The following is a summary of “Comparison Between Dimethyl Fumarate, Fingolimod, and Ocrelizumab After Natalizumab Cessation,” published in the June 2023 issue of Neurology by Zhu et al.

Natalizumab cessation raises severe relapse risk; minimizes rebound with optimal strategy. Comparing efficacy and persistence of dimethyl fumarate, fingolimod, and ocrelizumab in relapsing-remitting multiple sclerosis (RRMS) patients.

Researchers performed an observational cohort study with patient data from the MSBase registry, median follow-up of 2.7 years. Patients without baseline data were excluded. Primary outcomes were annualized relapse rate (ARR) and time first to relapse. Due to the small number of dimethyl fumarate patients, secondary outcomes focused on fingolimod and ocrelizumab comparisons. The associations were analyzed after balancing covariates using an inverse probability of treatment weighting method.

The results showed Among 66,840 patients with RRMS, 1,744 switched to dimethyl fumarate (138; 9.9%), fingolimod (823; 59.4%), or ocrelizumab (425; 30.7%) after natalizumab, within 3 months. After excluding 358 patients without baseline data, 1,386 were included (mean age: 41.3 [10.6] years; 990 female [71%]). ARR for each medication: ocrelizumab: 0.06 (95% CI, 0.04-0.08); fingolimod: 0.26 (95% CI, 0.12-0.48); dimethyl fumarate: 0.27 (95% CI, 0.12-0.56).

ARR ratio (compared to ocrelizumab): fingolimod: 4.33 (95% CI, 3.12-6.01); dimethyl fumarate: 4.50 (95% CI, 2.89-7.03). Hazard ratio (HR) of time to first relapse (compared to ocrelizumab): fingolimod: 4.02 (95% CI, 2.83-5.70); dimethyl fumarate: 3.70 (95% CI, 2.35-5.84). HR of treatment discontinuation (compared to ocrelizumab): fingolimod: 2.57 (95% CI, 1.74-3.80); dimethyl fumarate: 4.26 (95% CI, 2.65-6.84). 

Fingolimod is associated with a 49% higher risk for disability accumulation than ocrelizumab. No significant difference in disability improvement rates between fingolimod and ocrelizumab. 

They concluded RRMS patients switching from natalizumab to ocrelizumab had the lowest ARR, discontinuation rates, and longest time to first relapse.

Source: jamanetwork.com/journals/jamaneurology/article-abstract/2805561?resultClick=3