How do you manage an MS patient who has had attacks in spite of being on B-cell depleting therapy?

The data behind ocrelizumab, ofatumumab, and ublituximab show at least 70% reduction in annualized relapse rates. When you recall that most MS patients do not have one relapse every year or even every two years, the real-world implications are that having an MS attack while receiving B-cell therapy ...

I will switch them to another agent, and that could be natalizumab, cladribine, or consider S1P modulators.

True inflammatory breakthrough during adequately dosed, biologically effective anti-CD20 therapy is uncommon. Consequently, the initial response should prioritize diagnostic reassessment instead of immediate escalation.

The first step is to confirm that the event represents a true relapse rather than...

In patients with continued disease activity on B-cell suppression, generally, I do not switch from one B-cell therapy to another, as there is no clear evidence that one works better than another (Torkildsen et al., PMID 42384870). Largely, efficacy has been shown for nearly all drugs in this class o...