Abstract / Summary
Background: Anti-CD20 therapies provide strong suppression of inflammatory multiple sclerosis (MS), but prolonged exposure raises concerns about immunoglobulin depletion, infection and impaired vaccine responses.
Objectives: To critically evaluate biomarker-informed maintenance dosing and propose an implementation framework for the Gulf Cooperation Council (GCC).
Methods: A targeted narrative review examined indexed publications, trial registries, prescribing information and accessible conference reports through 27 September 2026. Randomised evidence, observational findings and proposed practice were distinguished.Key findings: Selected ocrelizumab and rituximab cohorts retain inflammatory control during extended intervals despite peripheral B-cell return. Randomised calendar-extension findings and preliminary B-cell-tailored trial observations support further evaluation but do not validate a universal threshold or the integrated BGAT strategy. Higher-dose ocrelizumab did not improve disability outcomes; this does not establish the equivalence of reduced exposure. Infection risk reflects immunoglobulin trajectories, cumulative treatment, disability and comorbidity. Biomarker-triggered ofatumumab and ublituximab dosing remain insufficiently studied.Proposed framework: Biomarker-Gated Anti-CD20 Therapy (BGAT) combines a depletion/repopulation gate, an immunoglobulin-and-infection safety gate and a clinical/MRI override. Laboratory validation, agent-specific eligibility and shared decisions are prerequisites. A GCC pathway links tiered laboratory capacity, prospective registry capture and a multicentre validation study.
Conclusions: BGAT requires prospective validation against both standard dosing and simpler extended calendar schedules. Success requires preserved inflammatory and disability outcomes, acceptable immune safety and demonstrable value to patients and health systems.