Ocrelizumab, teriflunomide and dymethylfumarate are becoming increasingly available and useful in therapy of multiple sclerosis. Ocrelizumab has been shown to be superior to interferon already in the first few weeks of use.

Barkhoff et al. Neurology 2019, 93:e1778-e1786

These investigators looked at MRI and clinically assessed disease activity in 1800 patientsw ho had participated in 3 international trials of ocrelizumab betyween 2008 and 2015. In the first ocrelizumab was compared to placebo. In the 2 later trials, to interferon. They underwent MRI scanning and clinical evaluations every 4-8 weeks during the trials. The reduction in disease activity was clear at 4 weeks and 8 weeks, on MRI and clinically, in the placebo and interferon studies, respectively.

Teriflunomide and dymethylfumarate are 2 oral treatments that have been approved for clinical use in people with relapse and remmission multiple sclerosis. They come to occupy the space that was used by azathioprine in the 1980s and 1990s, and by fingolimod more recently. Teriflunomide and dymethyl fumarate have already been demontrated to be superior to placebo and to interferon in a number of studies. Now they have been shown to have similar effects in multiple sclerosis.

David-Axel Laplaud et al. Neurology 2019, 93: e635-e646

During 2014-2016 investigators compared the 2 treatments in 1770 patients in 34 treatment centers in France. Relapse rates were similar in the 2 groups, around 20% within 1 and 30% within 2 years of treatment. There were no changes in disability scores in this period.

It is possible then to predict that patients may benefit from ocrelizumab, teriflunomide and dymethylfumarate. The 2 latter drugs, available orally and marginally superior to interferon, may be indicated in patients with remission and relapse multiple sclerosis, or with isolated syndromes, when their investigation indicates prognosis of a mild disease. On the other hand, ocrelizumab may be indicated in patients who are demonstrated to have a worse prognosis and the possibility of a faster evolution to progressive mutiple sclerosis.

Dr Paulo Bittencourt

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