Decreasing Multiple Sclerosis Treatment Expenditures and Improving Quality at the Health System Level

Langer‐Gould, Annette; Cheng, Stephen C.; Li, Bonnie H.; Smith, Jessica; Kanter, Michael H.

doi:10.1002/ana.26352

Cited by 12 publications

(7 citation statements)

References 13 publications

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“…Additionally, a study by a US healthcare provider indirectly assessed the cost-effectiveness of rituximab as part of the evaluation of their MS treatment optimization program. 32 They found that expert-led health system intervention, including the use of off-label rituximab, reduced both MS DMT costs and MS relapse rates. However, many clinicians were reluctant to prescribe rituximab because of its off-label status and perceived uncertainties regarding its safety and effectiveness.…”

Section: Discussionmentioning

confidence: 99%

“…Although severely limited by their size or use of simulation instead of real‐world data, the results were broadly in line with our findings. Additionally, a study by a US healthcare provider indirectly assessed the cost‐effectiveness of rituximab as part of the evaluation of their MS treatment optimization program 32 . They found that expert‐led health system intervention, including the use of off‐label rituximab, reduced both MS DMT costs and MS relapse rates.…”

Section: Discussionmentioning

confidence: 99%

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Real‐World Healthcare Cost Savings and Reduced Relapse Rate with Off‐Label Rituximab versus Disease‐Modifying Treatments Approved for Relapsing–Remitting Multiple Sclerosis: A Nationwide Cost‐Effectiveness Study

Alping,

Neovius,

Piehl

et al. 2024

Annals of Neurology

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ObjectiveAlthough off‐label use of rituximab is a common alternative to disease‐modifying therapies (DMTs) approved for multiple sclerosis (MS) in several countries, the impact of this on treatment cost‐effectiveness is not well known.MethodsWe evaluated the relative cost‐effectiveness of rituximab and MS‐approved DMTs in a register‐based cohort study of Swedish residents with relapsing–remitting MS, aged 18–65 years, starting treatment with rituximab, natalizumab, fingolimod, or dimethyl fumarate between January 2010 and July 2016, and followed through July 2021 (n = 5,924). By linking the population‐based Swedish MS register to several Swedish health care and demographic registers, we estimated health care costs in relation to number of relapses, over 5 years from treatment start. Differences between treatments were estimated in inverse probability of treatment‐weighted regression models, adjusting for a broad range of potential confounders covering demographics, medical history, and MS‐related clinical characteristics.ResultsOff‐label rituximab was associated with both lower total health care costs (mean cost savings ranged $35,000–$66,000 vs. each approved DMT), and fewer relapses (mean number of prevented relapses ranged 0.12–0.22), per started therapy over 5 years. Results were robust to variations in discounting and pricing of health care visits, with the main driver of cost‐savings being the price of the index drug itself.InterpretationThe cost‐effectiveness of rituximab dominated the MS‐approved alternatives. Off‐label, low‐dose rituximab should be considered for persons with MS and could reduce barriers to treatment, especially in resource‐limited settings. ANN NEUROL 2024

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Real‐World Healthcare Cost Savings and Reduced Relapse Rate with Off‐Label Rituximab versus Disease‐Modifying Treatments Approved for Relapsing–Remitting Multiple Sclerosis: A Nationwide Cost‐Effectiveness Study

Alping,

Neovius,

Piehl

et al. 2024

Annals of Neurology

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“…Expertise in neuroimmunology would greatly help this, but, when unavailable, data from real-world treatment courses are needed. These can also help in designing health system interventions that decrease the burden on both the patient and the health care system in finding the appropriate DMT while simultaneously providing better disease control [ 13 ].…”

Section: Discussionmentioning

confidence: 99%

Treatment Courses of Patients Newly Diagnosed with Multiple Sclerosis in 2012–2018

Sipilä

2023

JCM

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Treatment options for multiple sclerosis (MS) are now numerous, but it is unclear which Disease-Modifying Treatment (DMT) is the optimal choice for a given patient. Treatment switches are common, both because of side effects and because of lack of efficacy. There are few data available on the treatment courses of patients newly diagnosed with MS in the current DMT era. All patients newly diagnosed with MS in 2012–2018 at North Karelia Central Hospital were identified (N = 55), and those with complete follow-up data available (N = 43) were included. The minimum follow-up from diagnosis was 44 months with a maximum of 9 years. Seven patients (16%) had no DMT at any time during the follow-up. Treatment was most often initiated with interferon or glatiramer acetate (69%), but 72% of these treatments were discontinued. After cladribine, teriflunomide and fingolimod showed the best treatment persistence. Patients who experienced their first MS symptoms at ≥40 years of age all continued with their initial treatment category until the end of the follow-up. In a third of the patients who had received a DMT, at the end of the follow-up, the treatment had been escalated to fingolimod, cladribine or natalizumab. Only 13 patients (28%) continued with their initial DMT until the end of the follow-up.

