association must be assessed before assigning a primary immune disorder

Reference: Ocrevus 300 mg concentrate for solution for infusion: SmPC. https://www.medicines.org.uk/emc/product/8898/smpc NICE NG220: Multiple sclerosis in adults — recommendations. https://www.nice.org.uk/guidance/ng220/chapter/Recommendations