Ocrelizumab is an FDA approved CD20-directed humanized monoclonal antibody indicated for the treatment of adult patients with primary progressive or relapsing multiple sclerosis; it received approval from the FDA on March 28, 2017.
FDA-approved indications (with clinical trial summaries):
At the time of launch, ocrelizumab had a list price of $65000 annually. It is generally covered by commercial insurance and by Medicare. The manufacturer provides patient payment assistance in the forms of a co-pay program and also referrals to a patient payment assistance foundation.
Ocrelizumab is a second-generation anti-CD20 recombinant monoclonal antibody with a molecular mass of 145kDa. It is a follow up to the anti-CD20 monoclonal antibody rituximab, but with a humanized IgG1 tail. Humanization of the antibody is expected to reduce antigenicity and improve CD20 binding. CD20 is a phosphoprotein expressed on a broad range of human B-cells. However, it is not present in the early lineage (stem cells and pro-B-cells) or late lineage (plasmablasts and plasma cells). Ocrelizumab binds to CD20 on B-lymphocytes leading to antibody-dependent cellular cytolysis and complement-mediated lysis. While the precise method by which ocrelizumab exerts its effect on multiple sclerosis is unknown, it depletes B-cells which are thought to affect the pathogenesis of multiple sclerosis using cytokine regulation, antigen presentation, autoantibody production.
Ocrelizumab is FDA approved for intravenous infusion. It is supplied in 300 mg/mL single-dose vials. The initial dose is given as a 300 mg intravenous infusion over 2.5 hours, followed up with an additional 300 mg intravenous infusion 14 days later. Subsequent doses are given every six months as a 600 mg intravenous infusion over 3.5 hours. Maintenance doses of ocrelizumab should be at a minimum five months apart. Some argue that dosing should not be on a fixed schedule but based on CD19/20 counts to optimize dosing to minimize unnecessary patient exposure and allow for significant cost savings. For mild to moderate adverse events, a reduction in infusion rate is indicated, if tolerated. Severe and life-threatening reactions indicate interruption or discontinuation of the drug.
Adverse reactions in relapsing multiple sclerosis with an incidence of more than 5% and higher than interferon beta-1a:
Adverse reactions in primary progressive multiple sclerosis with an incidence of more the 5% and higher than placebo:
Ocrelizumab is contraindicated in the following patients:
Before initiating ocrelizumab:
Before every ocrelizumab infusion:
Before initiating ocrelizumab therapy, hepatitis B virus screening is indicated.
Patients receiving an ocrelizumab infusion will require monitoring for at least the next hour for the following signs and symptoms of refusion reactions:
In clinical trials, there was an incidence of life-threatening bronchospasm (which recovered with treatment) with the initial infusion of ocrelizumab.
Ocrelizumab is a new biological agent, and even though it has shown a positive risk/benefit trade-off in clinical trials, it does require close monitoring for safety; thus, besides the prescribing clinician, both nurses and pharmacists are responsible for educating the patient on the potential side effects of the drug.
During IV administration, the drug has shown infusion-reactions in more than one-third of patients, therefore it is essential to monitor side effects such as coughing, dizziness, fast heart rate, fatigue, feeling faint, fever, flushing, headache, hives, itchy skin, nausea, rash, shortness of breath, swelling of throat, throat irritation or pain, tiredness, trouble breathing and wheezing. In clinical trials, there was an incidence of life-threatening bronchospasm (which recovered with treatment) during the initial infusion of ocrelizumab. Therefore, because the drug can trigger a life-threatening infusion reaction, the interprofessional team needs to have the necessary medications and equipment in the room to ensure safe outcomes.
Since some of the adverse effects are delayed-onset, including opportunistic infections and malignancies, an outpatient neurology nurse should continue to follow the patients and coordinate additional surveillance between infusions. The nurses and pharmacists should regularly check immune titers to monitor immunosuppression. While there are no reported cases of progressive multifocal leukoencephalopathy (PML) to date (which has happened in other anti-CD20 antibodies and immunosuppressant therapies) it is crucial for the entire healthcare team to be on the lookout for clinical signs and symptoms including hemiparesis, clumsiness, visual changes, memory/thinking changes, and personality changes. The clinical trial experience showed a higher rate of breast malignancy in the ocrelizumab treated group. However, patients are not advised to undergo increased surveillance and instead to continue to undergo routine breast cancer screening as age-appropriate.
Pharmacists should also work with the prescriber and nursing to ensure proper dosing, preclude drug interactions, and educate the patient and nursing staff on potential adverse reactions. This information will allow nursing to administer the drug effectively, as well as monitor for any adverse reactions, and inform the ordering clinician should they encounter any concerns. This collaborative paradigm exemplifies the kind of interprofessional teamwork the healthcare team requires to administer ocrelizumab effectively to achieve optimal patient outcomes while minimizing patient risks. [Level V]
Finally, the drug is prohibitively expensive, and insurance health plans do not always cover the cost. Without long term data available, clinicians should always consider other similar cost-effective agents first.
Interprofessional communication between the primary treatment team and the patient’s PCP or OBGYN is essential to make sure such screenings occur as estimates are that roughly one-third of women do not get an appropriate annual screening.
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