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

Abstract

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;95:1099–1111