Effectiveness of cladribine compared to fingolimod, natalizumab, ocrelizumab and alemtuzumab in relapsing-remitting multiple sclerosis

Mult Scler. 2024 Aug;30(9):1163-1175. doi: 10.1177/13524585241267211. Epub 2024 Aug 1.

Abstract

Background: Comparisons between cladribine and other potent immunotherapies for multiple sclerosis (MS) are lacking.

Objectives: To compare the effectiveness of cladribine against fingolimod, natalizumab, ocrelizumab and alemtuzumab in relapsing-remitting MS.

Methods: Patients with relapsing-remitting MS treated with cladribine, fingolimod, natalizumab, ocrelizumab or alemtuzumab were identified in the global MSBase cohort and two additional UK centres. Patients were followed for ⩾6/12 and had ⩾3 in-person disability assessments. Patients were matched using propensity score. Four pairwise analyses compared annualised relapse rates (ARRs) and disability outcomes.

Results: The eligible cohorts consisted of 853 (fingolimod), 464 (natalizumab), 1131 (ocrelizumab), 123 (alemtuzumab) or 493 (cladribine) patients. Cladribine was associated with a lower ARR than fingolimod (0.07 vs. 0.12, p = 0.006) and a higher ARR than natalizumab (0.10 vs. 0.06, p = 0.03), ocrelizumab (0.09 vs. 0.05, p = 0.008) and alemtuzumab (0.17 vs. 0.04, p < 0.001). Compared to cladribine, the risk of disability worsening did not differ in patients treated with fingolimod (hazard ratio (HR) 1.08, 95% confidence interval (CI) 0.47-2.47) or alemtuzumab (HR 0.73, 95% CI 0.26-2.07), but was lower for patients treated with natalizumab (HR 0.35, 95% CI 0.13-0.94) and ocrelizumab (HR 0.45, 95% CI 0.26-0.78). There was no evidence for a difference in disability improvement.

Conclusion: Cladribine is an effective therapy that can be viewed as a step up in effectiveness from fingolimod, but is less effective than the most potent intravenous MS therapies.

Keywords: Cladribine; comparative effectiveness; multiple sclerosis; observational studies.

Publication types

  • Comparative Study

MeSH terms

  • Adult
  • Alemtuzumab* / adverse effects
  • Alemtuzumab* / therapeutic use
  • Antibodies, Monoclonal, Humanized* / adverse effects
  • Antibodies, Monoclonal, Humanized* / therapeutic use
  • Cladribine* / adverse effects
  • Cladribine* / therapeutic use
  • Female
  • Fingolimod Hydrochloride* / adverse effects
  • Fingolimod Hydrochloride* / therapeutic use
  • Humans
  • Immunologic Factors / adverse effects
  • Immunosuppressive Agents* / adverse effects
  • Immunosuppressive Agents* / therapeutic use
  • Male
  • Middle Aged
  • Multiple Sclerosis, Relapsing-Remitting* / drug therapy
  • Natalizumab* / adverse effects
  • Natalizumab* / therapeutic use
  • Treatment Outcome

Substances

  • Cladribine
  • Alemtuzumab
  • Fingolimod Hydrochloride
  • Natalizumab
  • ocrelizumab
  • Antibodies, Monoclonal, Humanized
  • Immunosuppressive Agents
  • Immunologic Factors