May Han, MD
Stanford University School of Medicine, California

Key Takeaways

  • Early initiation of disease-modifying therapies (DMTs) for multiple sclerosis (MS) has shown to delay relapse and disease progression but determining first-line therapy can be challenging due to the number of DMTs available and other factors, including patient preference that must be considered.
  • The decision to switch therapy, which should be a collaborative one between the clinician and patient, may be driven by lack of appropriate response, disease progression, or side effects.
  • There is no “one size fits all” treatment protocol as goals for treatment, disease activity, medication history, and personal preferences vary considerably among patients.
  • Clinician and patient priorities for switching therapy can differ, but patient preference must be a major consideration because it affects adherence to treatment.
  • The financial burden of therapy must be considered in the selection of a DMT as some drugs may not be covered by the patient’s health insurance or may be too costly even with insurance coverage.

May Han, MD, is an associate professor of neurology and neurological sciences at Stanford
University School of Medicine, in California. She also is a board-certified neurologist
and clinician-scientist who specializes in multiple sclerosis and central nervous system
demyelinating diseases. Her research focuses on utilizing a systems biology approach (eg,
genomics, transcriptomics, and proteomics) to identify targets for therapy in MS and
neuromyelitis optica. Dr. Han is an attending physician at the Stanford Neuroscience Health
Center’s Neuro-Immunology Clinic and at Stanford Hospital in California.

In patients with MS, DMTs have been shown to reduce the frequency and severity of relapses. They also can reduce the development of new lesions in the brain and spinal cord and slow the development of disabilities associated with MS. With DMTs, is there a standard protocol that patients initially receive, or is treatment more individualized to the patient?

We do know that early initiation of a DMT decreases the relapse rate and can prevent  progression of the disabilities associated with MS.1 As to how therapy is selected, we first determine what type of MS a patient has. We then clinically characterize the phenotype and narrow down our treatment choices to a suitable medication with which to begin therapy. But, as there is a growing number of medications now available for relapsing-remitting MS, choosing the most appropriate drug for an individual can be challenging.

While we do not have a treatment algorithm recommended to us by the US Food and Drug
Administration (FDA), we do have guidelines. We look at 3 factors: disease activity, size, and location of visible lesions on the magnetic resonance imaging (including evidence of spinal cord or optic nerve involvement), and lesion activity (all active, active and chronic, or just chronic). We also determine if the patient has 1 or 2 lesions or if the lesions have been progressing for a while. Based on these factors, we decide if the patient is appropriate for treatment with a DMT as first line therapy.

Clinicians typically opt for an oral medication or, less commonly, an injectable drug. Studies
have shown that patients who were on oral medications were less likely to relapse.2 Oral
medications, such as teriflunomide and dimethyl fumarate, reduce the frequency of relapse and
many patients find that they can remain on these medications for years due to the drugs’
tolerability and fewer severe adverse events.3,4

However, if the patient has highly active disease and other risk factors for poor outcomes, such
as older age, male gender, spinal cord involvement, and other comorbidities, we may opt for a
high-efficacy therapy such as ofatumumab or cladribine. Importantly, all of these drugs have
safety risks, so we don’t want to overtreat the disease, but we also don’t want to undertreat it.
We want the treatment to be efficacious enough for the level of disease activity in the patient.
Studies focusing on patients with relapsing-remitting disease show that patients who are placed
on high-efficacy therapies early on benefit from this initial aggressive therapy.5

The patient’s treatment preference is important because we want the patient to be able to live
his or her life rather than be consumed by therapies and the disease. Some people do not mind
getting injections and others just can’t do it. Some patients prefer oral medications, but others
often forget to take their pills. Fear of disability and impact on lifestyle can drive some patients’
desire for a high-efficacy DMT despite the success of their current treatment.6 Patient
preferences and behaviors certainly must be considered in treatment decisions.

Another key issue in choosing treatment is the financial burden on the patient due to the cost of
the drugs, which have steadily increased over the years.7,8 Drugs to treat MS are expensive in the
United States and insurance coverage varies based on factors such as drug cost and the
patient’s co-pay. If a drug costs $300 a month out of pocket, for example, and the patient cannot
afford it, then treatment adherence will be an issue. So then we must go with the next best
option, because at the end of the day, the treatment has to be something that is affordable to the
patient since they may be on this drug for a long time.

