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4yr
Considerations When Choosing Multiple Sclerosis Drug Therapy

Multiple sclerosis (MS) is a chronic disease for which there are a plethora of disease modifying therapies (DMTs) available for treatment. According to the American Academy of Neurology, these therapies share the following features: all modify measures of disease activity such as relapse rates, the emergence of new or enhancing lesions on MRI, disability, or other parameters; none is curative; and all may have adverse effects , which may vary from bothersome to life threatening. The options have different mechanisms of action, risk factors, monitoring requirements, and delivery methods. Metanalyses have been conducted to help physicians in choosing treatments. For example, DMTs have been categorized according to efficacy with classification of low-efficacy (all interferon-beta preparations, glatiramer acetate, teriflunomide, fingolimod, dimethyl fumarate) or high-efficacy (ocrelizumab, mitoxantrone, alemtuzumab, daclizumab, natalizumab). Additionally, charts are available showing the types of drugs, their side effect profile, and routes of administration. Head-to-head clinical trials have also been conducted with published results to provide insight into what drugs might be superior per efficacy and side effect profiles, and how that might influence patient adherence and persistence.

What have you found to be the pros and cons of the various options? Please share your treatment choices based on patient considerations.

References

  • Weideman, A., Tapia-Maltos, M., Johnson, K., Greenwood, M., and Bielekova, B., 2017. Meta-analysis of the Age-Dependent Efficacy of Multiple Sclerosis Treatments. Frontiers in Neurology, 8: 577, p. 12.
  • American Academy of Neurology Policy and Guidelines: Multiple Sclerosis., 2018. Review Summary: Disease-Modifying Therapies for Adults with Multiple Sclerosis. Presentation Slides.
  • 4yr
    Currently, we have more than a dozen DMTs available for treatment of relapsing MS, and it can be very difficult for MS patients and caregivers to choose between them. Each DMT comes with its own specific pros and cons and some of the more effective DMTS tend to have a higher risk of adverse effects. Therefore, it is important to take shared decision-making approach to achieve patient satisfaction and compliance.
  • 4yr
    After a long period of not having infusion centers available, it is now slowly changing. However, the patients are very used to oral therapies and several more effective orals have been releases in the last year.
  • 4yr
    It’s a great treatment choice overall. Very efficacious indeed. Unfortunately there is a potential COViD exposure risk having to come to a clinic to get the medication.
    Even if vaccinated communities people get COViD. And insurance authorization is still not the easiest to obtain.
  • 4yr
    It seems that, at least in the NYC area, the pandemic incidence has dropped to the point where risks of going to an infusion lab are minimal. I've been able to get all of my MS patients vaccinated and are re-establishing therapies, most staying the the same DMT as pre-pandemic. Would like to get the general consensus on this trend.
  • 4yr
    I have sort of compromised on the idea of hitting the immune system hard vs. safety by making orals first line like S1P or NRF2 meds. They have efficacy higher than platforms, yet safe and well tolerated, not as safe as platforms but close.
  • 4yr
    Unfortunately, one other barrier to patient care is insurance. Getting authorization can be a hassle for an office and can often hinder prescribing a certain medication for a patient, even though that might be deemed as the best one. Many pharmaceutical companies do offer assistance but then it is only for commercial insurances and not for medicare or medicaid, and those are the patients that need it most.
  • 4yr
    What insights can you provide when counseling patients on MS treatments? How do you monitor these treatments?
  • 4yr
    The prior authorization for the insurance is an increasing burden. Now some of them require preauthorization every 6 months. When you call the representative taking the information doesn't know anything and can't pronounce the names of the medications. I had one where I was transferred 4 times and had to start all over with each. Then disconnected and no call back. The patients think it's just a simple phone call. Have to do most online now. This is on top of all the issues with safety, efficacy and tolerance.
  • 4yr
    the pros include a variety of medications with different MOA and side effect profiles so can tailor to different patients. the con would be analysis by paralysis where there are too many options where hard for us to choose for a patient or for a patient to choose on their own, so a discussion has to be had between doc and patient and just commit to a treatment
  • 4yr
    Assessing an MS patient's level of disease activity can sometimes be challenging as well as matching that patient to the appropriate therapy. The Covid-19 epidemic has certainly put a damper on infusion therapies. The effect of disease modifying drugs on vaccination response also is a big unknown. Communication between the patient and treating neurologist has never been more important than now.
  • 4yr
    With the continuing FDA-approval of new disease-modifying therapies for multiple sclerosis, we now have numerous available options for the current optimal management of our patients with MS. While we can share the efficacy and safety data regarding these treatments with our patients, a patient's preference and the likelihood of the patient's adherence and compliance with the recommended management remains critical to achieving clinical success with any appropriate medication. Working with our patients to be comfortable to share their vital information with us regarding their disease symptoms and their concerns with their prescribed medications needs to one of the goals to help patients obtain the full benefits of our management. I agree with our colleague, as noted above, that to truly work as a team, a patient who plays an active role in their care is one who is likely to achieve the optimal clinical outcomes.
  • 4yr
    To choose an appropriate treatment for individual patient, I think shared decision-making is imperative to optimal treatment and patient adherence. Patients with MS should always play an active role in their care. Long term safety and efficacy are the major factors. Additionally, disease type and severity, treatment history and response, mode and frequency of administration, monitoring requirement, insurance coverage, and even life style should all be taken into consideration regarding treatment plan.
  • 4yr
    With a disease like MS, there are many factors when deciding on a treatment option. Safety is very important but side effects are also important to keep in mind. Infusions can also be difficult to do if there are oral treatments available. These are all things to keep in mind.
  • 4yr
    Safety is of course a major concern. Otherwise access to the medication and coverage is a major concern. Often too many prior authorizations put a burden on staff. And initial rejections of the medication
  • 4yr
    In our practice we refer to an infusion lab for DMT’s that require that service, very difficult through the pandemic as the chairs were re-allocated and risk entering the facility may outweigh benefit. Most MS patients preferred (I present options and the Patient choses) to resort to interferons until the vaccine became available rather than continue anti-CD19 tx. Ocrevus data from the pandemic was at first concerning but I am not sure if ultimately it presented more ridk to the patient then others. Am concerned with tge mutagenesis of this virus and what will come after delta but the availability of the self injecting autopens adds value to going with more aggressive therapy once again
  • 4yr
    There are many factors to be considered when choosing the treatment for a specific patient. Efficacy is priority but safety follows very closely. In this era of Covid-19 safety is of even more concern. Also, administration is a major issue today. Infusions have become very difficult to arrange due to Covid-19 and patients, already not liking infusions, have become even more resistant.

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