Effectiveness of multiple disease-modifying therapies in relapsing-remitting multiple sclerosis: causal inference to emulate a multiarm randomised trial.

Ibrahima Diouf, Charles B Malpas, Sifat Sharmin, Izanne Roos, Dana Horakova, Eva Kubala Havrdova, Francesco Patti, Vahid Shaygannejad, Serkan Ozakbas, Sara Eichau, Marco Onofrj, Alessandra Lugaresi, Raed Alroughani, Alexandre Prat, Pierre Duquette, Murat Terzi, Cavit Boz, Francois Grand'Maison, Patrizia Sola, Diana Ferraro, Pierre Grammond, Bassem Yamout, Ayse Altintas, Oliver Gerlach, Jeannette Lechner-Scott, Roberto Bergamaschi, Rana Karabudak, Gerardo Iuliano, Christopher McGuigan, Elisabetta Cartechini, Stella Hughes, Maria Jose Sa, Claudio Solaro, Ludwig Kappos, Suzanne Hodgkinson, Mark Slee, Franco Granella, Koen de Gans, Pamela A McCombe, Radek Ampapa, Anneke van der Walt, Helmut Butzkueven, José Luis Sánchez-Menoyo, Steve Vucic, Guy Laureys, Youssef Sidhom, Riadh Gouider, Tamara Castillo-Trivino, Orla Gray, Eduardo Aguera-Morales, Abdullah Al-Asmi, Cameron Shaw, Talal M Al-Harbi, Tunde Csepany, Angel P Sempere, Irene Treviño Frenk, Elizabeth A Stuart, Tomas Kalincik

Journal: Journal of neurology, neurosurgery, and psychiatry 2023;94(12):1004-1011

PMID: 37414534

Abstract

BACKGROUND

Simultaneous comparisons of multiple disease-modifying therapies for relapsing-remitting multiple sclerosis (RRMS) over an extended follow-up are lacking. Here we emulate a randomised trial simultaneously comparing the effectiveness of six commonly used therapies over 5 years.

METHODS

Data from 74 centres in 35 countries were sourced from MSBase. For each patient, the first eligible intervention was analysed, censoring at change/discontinuation of treatment. The compared interventions included natalizumab, fingolimod, dimethyl fumarate, teriflunomide, interferon beta, glatiramer acetate and no treatment. Marginal structural Cox models (MSMs) were used to estimate the average treatment effects (ATEs) and the average treatment effects among the treated (ATT), rebalancing the compared groups at 6-monthly intervals on age, sex, birth-year, pregnancy status, treatment, relapses, disease duration, disability and disease course. The outcomes analysed were incidence of relapses, 12-month confirmed disability worsening and improvement.

RESULTS

23 236 eligible patients were diagnosed with RRMS or clinically isolated syndrome. Compared with glatiramer acetate (reference), several therapies showed a superior ATE in reducing relapses: natalizumab (HR=0.44, 95% CI=0.40 to 0.50), fingolimod (HR=0.60, 95% CI=0.54 to 0.66) and dimethyl fumarate (HR=0.78, 95% CI=0.66 to 0.92). Further, natalizumab (HR=0.43, 95% CI=0.32 to 0.56) showed a superior ATE in reducing disability worsening and in disability improvement (HR=1.32, 95% CI=1.08 to 1.60). The pairwise ATT comparisons also showed superior effects of natalizumab followed by fingolimod on relapses and disability.

CONCLUSIONS

The effectiveness of natalizumab and fingolimod in active RRMS is superior to dimethyl fumarate, teriflunomide, glatiramer acetate and interferon beta. This study demonstrates the utility of MSM in emulating trials to compare clinical effectiveness among multiple interventions simultaneously.

© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.