As you can see, choosing the right drug is an art in itself. Ideally, we would like to do genetic
testing and use biomarkers, as is done in determining treatment strategies for cancer, but we do
not yet have that information for MS. That is a focal point of my research now.

Individual response to existing therapies for MS varies among patients as does the risk of adverse events. When should switching DMTs be considered and are there any formal guidelines for doing so?

There are no clearly defined guidelines on switching DMTs, and the decision to do so should be
a collaborative one between the clinician and patient. We have to take into consideration a
variety of factors, including goals of treatment, disease activity, medication history, and
personal preferences. One of the main reasons to switch a medication is if the patient is having
either clinical or radiographic breakthrough relapses. Some patients with relapsing-remitting
MS experience disease progression so in these cases, the therapy should be changed.

There also are specific circumstances for changing therapy. For example, a patient may have
tolerated natalizumab very well but now shows antibodies for anti-John Cunningham virus in
serum, which means an increased risk of developing progressive multifocal leukoencephalopathy.9 Other examples are B cell-depleting therapies, such as ocrelizumab, which, while convenient for some patients because it’s given via infusion twice a year, can place patients at a higher risk of infection, especially in patients with known risk factors. This in turn raised concerns during the pandemic about the potential risks of the COVID-19 virus on patient with MS who were receiving immunotherapy.10 The immune response to the COVID-19 vaccine also may be blunted due to the patient being immunocompromised.

As MS most often develops in young adults, pregnancy also is a factor for consideration. Most
medications that are used to treat MS symptoms are not compatible with pregnancy. Therefore,
treatment is generally stopped, and steroids are used to manage relapses during pregnancy.

So, from the physician’s perspective, a switch in medication becomes essential when the therapy
is not managing the disease activity, when the patient is experiencing relapses or regressing, or
when the patient is not tolerating side effects.

For patients, often the first reason for wanting to switch therapies is intolerance to a medication. While we consider some drugs to be well-tolerated, many patients never get used to the side effects. The second reason for wanting to switch is difficulty with adhering to a therapy’s administration. Some patients can never remember to take their evening pill or are unable to give themselves an injection. The third reason for wanting to switch is due to a change in the patient’s insurance coverage and the cost of treatment has increased. In these cases, we may need to use a generic version of a drug. The last most common reason for the desire to switch is lifestyle. In some cases, patients prefer to just get an infusion once a month or every 6 months and then not have to worry about it. Studies also suggest that patients have a higher preference for therapies that improve their symptoms and delay progression over those that decrease relapse rates.11 The frequency of dosing also has been identified as equally important as a therapy’s efficacy and safety.12


Considerations in the treatment of MS during pregnancy
Flip
During pregnancy, treatment is generally stopped and steroids are used to treat relapses.

Patient preferences in desiring to switch therapies (as opposed to switching due to
clinician-assessed efficacy) may include the therapy’s route of administration and side
effect profile, among other concerns. Patients also may place a higher value on certain
efficacy endpoints, such as effects on quality of life. How much input does the patient
have in the treatment decision?

It is a joint decision between the clinician and patient, and how much trust the patient has in the
clinician plays a role in this joint decision making. Most of my patients want to stay with me as
their clinician because of this partnership. I give my patients the best possible information that I
can, based on the evidence, and I give them the tools they need to make their decisions.
Sometimes they may be hesitant and feel uncomfortable about a therapy’s potential side effects,
for example, and in these cases, I give them the best explanation I can, backed by scientific
evidence. But, at the end of the day, it is their body and they need to be comfortable with the
treatment decisions. As their clinician, it is my role to support them while determining the
best course of therapy.


There are no clearly defined guidelines on switching DMTs, and the decision to do so should be a collaborative one between the clinician and patient.
May Han, MD

Ofatumumab is administered as a once-monthly subcutaneous injection while teriflunomide is taken orally as a once-daily tablet. In your experience, what attributes of DMTs are most important to patients that should be included in treatment decisions? Do you find that patient decisions typically lean more towards ease in route of administration or ease in dosing frequency?

