BackgroundMultiple sclerosis (MS) is a chronic inflammatory demyelinating disease affecting the central nervous system and is a major cause of disability in adults, particularly in those affected by progressive MS. A variety of drugs with different effects, some carrying significant risks, are currently available, making evidence-based approach essential for clinicians treating MS patients.ObjectiveTo compare the efficacy and safety of immunomodulators and immunosuppressants for progressive multiple sclerosis (PMS).MethodsA systematic search was performed in CENTRAL, MEDLINE, Embase, and trials registers on 8 august 2022, including RCTs comparing immunomodulators and immunosuppressants versus placebo or another drug.ResultsThe network meta-analysis (NMA) included 23 RCTs (with 10,167 participants). Moderate certainty of evidence suggests that rituximab probably not reduce the risk of relapse at 2 years, while interferon beta-1b probably reduces the risk of relapses at 3 years (-18%) compared to placebo in PMS people. Regarding SAE, low-to-very-low certainty of evidence for no increased risk with disease-modifying therapies (DMTs) versus placebo is available, except for immunoglobulins that seem to have a 7-fold increased risk of serious adverse events (SAEs). Only low-to-very low certainty of evidence is available about disability progression and SAEs in PMS people treated with DMTs versus placebo. On the other side, the risk for treatment discontinuation due to AEs is increased with interferon beta-1a by 2.93-fold, and probably increased with interferon-beta-1b, glatiramer acetate, and fingolimod by 2.98-fold, 3.98-fold, and 2.29-fold, respectively. Also, rituximab, natalizumab, siponimod, and ocrelizumab probably do not increase the risk for treatment discontinuation due to AEs, while laquinimod may not increase the risk treatment discontinuation due to AEs.ConclusionsCompared with placebo, two-, and three-year treatment with rituximab or interferon beta-1b, respectively, probably slightly reduce relapses in PMS people. A slight increase of treatment discontinuation due to AEs has been reported for rituximab, interferon beta-1b, interferon beta-1a, immunoglobulins, glatiramer acetate, natalizumab, fingolimod, siponimod, and ocrelizumab. No reliable evidence is available for disability progression and SAEs with available DMTs compared to placebo.