title: Efficacy and tolerability of oral versus injectable disease-modifying therapies for multiple sclerosis in clinical practice.
abstract: BACKGROUND
  The advent of oral disease-modifying therapies fundamentally changed the treatment of multiple sclerosis. Nevertheless, impressions of their relative efficacy and tolerability are primarily founded on expert opinion.
  
  
  OBJECTIVE
  The purpose of this study was to determine whether oral disease-modifying therapies were better tolerated and/or more effective for controlling multiple sclerosis compared to injectable therapies in clinical practice.
  
  
  METHODS
  Single-center, retrospective cohort study. 480 patients initiated oral (fingolimod, teriflunomide, or dimethyl fumarate) or injectable therapy between March 2013-March 2015 and follow-up data was collected for 5-31 months. Outcomes included on-drug multiple sclerosis activity and drug discontinuation. Cox proportional hazards models were used to control for baseline differences and sensitivity analyses using propensity-weighted matching were performed.
  
  
  RESULTS
  A higher proportion of teriflunomide-treated patients experienced multiple sclerosis activity compared to those treated with injectable therapies (p= 0.0053) in the adjusted model. Breakthrough multiple sclerosis was equally prevalent among fingolimod and dimethyl fumarate-treated compared to injectable therapy-treated patients. Of patients initiating a disease-modifying therapy, 32-46% discontinued or switched treatments during the study. After controlling for baseline differences, discontinuation rates were comparable across treatment groups.
  
  
  CONCLUSIONS
  In this cohort, oral and injectable disease-modifying therapies were equally well tolerated, but teriflunomide appeared less effective for controlling multiple sclerosis activity than injectable therapies. Further study is needed.
authors.affiliation: Department of Neurology, Yale University, USA; Department of Neurology, Washington University in St. Louis, USA.
authors.forename: Erin E
authors.initials: EE
authors.lastname: Longbrake
authors.affiliation: Department of Neurology, Washington University in St. Louis, USA.
authors.forename: Anne H
authors.initials: AH
authors.lastname: Cross
authors.affiliation: Division of Biostatistics, Washington University in St. Louis, USA.
authors.forename: Amber
authors.initials: A
authors.lastname: Salter
keywords: Multiple sclerosis; dimethyl fumarate; disease modifying therapy; fingolimod; teriflunomide; tolerability