Table 1.

Efficacy ranking of approved therapies for multiple sclerosis^*

Drug	Era of development	Mechanism of action	Key considerations
Most effective
Natalizumab	Second	Monoclonal antibody against integrin-α4 in leukocytes	Risk of PML must be assessed via presence of JCV antibodies Substantial risk of relapse after discontinuation
Highly effective
Fingolimod	Second	Sphingosine S1P receptor modulator	Cardiac complications preclude use in individuals aged ≥50 years, and in those with history of cardiac disease VZV antibody testing must be conducted to mitigate risk of disseminated herpes zoster
Dimethyl fumarate	Third	Immunomodulator	Necessary to monitor lymphocyte count as risk mitigation against PML Gastrointestinal complications may limit use
Moderately effective
IFN-β	First	Immunomodulator	Well characterized long-term safety and efficacy profiles Patients should not be required to ‘fail’ treatment before receiving alternatives
Glatiramer acetate	First	Immunomodulator	Best safety profile for pregnant women with mild disease Patients should not be required to ‘fail’ treatment before receiving alternatives
Teriflunomide	Third	Pyrimidine synthesis inhibitor	Risk of teratogenicity precludes use in women who are, or intend to become, pregnant

^*Rankings are estimated on the basis of clinical trials, postapproval studies and few head-to-head comparisons. The factors that determine drug efficacy in any individual patient are largely undefined, and good clinical judgement is essential for treatment selection, especially in women of childbearing age. Abbreviations: JCV, polyomavirus JC; PML, progressive multifocal leukoencephalopathy; VZV, varicella zoster virus.