Cladribine tablets in people with relapsing multiple sclerosis: A real-world multicentric study from southeast European MS centers

Real world experience with cladribine tablets for multiple sclerosis at four academic multiple sclerosis centers

BACKGROUND

Cladribine tablets (CladT) are a multiple sclerosis (MS) disease-modifying therapy (DMT) with safety and efficacy established in the CLARITY trial and extension. A better understanding of the role of CladT in real-world populations is needed, including the clinical and radiographic trajectories of persons with MS (PwMS) treated with CladT and how CladT compares to other MS DMTs.

METHODS

PwMS receiving CladT at 4 tertiary MS centers were identified and characterized. A validated electronic neuroperformance test adapted from the Multiple Sclerosis Functional Composite was administered at each visit, which provides z-scores for the Walking Speed Test (zWST), Manual Dexterity Test (zMDT), and the Processing Speed Test (zPST). The Patient Determined Disease Steps (PDDS) and NeuroQoL patient-reported outcomes are also administered. Regression modeling using generalized estimating equations was used to compare neuroperformance testing and brain MRI metrics at 6-, 12-, 18-, and 24-months to baseline. In a comparative effectiveness analysis, PwMS receiving other DMTs were propensity matched to CladT treated PwMS on variables including age, race, and disease duration. Outcomes were then compared at the same time points.

RESULTS

We identified 117 PwMS treated with CladT who had an average age of 46.7 years (SD=10.5) and average disease duration of 13.2 years (SD=5.6). Relative to baseline, there were no significant differences in zMDT and zPST at any time point. There were significant increases in zWST over the study duration, suggesting improvement in walking speed, and PDDS scores remained stable during the study period. The odds of new T2 lesions relative to baseline were lower at all time points, but this did not reach significance. There were significantly lower odds of gadolinium enhancing (GdE) lesions at 6- and 18- months relative to baseline. Twelve PwMS (11 %) started a post-CladT DMT. We matched 476 PwMS on alternative DMT (most commonly ocrelizumab, n=280, 58.8 %) to CladT-treated PwMS. zWST scores were significantly better among those receiving other CladT at 12-, 18-, and 24 months, and NeuroQoL fatigue scores also favored the CladT-treated group. Odds of new T2 and GdE lesions were higher among those receiving CladT initially, but the disparity was no longer evident at 24-months (p=0.77 and p=0.55 respectively).

CONCLUSION

Real-world data for PwMS receiving CladT suggest it is prescribed to older patients with longer disease durations than in the pivotal trials. The pre-post analysis and the comparative effectiveness analysis suggested good performance of CladT in this broader population. There may be a delayed effect of CladT on radiographic outcomes relative to other DMTs.

Administration and Monitoring Burden of High-Efficacy Disease-Modifying Therapies for Multiple Sclerosis: A Delphi Consensus of Clinical Experts from Saudi Arabia

INTRODUCTION

The emergence of high-efficacy disease-modifying therapies (HE DMT) for multiple sclerosis (MS) may pose challenges to the administration and monitoring burden of the therapies. This article presents the results of the Delphi consensus method to generate insights from experts on the administration and monitoring burden of HE DMT in Saudi Arabia with a special focus on cladribine.

METHODS

Between January and March 2023, a two-round modified Delphi method was used to establish consensus regarding the administration and monitoring burden of HE DMTs used for MS. Through a questionnaire, the advisors evaluated 17 properties of six individual HE DMTs on the basis of their clinical experience. Advisors were required to rank each property on a scale of 1-5, with 1 being the lowest burden and 5 being the highest burden.

RESULTS

Experts ranked cladribine as having the lowest monitoring burden, followed by ofatumumab and ocrelizumab. Natalizumab and fingolimod were ranked fourth, and alemtuzumab had the highest burden. During the first round, experts agreed on the scores of the administration burden properties, except for hospital visit time and facility use during administration for ofatumumab, route of administration for fingolimod, monitoring of specific side effects and frequency of lab tests at follow-up, and the washout period for natalizumab. During the second round, there was agreement on all properties.

CONCLUSION

In the absence of alternative scientific data, recommendations from experts and their consensus provide useful insights into the administration and monitoring burden of HE DMTs used for MS in Saudi Arabia.

Holistic, Long-Term Management of People with Relapsing Multiple Sclerosis with Cladribine Tablets: Expert Opinion from France

Cladribine tablets (CladT) has been available for therapeutic use in France since March 2021 for the management of highly active relapsing multiple sclerosis (RMS). This high-efficacy disease-modifying therapy (DMT) acts as an immune reconstitution therapy. In contrast to most high-efficacy DMTs, which act via continuous immunosuppression, two short courses of oral treatment with CladT at the beginning of years 1 and 2 of treatment provide long-term control of MS disease activity in responders to treatment, without the need for any further pharmacological treatment for several years. Although the labelling for CladT does not provide guidance beyond the initial treatment courses, real-world data on the therapeutic use of CladT from registries of previous clinical trial participants and patients treated in routine practice indicate that MS disease activity is controlled for a period of years beyond this time for a substantial proportion of patients. Moreover, this clinical experience has provided useful information on how to initiate and manage treatment with CladT. In this article we, a group of expert neurologists from France, provide recommendations on the initiation of CladT in DMT-naïve patients, how to switch from existing DMTs to CladT for patients with continuing MS disease activity, how to manage patients during the first 2 years of treatment and finally, how to manage patients with or without MS disease activity in years 3, 4 and beyond after initiating treatment with CladT. We believe that optimisation of the use of CladT beyond its initial courses of treatment will maximise the benefits of this treatment, especially early in the course of MS when suppression of focal inflammation in the CNS is a clinical priority to limit MS disease progression.