The post below has very little to do with the title of my post but it looks at what happens after rituximab and they recon that cladribine is the next most cost effective drug. People getting rituximab switch after side effects such as infections related to loss of circulating antibody or because of breakthrough disease activity.
Now the way I understand it, the budgets for neurology treatment was put in the hands of neurologists by the Government and they thought why not use the cheapest most effective treatments and they shunned the licenced expensive MS drugs in favour of off-label rituximab and rituxiland (neigbouring country to Norway) was born…
However, I suspect we could be entering a new era and that is following the end of the patent of cladribine tablets. It has become generic and if there is any real competition then the price should drop and it should be way cheaper than rituximab as it really should not cost as much to make. So will rituxiland now pick cladribine?
However greed will no doubt fuel the minds some generic makers and I can see that happening in the US already and they will charge top dollar….Maybe the Indian Generics Makers will now help cladribine become the MS essential medicine that the World Health Organisation dreamt of and send the bird to the greedy generic makers in the West. The list price for 10mg tablet was about £2,000 in UK and was about $10,000 at tablet in US. Buy cladribine from the same company that manufactures the clinical tablet and the chemical stuff costs £18 for 10mg and they make a profit on this, so the generic manufacturers would be scumbags to charge anything like the current cost.
Will rituxiland become Mavenland (I doubt it see below)….or Cladland?
In the UK the label was changed from oral cladribine being a second line to it being a first line drug…so you can use it early….I have noticed that the manufacturers of the current licenced cladribine tablets (formally known as Mavenclad) have been getting ready for generic time….They have probably being on a diet, not to shed fat, but to shed sales staff and they have even given Mavenclad a new name…..Cladribine Merck. Sadly I suspect that ECTRIMS will be minus the boys and girls from German Merck as their MS portfolio has turned to ash. Will the other companies call it generic Cladribine Merck, or perhaps Cladribine Sandoz/Cladribine Teva? or oral cladribine.
Will NICE dictate that everyone with newly diagnosed MS start with cladribine, after all there is evidence that it works at the onset of demyelinating disease. The Norwegian study indicates there is value after a CD20 switch. The World of MS is about to change with a generic chemical.
In 2011 Cladribine tablets was killed off, it was resurected with the work of ProfK and others…Is is a next easter drug:-)
Huygens S, Versteegh M, Berg-Hansen P, Bjelland SH, Holmøy T, Torkildsen Ø. Cost-effectiveness of treatment sequences following first-line rituximab in relapsing-remitting multiple sclerosis: a Norwegian microsimulation study. Front Neurol. 2026;17:1783506.
Background: The Norwegian guideline recommends highly effective disease-modifying therapies (DMTs) as the first line treatment for multiple sclerosis (MS), with rituximab preferred in clinical practice. While rituximab is effective, patients may discontinue due to side-effects or develop disease activity. Limited guidance exists on optimal switches following first line rituximab.
Objectives: To estimate the costs and effects of different treatment sequences following first line rituximab in relapsing remitting MS patients in Norway.
Design: A microsimulation model adapted to the Norwegian setting estimated outcomes for different treatment sequences following first line rituximab. Four neurologists were interviewed using a structured expert elicitation tool to inform switching behavior. The model allowed for three treatment lines after rituximab, with switches possible to fingolimod, ponesimod, cladribine tablets, or natalizumab.
Methods: The model simulated all 32 possible treatment sequences and calculated costs per quality adjusted life year (QALY) according to Norwegian pharmacoeconomic guidelines.
Results: Neurologists were more likely to switch patients with more than relapse (78%) or relapse and disability progression (66%) versus one relapse (54%). The most cost-effective sequence after rituximab is cladribine tablets (line 2), ponesimod (line 3), and natalizumab (line 4). The probability that second line cladribine tablets are most cost-effective is >75%. Mean time on first line rituximab was 15.2 years. The model predicts that over lifetime 21% of patients would require a fourth line of treatment due to the cumulative effects of discontinuation and recurring disease activity triggering treatment switches.
Conclusion: Patients on first line rituximab may require a treatment switch due to side-effect induced discontinuation or new disease activity. If a switch from rituximab to another DMT is the preferred clinical course of action, this study showed that it is most cost-effective to switch to cladribine tablets followed by ponesimod and natalizumab.
Source: multiple-sclerosis-research.org