How do you decide on initial and sequential anti-CD20 therapy for patients with multiple sclerosis given the availability of rituximab, ocrelizumab, ublituximab, and ofatumumab?

In my practice, I generally discuss the B cell depleter drug class with patients, as these drugs have similar clinical profiles. I do not have a particular preference for sequencing one anti-CD20 drug over another. Treatment decisions are primarily driven by practical differences for patients, such as the route of administration, infusion time, and insurance coverage. I focus on what is important to patients regarding their medication. Some patients prefer the once-monthly subQ flexibility of ofatumumab, while others prefer a longer interval infusion. Some strongly favor the shorter infusion time with ublituximab, while others appreciate the longer-term clinical experience with ocrelizumab.

Monoclonal antibodies for MS include natalizumab, ocrelizumab, rituximab, ofatumumab, alemtuzumab, and ublituximab. These DMTs are highly efficacious for reducing the relapse rate in patients with MS, but serious safety issues, including infections, are possible adverse effects of several of these medications. Thus, monoclonal antibody DMTs may be preferred for patients with more active disease and for those who place a high value on efficacy and are risk-tolerant.

However, there is no uniform method for choosing the best DMT for an individual patient. The choice of a specific agent for patients with MS should be individualized according to disease activity, comorbid conditions, and patient values and preferences.

An algorithm can be found ...