Rituximab or Fingolimod for RRMS Patients Switching From Natalizumab?

MS IV infusion
MS IV infusion
Patients stable on natalizumab may need to switch therapy based on JC-virus antibody positivity.

Rituximab appears to be more effective at preventing clinical relapse compared to fingolimod in patients with relapsing-remitting multiple sclerosis (RRMS) who were previously stable on natalizumab.

Despite no disease activity, RRMS patients who are stable on natalizumab may switch to other therapies due to JC-virus antibody positivity.

In order to compare outcomes in RRMS patients who switch to rituximab or fingolimod, Peter Alping, of Karolinska Institutet in Stockholm, Sweden, and colleagues compared clinical relapse data from 3 Swedish MS centers. In total, 256 patients were included in the analyses, of whom 55% switched to fingolimod.

Within 18 months of switching from natalizumab, 1.8% of patients taking rituximab and 17.6% of patients taking fingolimod experienced a clinical relapse (hazard ratio for rituximab 0.10 (95% CI: 0.02-0.43). The hazard ratios for adverse events and treatment discontinuation were 0.25 (95% CI: 0.10-0.59) and 0.07 (95% CI: 0.02-0.30), respectively. Adverse events occurred in 5.3% of patients taking rituximab versus 21.1% of those taking fingolimod, and treatment discontinuation occurred in 1.8% of patients taking rituximab versus 28.2% of those taking fingolimod.

Researchers also recorded contrast-enhancing lesions in 24.2% of patients taking fingolimod compared to 1.4% of patients taking rituximab. These differences remained after adjusting for confounders including age, sex, disability status, treatment duration on natalizumab, washout time, follow-up time, and study center.

Overall, the results suggest that rituximab has superior effectiveness and tolerability compared to fingolimod in JC-virus antibody positive-patients switching from natalizumab.


Alping P, Frisell T, Novakova L, et al. Rituximab versus fingolimod after natalizumab in multiple sclerosis patients. Ann Neurol. 2016; doi:10.1002/ana.24651.