Disease Modifying Therapy Initiation

Specialised Nurse **Management Plan** 1. Initiate Ocrelizumab (Ocrevus) therapy as per treatment plan. 2. Schedule baseline investigations including full blood count (FBC), liver function tests (LFTs), renal function tests (RFTs), and Hepatitis B and C serology. 3. Arrange for initial infusion appointment at the hospital's infusion unit. 4. Provide patient with comprehensive educational materials regarding Ocrelizumab. 5. Schedule a follow-up appointment with the neurology team in 3 months. **Current Diagnosis and Rationale for Treatment Change** Mrs. Sarah Jenkins presents with a diagnosis of Relapsing-Remitting Multiple Sclerosis (RRMS). She has experienced increasing frequency of relapses over the past 12 months, with her most recent relapse involving significant left-sided weakness and optic neuritis, leading to a decline in her Expanded Disability Status Scale (EDSS) score from 3.0 to 4.5. Recent brain MRI imaging revealed new T2 lesions and gadolinium-enhancing lesions, indicating ongoing disease activity despite treatment with interferon beta-1a (Avonex). The decision to switch to a higher efficacy disease-modifying therapy (DMT) is based on the escalation of disease activity and the patient's desire for a more potent treatment to prevent further disability progression. Mrs. Jenkins is currently taking interferon beta-1a (Avonex) via subcutaneous injection thrice weekly, which will be discontinued prior to initiating new therapy. She has no known drug allergies. No specific contraindications to Ocrelizumab were identified during the pre-treatment assessment. **Treatment Options Discussed** The specialist nurse discussed various high and lower efficacy therapy options with Mrs. Jenkins. High efficacy options presented included Ocrelizumab (Ocrevus), a monoclonal antibody targeting CD20 B-lymphocytes, which works by depleting B cells responsible for myelin damage. Expected benefits include a significant reduction in relapse rates (up to 46% reduction compared to interferon beta-1a in clinical trials) and slowing of disability progression. Lower efficacy options like glatiramer acetate (Copaxone) were also briefly reviewed, but the emphasis was placed on the benefits of higher efficacy treatments given Mrs. Jenkins's current disease activity. **Risk Discussion** A comprehensive discussion on the risks associated with Ocrelizumab (Ocrevus) was held. Common side effects, such as infusion-related reactions (headache, rash, fever), were explained. Serious adverse events, including increased risk of infections (particularly upper respiratory tract infections and urinary tract infections), progressive multifocal leukoencephalopathy (PML), and potential for malignancy, were reviewed in detail. The need for regular blood tests for monitoring and long-term safety considerations were also highlighted. **Administration and Logistics** Ocrelizumab (Ocrevus) is administered intravenously. The initial dosing schedule involves two infusions given two weeks apart, followed by subsequent infusions every six months. Arrangements for Mrs. Jenkins's initial infusion have been made with the hospital's dedicated infusion unit. She was also provided with information on patient support programmes and advised on coordinating with the hospital pharmacy for medication supply. The schedule for ongoing safety monitoring blood tests will be provided at her first infusion. **Family Planning** Family planning advice was provided, emphasising the importance of effective contraception during Ocrelizumab (Ocrevus) treatment and for at least six months following the last infusion. Considerations regarding pregnancy and breastfeeding while on this medication were discussed, and Mrs. Jenkins was advised to inform the clinical team immediately should she plan to conceive. **Patient Understanding and Consent** Mrs. Jenkins actively participated in the decision-making process. She was provided with information leaflets from the MS Society and directed to their website for further resources. Her questions regarding the duration of treatment, potential impact on her daily life, and long-term prognosis were addressed comprehensively. Her husband also expressed some concerns about the side effects, which were thoroughly explained. Mrs. Jenkins confirmed her understanding of the proposed treatment plan, including the benefits and risks, and verbally consented to proceed with Ocrelizumab (Ocrevus) initiation. **Pre DMT Initiation Investigations** Laboratory studies ordered prior to Ocrelizumab (Ocrevus) initiation include a full blood count (FBC), liver function tests (LFTs), renal function tests (RFTs), Hepatitis B surface antigen, Hepatitis B core antibody, Hepatitis C antibody, and Varicella Zoster Virus (VZV) serology. No cardiac evaluations were deemed necessary. Her vaccination status was reviewed, and she confirmed up-to-date vaccinations, including the annual influenza vaccine. **Follow-up Plan** The next scheduled appointment is with the neurology consultant on 1 November 2024, to review her progress after the initial infusions. A structured monitoring schedule will be established by the infusion centre team. Emergency contact information for the MS team was provided. She was also offered details for local MS support groups and signposted to the MS Trust for additional patient support resources.