# Real-world comparison of lymphopenia profiles in S1P receptor modulators for multiple sclerosis: a multicenter retrospective study

## TL;DR

This study compares how different S1P receptor modulators used for multiple sclerosis affect lymphopenia in real-world patients.

## Contribution

The first real-world, head-to-head observational study comparing lymphopenia profiles among different S1P modulators.

## Key findings

- Ozanimod and Ponesimod showed higher lymphocyte counts than Siponimod and Fingolimod at various time points.
- Severe lymphopenia was more common with Siponimod compared to Ponesimod and Ozanimod.
- Grade 4 lymphopenia was observed in Ozanimod and Siponimod at three months.

## Abstract

Sphingosine-1-phosphate (S1P) receptor modulators, regulating the S1P/S1PR pathway, lead to lymphocyte sequestration in lymphoid organs, which results in peripheral lymphopenia. This study evaluates the degree of lymphopenia induced by S1P modulators in people with Multiple Sclerosis (MS): Ozanimod, Siponimod, Ponesimod, and Fingolimod.

We conducted a retrospective multicenter study across thirteen MS centers in Italy, including 191 MS patients (mean age 46.4 years; 61.3% women). Of these, 28.8% received Siponimod, 26.2% Ozanimod, 24.1% Fingolimod, and 20.9% Ponesimod. Lymphocyte counts were measured at baseline (T0), one month (T1), three months (T3), and six months (T6) post-treatment. Lymphopenia grades range from 0 (≥ 1.0 × 10^9 cells/L) to 4 (< 0.2 × 10^9 cells/L), according to Common Terminology Criteria for Adverse Events.

At T1, Ozanimod showed a significantly higher mean lymphocyte count than Siponimod and Fingolimod (p < 0.001), Ponesimod higher mean lymphocyte count than Siponimod (p = 0.006). The differences persisted between Ozanimod than Siponimod and Fingolimod at T3 (p = 0.01 and p = 0.04), and between Ponesimod and Siponimod at T6 (p = 0.03). Severe lymphopenia cases were significantly higher in Siponimod than in Ponesimod and Ozanimod, at T1 (p = 0.001 and p = 0.0001). The differences remained significant between Ozanimod and Siponimod, at T3 (p = 0.001), and between Ponesimod and Siponimod, Fingolimod and Ozanimod, at T6 (p = 0.001). Grade 4 lymphopenia was observed in Ozanimod and Siponimod at T3.

This is the first real-world, head-to-head observational study comparing lymphopenia among different S1P modulators. Our results might assist in therapy choice depending on patients baseline hematological characteristics.