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Immunotherapy for MS: No difference between the cheap and the expensive variant
That’s according to a new study of Norwegian and Swedish patients.
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Immunotherapy is not like regular medications. It forces your own immune system to help you.
For patients whose multiple sclerosis (MS) is diagnosed at an early stage, these medications have changed their prognosis.
“It has really revolutionized MS treatment," says Øivind Torkildsen.
Torkildsen is a professor of neurology at the University of Bergen and a senior consultant at the Department of Neurology at Haukeland University Hospital.
He and his Norwegian and Swedish colleagues have published a new study in The New England Journal of Medicine. It shows that the cheapest immunotherapy for MS, rituximab, is no worse than the much more expensive variant, ocrelizumab.
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Forcing the immune system to help
The two drugs are based on antibodies. They bind to a type of white blood cell called B cells.
These cells are actually supposed to alert the immune system about invaders such as viruses and bacteria. But because MS is an autoimmune disease, some of them sound the alarm about the person’s own cells instead.
More specifically, nerve cells.
This leads to inflammation in the brain and spinal cord that can eventually cause serious functional impairment.
But when the drug binds to the problematic blood cells, the immune system is directed against them instead.
Price plummeted when patent expired
Torkildsen believes the use of these antibodies is one of the most important happenings in the field of MS treatments.
“The fact that we can start such effective treatment right away means that we are largely able to stop the development of the disease,” he says.
But the cheapest antibody is not an officially approved treatment for MS.
Rituximab was approved in the US in 1997. At the time, it was the world's first antibody medicine against cancer.
Then the patent expired, and the price plummeted. At that time, no one invested money in expanding the documentation to apply to other diseases.
“Many people still chose to use it, because they thought it worked,” says one of the other researchers behind the new study, Andreas Lossius.
Lossius researches MS at the University of Oslo and is a senior consultant in neurology at Akershus University Hospital.
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216 patients from Norwegian and Swedish hospitals
At the same time, the pharmaceutical industry began to develop versions of the antibody.
One of the most promising antibodies that has emerged to treat MS is ocrelizumab. This has good, thorough documentation. In Norway, however, the experimental variant has been most widely used.
“It is considerably cheaper. Nevertheless, some critics have said that we do not have good enough evidence for the use of this drug, and that ocrelizumab is a safer choice,” says Lossius.
As a result, several Norwegian and Swedish hospitals have collaborated to carry out the new clinical study.
It went like this:
A total of 216 patients with newly diagnosed MS were randomly assigned to receive one of the two drugs. Neither the patients nor the doctors knew which of the drugs they were receiving.
The patients were treated for two years, and their brains were measured with MRI.
More than 90 per cent of patients in both groups experienced no flare-ups of the disease during the study period.
Good to see, says Danish MS researcher
Unlike in Norway, Danish health authorities have not approved the use of the cheapest antibody.
Jeppe Romme Christensen is a senior consultant and does research on MS at Rigshospitalet Glostrup in Denmark. He thinks it is good to see confirmation that the cheaper rituximab is not less effective than the more expensive antibody.
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This is especially important for the many MS patients who use this medication around the world, he said.
“It shows that this is not a treatment they are just getting because they couldn't think of anything else. It really is good treatment, both in terms of its effectiveness and probably also in terms of side effects,” says Christensen.
Easier to develop infections
Nevertheless, the use of antibodies is not without problems.
These drugs remove more than just the overzealous B cells. They also kill healthy B cells that are supposed to alert the body to invading viruses and bacteria.
That makes it easy for patients to become infected with many different diseases.
“The longer people have been on these treatments, the more often they get serious infections,” Christensen said.
But is there a difference in how many side effects the two drugs cause?
In the new study, more of those who received the cheapest drug experienced infections.
At the same time, the study is small and too short to be able to say anything for certain about side effects, particularly other types of side effects that occur very rarely, Christensen points out.
Studies underway in several countries
The answers may come in a few years.
Similar studies are underway in Denmark, the Netherlands and France.
Christensen is involved in the Danish study. Here they have also included patients who have tried other medications before.
A collaboration is now underway across countries.
The researchers want to find out whether the medications are equally effective and safe for different groups of patients. But not only that. They will also find out how the disease develops over many years.
Although previous research suggests that most people will be able to keep their disease in check with immunotherapy, this probably does not apply to everyone, Christensen points out.
An unanswered question is how many patients will slowly deteriorate over time.
Can save a lot of money
Øivind Torkildsen points out that the Norwegian health system could save lot of money by using the cheapest immunotherapy.
He and colleagues have previously estimated that it would cost the Norwegian health system NOK 500 million a year, or about EUR 46 million, if everyone were to be treated with the expensive medicine.
Andreas Lossius also points out that this may have even more significance elsewhere than in Norway.
“For health systems in other parts of the world that may not have as many resources, they see that they can give rituximab and be confident that it works just as well,” Lossius said.
Reference:
Ø. Torkildsen: Rituximab versus Ocrelizumab in Newly Diagnosed Relapsing Multiple Sclerosis. N Engl J Med, July 2026.
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Translated by Nancy Bazilchuk
Read the Norwegian version of this article at forskning.no
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