Multiple sclerosis (MS) is a lifelong, complex, heterogenous, neurodegenerative disease with more than 20 disease-modifying therapeutic treatment options. During a presentation at NAMCP 2020 Virtual Spring Managed Care Forum, Clyde E. Markowitz, MD, associate professor of neurology and director of the multiple sclerosis center in the Department of Neurology at the Perelman School of Medicine at the University of Pennsylvania, discussed MS treatment considerations and how to involve the patient in decision-making.
The complexity of the therapeutic landscape requires a multidisciplinary team to deliver comprehensive care, and patients and caregivers should be included in the treatment decision-making process. Treatment decisions should consider all benefits and risks, including mechanism of action, tolerability, patient preference, cost, and more.
Real-world treatment considerations should assess disease factors (e.g., frequency and severity of relapse, duration since disease onset, lesion location, etc.), treatment accessibility (e.g., out-of-pocket costs, formulary restrictions), and patient factors (e.g., risk tolerability, route of administration, age, comorbidities, etc.).
When patients engage in shared decision-making, they learn about their health and understand the condition, are informed about treatment options, understand the pros and cons of each option, are better prepared to talk to their healthcare provider, and are more likely to adhere to treatment, said Dr. Markowitz.
The best drug for a given patient is one that suppresses disease activity, is tolerable, causes no adverse events (AEs), is accessible, and allows the patient to continue a high quality of life, he noted. Matching a patient with a disease-modifying agent should consider risk tolerance, access, lifestyle issues, tolerability, safety and monitoring, and treatment potency. Once the patient is on a treatment, the healthcare provider should monitor the efficacy via relapses, magnetic resonance imaging monitoring, and setting treatment targets.
Dr. Markowitz shared recommendations from the American Academy of Neurology guidelines on initiating therapy, recognizing treatment failure, and switching therapies. Some highlights of these guidelines include setting patient expectations prior to treatment, counseling patients about the effects of comorbidities and adverse health behaviors on disease course, evaluating barriers to adherence, monitoring AEs and adherence, and considering a disease-modifying therapy with a different mechanism of action and more robust efficacy profile when switching therapies.
When considering switching therapies, Dr. Markowitz suggested patients should be on therapy for at least six months or more and the washout period should be as short as possible.
In conclusion, when deciding on a treatment option, physicians should stress the importance of treatment adherence and involve patients in the decision-making process, so they buy into the course of therapy. Finally, physicians should monitor patients closely and make adjustments based on tolerability and efficacy.
Presentation: Informed Decision-Making in the Treatment and Management of Multiple Sclerosis: Optimizing Therapeutic Switching and Sequencing Strategies. NAMCP 2020 Virtual Spring Managed Care Forum, April 16-17.