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“…Rituximab biosimilars have marked affordability, efficacy, and convenience advantages over other DMTs, particularly in countries with poor access to MS specialty care and unaffordable drug prices, including the US. 28 The low risk of hospitalization for COVID-19 among mRNA-vaccinated individuals with MS receiving rituximab should not preclude rituximab use. Instead, expanding access to SARS-CoV-2 vaccines for individuals receiving rituximab therapy in low-and middle-income countries should be prioritized.…”

Section: Discussionmentioning

confidence: 99%

Analysis of Rituximab Use, Time Between Rituximab and SARS-CoV-2 Vaccination, and COVID-19 Hospitalization or Death in Patients With Multiple Sclerosis

Smith¹,

Gonzales²,

Li³

et al. 2022

JAMA Netw Open

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ImportanceRituximab and other B-cell–depleting therapies blunt humoral responses to SARS-CoV-2 vaccines, particularly when the vaccine is administered within 6 months of an infusion. Whether this translates into an increased risk of hospitalization or death from COVID-19 is unclear.ObjectivesTo examine whether rituximab treatment is associated with an increased risk of hospitalization for COVID-19 among SARS-CoV-2–vaccinated persons with multiple sclerosis (MS) and whether delaying vaccination more than 6 months after rituximab treatment is associated with decreased risk.Design, Setting, and ParticipantsThis retrospective cohort study used Kaiser Permanente Southern California’s electronic health record to identify individuals from January 1, 2020, to February 15, 2022, who had MS and who had been vaccinated against SARS-CoV-2.ExposuresRituximab treatment compared with disease-modifying therapies (DMTs) that do not interfere with vaccine efficacy or being untreated (no or other DMT group). Among rituximab-treated patients, the exposure was receiving at least 1 vaccine dose more than 6 months after their last infusion compared with receiving all vaccine doses 6 months or less since their last infusion.Main Outcomes and MeasuresThe main outcome was hospitalization due to COVID-19 infection. The odds of infection resulting in hospitalization following SARS-CoV-2 vaccination were adjusted for race and ethnicity, advanced MS-related disability; vaccine type; booster dose; and, among rituximab-treated only analyses, cumulative rituximab dose and dose at last infusion. Exposures, outcomes, and covariates were collected from the electronic health record.ResultsAmong 3974 SARS-CoV-2–vaccinated people with MS (mean [SD] age, 55.3 [15] years; 2982 [75.0%] female; 103 [2.6%] Asian or Pacific Islander; 634 [16.0%] Black; 953 [24.0%] Hispanic; 2269 [57.1%] White; and 15 [0.3%] other race or ethnicity), rituximab-treated patients (n = 1516) were more likely to be hospitalized (n = 27) but not die (n = 0) compared with the 2458 individuals with MS receiving no or other DMTs (n = 7 and n = 0, respectively; adjusted odds ratio [aOR] for hospitalization, 7.33; 95% CI, 3.05-17.63). Receiving messenger RNA (mRNA) SARS-CoV-2 vaccine (aOR, 0.36; 95% CI, 0.15-0.90; P = .03) and receiving a booster vaccination (aOR, 0.31; 95% CI, 0.15-0.64; P = .002) were independently associated with a decreased risk of hospitalization for COVID-19. Among vaccinated rituximab-treated individuals with MS, receiving any vaccination dose more than 6 months after the last rituximab infusion was associated with a reduced risk of COVID-19 hospitalization (aOR, 0.22; 95% CI, 0.10-0.49).Conclusions and RelevanceThis cohort study’s findings suggest that rituximab-treated people with MS should be strongly encouraged to receive mRNA SARS-CoV-2 vaccines and boosters more than 6 months after their last rituximab infusion whenever possible. The low absolute risk of hospitalization for COVID-19 among mRNA-vaccinated individuals with MS should not preclude use of rituximab, which has marked efficacy, cost, and convenience advantages over other DMTs.

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Decreasing Multiple Sclerosis Treatment Expenditures and Improving Quality at the Health System Level

Cited by 12 publications

References 13 publications

Real‐World Healthcare Cost Savings and Reduced Relapse Rate with Off‐Label Rituximab versus Disease‐Modifying Treatments Approved for Relapsing–Remitting Multiple Sclerosis: A Nationwide Cost‐Effectiveness Study

Real‐World Healthcare Cost Savings and Reduced Relapse Rate with Off‐Label Rituximab versus Disease‐Modifying Treatments Approved for Relapsing–Remitting Multiple Sclerosis: A Nationwide Cost‐Effectiveness Study

Treatment Courses of Patients Newly Diagnosed with Multiple Sclerosis in 2012–2018

Analysis of Rituximab Use, Time Between Rituximab and SARS-CoV-2 Vaccination, and COVID-19 Hospitalization or Death in Patients With Multiple Sclerosis

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