Rituximab vs Ocrelizumab in Relapsing-Remitting Multiple Sclerosis
Authors: Roos Izanne , Hughes Stella , McDonnell Gavin , Malpas Charles B. , Sharmin Sifat , Boz Cavit , Alroughani Raed , Ozakbas Serkan , Buzzard Katherine , Skibina Olga , van der Walt Anneke , Butzkueven Helmut , Lechner-Scott Jeannette , Kuhle Jens , Terzi Murat , Laureys Guy , Van Hijfte Liesbeth , John Nevin , Grammond Pierre , Grand’Maison Francois , Soysal Aysun , Jensen Ana Voldsgaard , Rasmussen Peter Vestergaard , Svendsen Kristina Bacher , Barzinji Ismael , Nielsen Helle Hvilsted , Sejbæk Tobias , Prakash Sivagini , Stilund Morten Leif Munding , Weglewski Arkadiusz , Issa Nadia Mubder , Kant Matthias , Sellebjerg Finn , Gray Orla , Magyari Melinda , Kalincik Tomas ,   MSBase Study GroupDanish MS Registry Study Group, Cabrera-Gomez Jose Antonio , Roullet Etienne , Zwanikken Cees , Den braber-Moerland Leontien , Barnett Michael , Hodgkinson Suzanne , Garber Justin , Slee Mark , McCombe Pamela , Taylor Bruce , MacDonell Richard , Massey Jennifer , Van Pesch Vincent , Decoo Danny , Willekens Barbara , Fragoso Yara , Prevost Julie , Prat Alexandre , Girard Marc , Grammond Pierre , Larochelle Catherine , Oh Jiwon , Lalive Patrice , Gobbi Claudio , Horakova Dana , Havrdova Eva , Ampapa Radek , Izquierdo Guillermo , Eichau Sara , Sanchez-Menoyo Jose L. , Ramo-Tello Cristina , Blanco Yolanda , Saiz Albert , Besora Sarah , Shaygannejad Vahid , Cartechini Elisabetta , Diamanti Matteo , Amato Maria Pia , Spitaleri Daniele , Patti Francesco , Chisari Clara , D'Amico Emanuele , Salvatore Lo Fermo , Yamout Bassem , Khoury Samia J. , Al-Asmi Abdullah , Jose Sa Maria , Al-Harbi Talal , Karabudak Rana , Turkoglu Recai , Kilpatrick Trevor , King John , Nguyen Ai-Lan , Dwyer Chris , Monif Mastura , Taylor Lisa , Baker Josephine 
Published: June 2023

ImportanceOcrelizumab, a humanized monoclonal antibody targeted against CD20+ B cells, reduces the frequency of relapses by 46% and disability worsening by 40% compared with interferon beta 1a in relapsing-remitting multiple sclerosis (MS). Rituximab, a chimeric monoclonal anti-CD20 agent, is often prescribed as an off-label alternative to ocrelizumab.ObjectiveTo evaluate whether the effectiveness of rituximab is noninferior to ocrelizumab in relapsing-remitting MS.Design, Setting, and ParticipantsThis was an observational cohort study conducted between January 2015 and March 2021. Patients were included in the treatment group for the duration of study therapy and were recruited from the MSBase registry and Danish MS Registry (DMSR). Included patients had a history of relapsing-remitting MS treated with ocrelizumab or rituximab, a minimum 6 months of follow-up, and sufficient data to calculate the propensity score. Patients with comparable baseline characteristics were 1:6 matched with propensity score on age, sex, MS duration, disability (Expanded Disability Status Scale), prior relapse rate, prior therapy, disease activity (relapses, disability accumulation, or both), magnetic resonance imaging lesion burden (missing values imputed), and country.ExposureTreatment with ocrelizumab or rituximab after 2015.Main outcomes and MeasuresNoninferiority comparison of annualized rate of relapses (ARRs), with a prespecified noninferiority margin of 1.63 rate ratio. Secondary end points were relapse and 6-month confirmed disability accumulation in pairwise-censored groups.ResultsOf the 6027 patients with MS who were treated with ocrelizumab or rituximab, a total of 1613 (mean [SD] age; 42.0 [10.8] years; 1089 female [68%]) fulfilled the inclusion criteria and were included in the analysis (898 MSBase, 715 DMSR). A total of 710 patients treated with ocrelizumab (414 MSBase, 296 DMSR) were matched with 186 patients treated with rituximab (110 MSBase, 76 DMSR). Over a pairwise censored mean (SD) follow-up of 1.4 (0.7) years, the ARR ratio was higher in patients treated with rituximab than in those treated with ocrelizumab (rate ratio, 1.8; 95% CI, 1.4-2.4; ARR, 0.20 vs 0.09; P &amp;lt; .001). The cumulative hazard of relapses was higher among patients treated with rituximab than those treated with ocrelizumab (hazard ratio, 2.1; 95% CI, 1.5-3.0). No difference in the risk of disability accumulation was observed between groups. Results were confirmed in sensitivity analyses.ConclusionIn this noninferiority comparative effectiveness observational cohort study, results did not show noninferiority of treatment with rituximab compared with ocrelizumab. As administered in everyday practice, rituximab was associated with a higher risk of relapses than ocrelizumab. The efficacy of rituximab and ocrelizumab administered at uniform doses and intervals is being further evaluated in randomized noninferiority clinical trials.