What multiple sclerosis (MS) drug can be used in a patient not vaccinated against hepatitis B (HBV)?

MS Medications for Patients Not Vaccinated Against Hepatitis B

For patients with multiple sclerosis who are not vaccinated against hepatitis B, glatiramer acetate is the safest and most appropriate disease-modifying therapy to use, as it does not require hepatitis B screening or carry risk of hepatitis B reactivation.

Understanding the Risk of Hepatitis B in MS Therapies

Hepatitis B virus (HBV) infection or reactivation is a significant concern with certain MS medications, particularly those with immunosuppressive properties. The management approach should be guided by the following considerations:

Screening and Risk Assessment

• HBV screening is required before initiating certain MS therapies, particularly anti-CD20 therapies like ocrelizumab 1
• Patients with positive hepatitis B core antibodies or surface antigens should receive antiviral prophylaxis when using immunosuppressive therapies 2
• Unvaccinated individuals are at risk for acquiring HBV infection, which can be severe in immunocompromised patients

MS Medication Options Based on HBV Status

First-Line Options for Unvaccinated Patients

1. Glatiramer Acetate

   • No requirement for hepatitis B screening or vaccination
   • No risk of hepatitis B reactivation
   • Available in two formulations:
     • 20 mg/mL daily injection 3
     • 40 mg/mL three times weekly injection (better tolerated with 50% fewer injection site reactions) 4
   • Effective in reducing relapse rates in RRMS 3
   • Well-established long-term safety profile with up to 15 years of data 3
   • No immunosuppressive effects that would increase risk of HBV infection

2. Beta-interferons

   • Generally safe for unvaccinated patients
   • No significant risk of hepatitis B reactivation
   • May be considered as an alternative to glatiramer acetate

Medications to Avoid or Use with Caution

1. Anti-CD20 Therapies (Ocrelizumab, Rituximab)

   • Require hepatitis B screening before initiation 1
   • High risk of hepatitis B reactivation in infected patients
   • Should be avoided in unvaccinated patients until vaccination series is completed

2. S1P Receptor Modulators (Fingolimod, Siponimod, Ozanimod)

   • Have immunosuppressive effects
   • May increase risk of viral infections
   • Use with caution in unvaccinated patients

3. Other Immunosuppressive Therapies

   • Alemtuzumab, cladribine, and other potent immunosuppressants
   • Higher risk of infections in general
   • Not recommended for unvaccinated patients

Management Algorithm

1. For newly diagnosed MS patients not vaccinated against HBV:

   • Start glatiramer acetate immediately
   • Simultaneously begin hepatitis B vaccination series (0,1, and 6 months) 2
   • Consider 40 mg/mL three times weekly formulation for better tolerability 4

2. For patients already on MS therapy needing a switch:

   • Switch to glatiramer acetate if current therapy requires HBV immunity
   • Begin hepatitis B vaccination series
   • Consider monitoring antibody response to vaccination if immunosuppressed

Important Considerations

• Hepatitis B vaccine is highly immunogenic with protective antibody levels in >90% after three doses 2
• Vaccination should not be delayed while starting MS treatment with glatiramer acetate
• Genetic polymorphisms may influence response to glatiramer acetate therapy 5
• If more potent MS therapy is eventually needed, complete the full HBV vaccination series first

Pitfalls to Avoid

• Do not initiate anti-CD20 therapies without confirming HBV status
• Do not assume partial vaccination provides adequate protection (all three doses are needed for long-term immunity) 2
• Do not delay MS treatment while waiting for vaccination completion when glatiramer acetate is an option
• Avoid assuming that all MS medications carry equal risk for HBV reactivation

By selecting glatiramer acetate for unvaccinated MS patients, you can effectively treat the MS while simultaneously allowing the patient to complete their hepatitis B vaccination series without increased risk.