Rituximab may be superior to natalizumab for relapse-remitting multiple sclerosis

1. For patients with relapsing-remitting multiple sclerosis (RRMS), rituximab demonstrated greater effectiveness at halting disease progression and was more cost-effective than natalizumab.

2. Ocrelizumab used as a 2nd line therapy after failure of natalizumab showed the least clinical effectiveness at halting disease progression, and was the most expensive therapy compared to rituximab and natalizumab.

Evidence Rating Level: 2 (Good)

There are numerous disease-modifying therapies (DMTs) available for slowing the progression of multiple sclerosis (MS). In particular, monoclonal antibodies (mAbs) have been shown to be superior to other DMTs, including interferons and fingolimod. Examples of mAbs used for MS include rituximab and natalizumab, with ocrelizumab used as 2nd line therapy following the failure of natalizumab. However, mAbs are costly therapies and may have differing rates of efficacy.  Therefore, this retrospective cohort study based in Saudi Arabia aimed to examine the efficacy and cost-effectiveness of the aforementioned mAbs in patients with relapsing remitting MS (RRMS). Patients were included if they were treated with mAbs for 6 or more months between 2015 and 2022, and who were biologic-naïve prior to starting mAb treatment (for rituximab and natalizumab patients). Effectiveness was evaluated with the NEDA-3 criteria, which includes the absence of disability progression, clinical relapse, and new lesions on MRI. In total, there were 93 patients included, with 54% on natalizumab, 28% on rituximab, and 18% on ocrelizumab. The mean effectiveness overall was 70.96% (95% CI 61.56-80.36%): The effectiveness rates for individual mAb therapies were 72.00% (95% CI 59.11-84.88%) for natalizumab, 76.92% (95% CI 59.57-94.27%) for rituximab, and 58.83% (95% CI 32.74-84.91%) for ocrelizumab. Furthermore, the mean annual cost for each mAb therapy was $20,110.74 for natalizumab, $7,672.61 for rituximab, and $36,698.90 for ocrelizumab. Therefore, natalizumab cost $35,383 (95% CI $25,401.09-$49,717.92) more than rituximab, with a 4.92% lower rate of effectiveness (95% CI -30 to 27.5) compared to rituximab. Overall, this study demonstrated that rituximab is more clinically effective at halting the progression of RRMS and is more cost-effective than natalizumab, whereas ocrelizumab was the least effective clinically and cost-wise.

Click to read the study in BMC Health Services Research

Image: PD

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