Address: CORe, Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia.; Health and Biosecurity Unit, Commonwealth Scientific and Industrial Research Organisation, Melbourne, Victoria, Australia.; CORe, Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia.; Neuroimmunology Centre, Department of Neurology, The Royal Melbourne Hospital City Campus, Parkville, Victoria, Australia.; CORe, Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia.; Department of Neurology, Center of Clinical Neuroscience, Charles University, Praha, Czech Republic.; General University Hospital in Prague, Praha, Czech Republic.; Department of Medical and Surgical Sciences and Advanced Technologies, University of Catania 'G.F. Ingrassia', Catania, Italy.; Department of Neurology, Isfahan University of Medical Sciences, Isfahan, Iran (the Islamic Republic of).; Dokuz Eylul University, İzmir, Turkey.; Neurology, Hospital Universitario Virgen Macarena, Sevilla, Spain.; Deptartment of Neuroscience, Imaging, and Clinical Sciences, Gabriele d'Annunzio University of Chieti and Pescara, Chieti, Italy.; UOSI Riabilitazione Sclerosi Multipla, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy.; Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Bologna, Italy.; Division of Neurology, Department of Medicine, Amiri Hospital, Kuwait City, Kuwait.; CHUM MS Center, Montreal, Quebec, Canada.; Universite de Montreal, Montreal, Quebec, Canada.; School of Medicine, Ondokuz Mayis Universitesi, Samsun, Turkey.; KTU Medical Faculty Farabi Hospital, Trabzon, Turkey.; Neuro Rive-Sud, Greenfield Park, Quebec, Canada.; Department of Neuroscience, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy.; CISSS de Chaudiere-Appalaches, Levis, Quebec, Canada.; Nehme and Therese Tohme Multiple Sclerosis Center, American University of Beirut Medical Center, Beirut, Lebanon.; Department of Neurology, American University of Beirut, Beirut, Lebanon.; Department of Neurology, Koc Universitesi, Istanbul, Turkey.; Koc University Research Center for Translational Medicine, Istanbul, Turkey.; Department of Neurology, Zuyderland Medical Centre Sittard-Geleen, Sittard-Geleen, The Netherlands.; School for Mental Health and Neuroscience, Maastricht University, Maastricht, The Netherlands.; University of Newcastle Hunter Medical Research Institute, Newcastle, New South Wales, Australia.; Department of Neurology, John Hunter Hospital, Newcastle, New South Wales, Australia.; Foundation National Neurological Institute C Mondino Institute for Hospitalization and Care Scientific, Pavia, Italy.; Department of Neurology, Faculty of Medicine, Hacettepe University, Ankara, Turkey.; Ospedali Riuniti di Salerno, Salerno, Italy.; Department of Neurology, St Vincent's University Hospital, Dublin, Ireland.; UOC Neurologia, Azienda Sanitaria Unica Regionale Marche - AV3, Macerata, Italy.; Royal Victoria Hospital, Belfast, UK.; Department of Neurology, Centro Hospitalar de São João, Porto, Portugal.; Department of Neurology, ASL3 Genovese, Genova, Italy.; Department of Rehabilitaiton, Casa di Cura Centro di Recupero e Rieducazione Funzionale Mons Luigi Novarese, Moncrivello, Italy.; Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB) and MS Center, Neurologic Clinic and Policlinic, Departments of Head, Spine and Neuromedicine and Clinical Research, University Hospital Basel, Basel, Switzerland.; University of Basel, Basel, Switzerland.; Liverpool Hospital, Sydney, New South Wales, Australia.; Flinders University, Adelaide, South Australia, Australia.; Department of Medicine and Surgery, University of Parma, Parma, Italy.; Groene Hart Ziekenhuis, Gouda, The Netherlands.; UQCCR, The University of Queensland, Brisbane, Queensland, Australia.; Nemocnice Jihlava, Jihlava, Czech Republic.; Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia.; Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia.; Department of Neurology, Galdakao-Usansolo Hospital, Galdakao, Spain.; Westmead Hospital, Westmead, New South Wales, Australia.; Universitair Ziekenhuis Gent, Gent, Belgium.; Department of Neurology, Razi University Hospital, Tunis, Tunisia.; Department of Neurology, University of Tunis El Manar, Tunis, Tunisia.; Department of Neurology, University of Tunis El Manar, Tunis, Tunisia.; Instituto de Investigacion Sanitaria Biodonostia, Hospital Universitario de Donostia, San Sebastian, Spain.; South and East Belfast Health and Social Services Trust, Belfast, UK.; Neurology, Hospital Universitario Reina Sofia, Cordoba, Spain.; Department of Medicine, Sultan Qaboos University Hospital, Seeb, Oman.; Sultan Qaboos University, Muscat, Oman.; University Hospital Geelong, Geelong, Victoria, Australia.; Department of Neurology, King Fahad Specialist Hospital-Dammam, Khobar, Saudi Arabia.; Department of Neurology, University of Debrecen, Debrecen, Hungary.; Department of Neurology, Hospital General de Alicante, Alicante, Spain.; Department of Neurology, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City, Mexico.; Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA.; CORe, Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia [email protected].; Neuroimmunology Centre, Department of Neurology, The Royal Melbourne Hospital City Campus, Parkville, Victoria, Australia.
Bant logo

© Copyright 2026, Nutrition Evidence

NED wishes to thank the following organisations for their support:

We use cookies to improve your experience and analyze site traffic with Google Analytics. By continuing to use our site, you agree to our use of cookies. Learn more.