AAN 2026 | The comparative effectiveness of fumarates versus cladribine in people with MS
Regina Berkovich, MD, PhD, University of Southern California, Los Angeles, CA, discusses the comparative effectiveness of fumarates versus cladribine in people with multiple sclerosis (MS). Dr Berkovich highlights that both classes of medications are needed and can be suited for different scenarios, and that close monitoring of clinical and MRI responses is crucial in determining the best treatment approach. This interview took place at the 78th American Academy of Neurology (AAN) Annual Meeting in Chicago, IL.
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Transcript
So as we know, the question of potential effectiveness of the cladribine versus fumarates is completely empirical, of course, because we don’t have any clinical trials that would have compared one to another. And therefore, I have to rely on my clinical experience of using them. And either one class can be effective for different patients. But within the scenario of the same patient during different stages of life, there could be a need for one versus another...
So as we know, the question of potential effectiveness of the cladribine versus fumarates is completely empirical, of course, because we don’t have any clinical trials that would have compared one to another. And therefore, I have to rely on my clinical experience of using them. And either one class can be effective for different patients. But within the scenario of the same patient during different stages of life, there could be a need for one versus another. So in my view, according to my experiences, cladribine is closer to what we understand, high-efficacy therapy, and it has a robust effect, quite effective and quick to start expressing the anti-inflammatory effects and would be a very reliable medication to use in the scenarios when there is a need for high efficacy therapy. At the very same time, the fumarates can be very reliable disease-modifying therapies, especially for the patients who may not be in need of immediate, higher efficacy anti-inflammatory therapies. So coming from that scenario, of course, we understand that those two classes of medications could be very well suited for different scenarios. However, even within the same patient, there might be a situation that there could be a good reason to switch from one to another. And patients who did well on cladribine may continue on fumarates. Patients who previously failed fumarates may actually respond very well to the cladribine. So that’s why it’s hard to compare them even within the clinical setting in the absence of the immediate clinical trials of the class to evidence to provide it. So we can only rely on the clinical experiences. And I would say that definitely we need both. We need both classes. And we probably, in my view, the cladribine is closer to the higher efficacy disease-modifying therapy. Fumarates are very good for some of the patients who may not require higher efficacy therapy. However, in the setting when we, for example, switch from a different therapy, let’s say anti-CD20 or natalizumab, and we consider one versus another, in that particular setting, actually, we may see that fumarates can be surprisingly reliable. It’s not necessarily a promise for every single scenario, but we can actually see fumarates carrying on after the high efficacy therapy in a very good way. Either way, of course, every case is different, and every time we need to monitor the patient’s responses, and this is where I will heavily rely on the close monitoring clinical and MRI monitoring as well.
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