If the heavy weights of MS drugs go head to head in the boxing ring, it is anyone’s guess who will come out on top. The MS Base publication in 2019 states that starting on fingolimod, alemtuzumab or natalizumab is superior to glatiramer acetate or interferon beta.
This March, the Italians have sneakily put together their own contest between fingolimod and natalizumab. You may say this one is a stitch up (maybe) but unsurprisingly natalizumab is the clear winner here. This is in terms of relapse rates, EDSS (disability) progression, and new T2 and/or Gd+ lesions on MRI (see figure below). Of course, the long term strategy is weak, with NEDA rates even on natalizumab falling from 63% to 46% by 4 years meaning their still room for improvement.
Neurol Sci. 2021 Mar 6. doi: 10.1007/s10072-021-05127-z. Online ahead of print.
Long-term comparative analysis of no evidence of disease activity (NEDA-3) status between multiple sclerosis patients treated with natalizumab and fingolimod for up to 4 years
Background: Comparative effectiveness of natalizumab and fingolimod over a follow-up longer than 2 years has been not addressed yet.
Objectives: To compare the effect on no evidence of disease activity (NEDA-3) in relapsing-remitting multiple sclerosis (RRMS) patients treated with natalizumab or fingolimod for at least 4 years.
Methods: We included RRMS patients switched from first-line agents to natalizumab or fingolimod. Patients were propensity score (PS)-matched on a 1-to-1 basis. Percentages of patients reaching NEDA-3 status at 2 and 4 years of follow-up were compared using the chi-square test. The risk of not achieving NEDA-3 at 4 years was explored in matched samples by Cox regression models.
Results: We evaluated 174 PS-matched patients. Patients receiving natalizumab reached a NEDA-3 status at 2 and 4 years more frequently than those exposed to fingolimod (63% vs 44%, p=0.037; 45.7% vs 25.8%, p=0.015, respectively). Patients receiving natalizumab were at a significant lower risk of not achieving the NEDA-3 status at 4 years compared to those exposed to fingolimod (hazard ratio (95% confidence interval): 0.54 (0.36-0.80), p=0.002).
Conclusions: Although both medications were effective in patients non-responding to first-line agents, natalizumab seems to be superior to fingolimod in RRMS in obtaining NEDA-3 status at 4 years.