Related Experiment Video
Updated: Apr 4, 2026
A Method of Trigonometric Modelling of Seasonal Variation Demonstrated with Multiple Sclerosis Relapse Data
Published on: December 9, 2015
Cost-effectiveness of treatment sequences following first-line rituximab in relapsing-remitting multiple sclerosis: a
Simone Huygens1, Matthijs Versteegh1, Pål Berg-Hansen2
1Huygens and Versteegh B.V., Zwijndrecht, Netherlands.
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 >1 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.
