Click here to watch Dr. Virginia Devonshire discuss the case and the responses to the survey.

Thomas, 38, is a chemical engineer who initially presented in 2019 with optic neuritis followed two months later by a myelopathic episode. MRI was highly active with two gadolinium-enhancing T1 and multiple T2 lesions. EDSS was 2.5 (optic 1, sensory 2, bladder 2). Thomas had no relevant medical conditions other than obesity; his body weight was 120 kg (BMI 34 kg/m2) at presentation.

He was started on ocrelizumab 300 mg q6monthly. For the past four years his MRI has been stable and he has been relapse-free. At his most recent visit in June 2023, he complained of significant fatigue and feeling generally unwell in the month prior to ocrelizumab dosing. During his course of treatment, Thomas has experienced recurrent upper respiratory tract infections, and one episode of atypical pneumonia (no organisms cultured).

The survey is now closed. There were 39 responses. See below for a summary of the answers you provided.

Question 1: In your opinion, is Thomas experiencing wearing-off symptoms?
About one-third (35.9%) thought Thomas was experiencing wearing-off symptoms; one-third (35.9%) were unsure and would like to obtain a CD19+ count; 20.1% thought the symptoms could be attributable to other causes; and 7.69% were unsure.

Question 2: Would you consider a personalized dosing regimen (based on CD19+ count) in this patient if this option were available to you?
Most respondents (76.92%) would consider personalized dosing, 5.13% would not, and 17.95% were unsure.

Question 3: Is a patient’s BMI a consideration when deciding whether or not to initiate an anti-CD20 agent?
One-third thought Yes (34.21%) and two-thirds (65.79%) thought No.

Question 4: How would you manage Thomas’ symptoms of fatigue and unwellness?
Most respondents (51.28%) would maintain the standard ocrelizumab dosing but initiate lifestyle and drug interventions to manage fatigue. Some respondents (23.08%) would shorten the dosing interval to q5 mths if CD19 >10 cells/µL. A total of 15.38% said they would switch to ofatumumab. A few respondents would switch to natalizumab (7.69%) or oral cladribine (2.56%).

Question 5: How would you manage Thomas’ frequent infections?
A few respondents would advise taking precautions against infection (2.56%), assessing immunoglobulins (7.69%), or recommending regular vaccinations for influenza, pneumonia and COVID-19 (7.60%). A majority of respondents (84.62%) would recommend all of the above measures.

View the video commentary from Dr. Virginia Devonshire.