Cladribine for people with multiple sclerosis.

rationaleMultiple sclerosis (MS) is a chronic, degenerative, autoimmune-mediated disease of the central nervous system (CNS). Although its pathogenesis is not fully understood, inflammation involving both T and B cells is considered an essential factor. Cladribine induces targeted lymphocyte depletion in the peripheral and central nervous system, potentially lowering inflammation and slowing disease progression.

objectivesTo assess the short- and long-term benefits and harms of cladribine compared to no intervention, placebo, or any other disease-modifying drugs (DMDs) in people with any form of multiple sclerosis (MS). SEARCH

methodsWe searched the Cochrane MS and Rare Diseases of the CNS Trials Register (part of CENTRAL), MEDLINE, Embase, CINAHL, LILACS, major trials registries, and conference abstracts up to 3 February 2025. ELIGIBILITY CRITERIA: We included randomised controlled trials (RCTs), their open-label extension trials (OLEs), the first phase of cross-over trials, and non-randomised studies of interventions (NRSIs) that investigated cladribine, alone or in combination, at any dose or duration versus no intervention, placebo, or any other DMDs. Participants had a confirmed diagnosis of MS or clinically isolated syndrome according to accepted criteria. We excluded retrospective studies and studies without a comparison group. OUTCOMES: Critical outcomes Number of participants at the end of follow-up: with at least one serious adverse event (SAE), free from disability worsening, with no evidence of disease activity (NEDA), who withdrew from treatment, and with cognitive impairment; and quality of life. Important outcomes Number of participants at the end of follow-up with: at least one advert event, at least one new relapse, and new gadolinium-enhancing positive T1-weighted (Gd+ T1) or new/enlarging T2-weighted magnetic resonance imaging (MRI) lesions. RISK OF BIAS: We used the Cochrane risk of bias tools RoB 2 (for RCTs and OLEs) and ROBINS-I (for NRSIs). SYNTHESIS

methodsWe conducted random-effects meta-analyses to calculate risk ratios (RRs) with 95% confidence intervals (CIs), assessing RCTs, OLEs, and NRSIs separately. We assessed the certainty of evidence using GRADE. INCLUDED STUDIES: We included 15 studies: nine RCTs (follow-up 52-96 weeks; 2571 participants), two medium-term follow-up OLEs (24-96 weeks; 915 participants), two long-term follow-up OLEs (9.5-11.4 years), one NRSI with one year of follow-up (37 participants in cladribine group vs 599 in interferon beta [IFN-β], fingolimod, and natalizumab groups), and one NRSI with three years of follow-up (633 participants in cladribine group vs 2842 in fingolimod, dimethyl fumarate, and teriflunomide groups). Three reports assessed MRI outcomes. No studies reported quality of life or cognitive impairment. SYNTHESIS OF

resultsRandomised controlled trials Cladribine compared to placebo may have little to no effect on the risk of SAEs (RR 1.08, 95% CI 0.80 to 1.45; 8 studies, 2495 participants) and treatment withdrawal (RR 1.43, 95% CI 0.77 to 2.66; I² = 76%; 8 studies, 2503 participants), but the evidence for both outcomes is very uncertain. Cladribine may have little to no effect on the number of people remaining free from disability worsening up to 24 months (RR 1.05, 95% CI 0.96 to 1.16; 3 studies, 1549 participants; low certainty). Cladribine compared to placebo may increase the risk of any adverse events, but the evidence is very uncertain (RR 1.14, 95% CI 1.02 to 1.28; 8 studies, 2405 participants). Cladribine likely reduces the risk of new relapses (RR 0.53, 95% CI 0.45 to 0.62; 2 studies, 1498 participants; moderate certainty), and it may reduce the risk of new Gd+ T1 MRI lesions, although the results are heterogeneous and the evidence is very uncertain (RR 0.30, 95% CI 0.19 to 0.47; I² = 79%; 4 studies, 2153 participants). Open-label extension trials With follow-up beyond two years, cladribine compared to placebo may have little to no effect on the risk of SAEs (RR 0.89, 95% CI 0.60 to 1.33; 2 studies, 915 participants), freedom from disability worsening (RR 1.02, 95% CI 0.93 to 1.11; 1 study, 806 participants), and treatment withdrawal (RR 0.93, 95% CI 0.81 to 1.08; 2 studies, 915 participants), but the evidence is very uncertain for all three outcomes. Cladribine may increase the proportion of people with NEDA at four years (RR 1.63, 95% CI 1.23 to 2.16; 2 studies, 662 participants; low certainty). Cladribine compared to placebo may have little to no effect on the risk of any adverse events (RR 1.04, 95% CI 0.96 to 1.12; 2 studies, 916 participants) and may reduce relapses at long-term follow-up (RR 0.68, 95% CI 0.59 to 0.79; 2 studies, 662 participants), but the evidence is very uncertain for both outcomes. In one study, cladribine reduced new Gd+ T1 MRI lesions, but the evidence is very uncertain (RR 0.68, 95% CI 0.52 to 0.88; 806 participants). Non-randomised studies of interventions Observational comparisons (1 study) showed reductions in relapse over three years with cladribine versus: • dimethyl fumarate (RR 0.57, 95% CI 0.38 to 0.88; low certainty); • teriflunomide (RR 0.30, 95% CI 0.20 to 0.47; moderate certainty); and • fingolimod (RR 0.51, 95% CI 0.36 to 0.74; moderate certainty). However, the evidence is very uncertain for the effect of cladribine on relapse over 12 months versus: • fingolimod (RR 1.05, 95% CI 0.52 to 2.10; very low certainty); • natalizumab (RR 1.25, 95% CI 0.58 to 2.71; very low certainty); and • interferon beta (RR 0.65, 95% CI 0.26 to 1.62; very low certainty). AUTHORS'

conclusionsCladribine is an oral treatment for adults with MS requiring few monitoring visits and only short courses over two years, thereby reducing treatment burden, with a safety profile that appears acceptable based on very low-certainty evidence. Evidence from RCTs suggests cladribine likely reduces new relapses, may reduce new Gd+ T1 MRI lesions (although the evidence is very uncertain), but may have little to no effect on slowing disability progression. Results from OLEs showed cladribine may increase the proportion of people with NEDA at four years. Benefits in subgroups and for some critical outcomes remain uncertain due to the paucity of studies. Further high-quality controlled trials and patient-centred pragmatic registries are needed to strengthen the evidence base.

fundingThis Cochrane review had no dedicated funding. REGISTRATION: Protocol available via https://doi.org/10.1002/14651858.CD013524.