Every patient is different. Some do not mind taking an oral drug every day and would in fact
prefer that over an injection, while others would prefer the injection once a month. The ease at
which a therapy works for a patient might be different for another. I have found that the least
preferred regimen was subcutaneous injections 3 times weekly. A sample study found that
intravenous infusions given 3 or less times per year was the preferred regimen, while self-
injection 1 to 3 times per week was the least preferred treatment option.13

In your experience, does patient preference in the selection of DMT typically have an
effect on medication adherence?

Absolutely and sometimes a patient will start on a therapy that they had doubts about only to
discover their fears were unfounded. For example, after getting 1 or 2 infusions, they may feel
that infusion therapy is not a huge deal. Some patients get over their fear of injections to find
out it’s their preferred route of administration. Sometimes, the opposite occurs. The patient may have thought an infusion would be easy but learns they aren’t able to tolerate the side effects. All patients respond to therapies differently and that’s why we sometimes need to switch medications — to find the therapy that is most effective and comfortable for the patient so they are able to adhere to the treatment regimen.

This Q&A was edited for clarity and length.

References
  1. Schmierer K, Sørensen PS, Baker D. Highly effective disease-modifying treatment as initial MS therapy. Curr Opin Neurol. 2021;34(3):286-294. doi:10.1097/WCO.0000000000000937
  2. Kantor D, Mehta R, Pelletier C, et al. Treatment patterns and relapses among newly treated multiple sclerosis patients from a retrospective claims analysis. Clin Ther. 2020;42(11):2136-2147.e3. doi:10.1016/j.clinthera.2020.09.014
  3. Miller AE. Oral teriflunomide in the treatment of relapsing forms of multiple sclerosis: clinical evidence and long-term experience. Ther Adv Neurol Disord. 2017;10(12):381-396. doi:10.1177/1756285617722500
  4. Gold R, Arnold DL, Bar-Or A, et al.  Safety and efficacy of delayed-release dimethyl fumarate in patients with relapsing-remitting multiple sclerosis: 9 years’ follow-up of DEFINE, CONFIRM, and ENDORSE. Ther Adv Neurol Disord. 2020;13:1756286420915005. doi:10.1177/1756286420915005
  5. Rotstein D, Montalban X. Reaching an evidence-based prognosis for personalized treatment of multiple sclerosis. Nat Rev Neurol. 2019;15(5):287-300. doi:10.1038/s41582-019-0170-8
  6. Maurino J, Sotoca J, Sempere AP, et al. High-efficacy disease-modifying therapies in people with relapsing-remitting multiple sclerosis: the role of risk attitude in treatment decisions. Patient. 2021;14(2):241-248. doi:10.1007/s40271-020-00454-3
  7. Elsisi Z, Hincapie AL, Guo JJ. Expenditure, utilization, and cost of specialty drugs for multiple sclerosis in the US medicaid population, 2008-2018. Am Health Drug Benefits. 2020;13(2):74-84.
  8. San-Juan-Rodriguez A, Good CB, Heyman RA, Parekh N, Shrank WH, Hernandez I. Trends in prices, market share, and spending on self-administered disease-modifying therapies for multiple sclerosis in Medicare Part D. JAMA Neurol. 2019;76(11):1386-1390. doi:10.1001/jamaneurol.2019.2711
  9. Ho PR, Koendgen H, Campbell N, Haddock B, Richman S, Chang I. Risk of natalizumab-associated progressive multifocal leukoencephalopathy in patients with multiple sclerosis: a retrospective analysis of data from four clinical studies. Lancet Neurol. 2017;16(11):925-933. doi:10.1016/S1474-4422(17)30282-X
  10. Hughes R, Whitley L, Fitovski K, et al. COVID-19 in ocrelizumab-treated people with multiple sclerosis. Mult Scler Relat Disord. 2021;49:102725. doi:10.1016/j.msard.2020.102725
  11. Wilson LS, Loucks A, Gipson G, et al. Patient preferences for attributes of multiple sclerosis disease-modifying therapies: development and results of a ratings-based conjoint analysis. Int J MS Care. 2015;17(2):74-82. doi:10.7224/1537-2073.2013-053
  12. Poulos C, Kinter E, Yang JC, et al. A discrete-choice experiment to determine patient preferences for injectable multiple sclerosis treatments in Germany. Ther Adv Neurol Disord. 2016;9(2):95-104. doi:10.1177/1756285615622736
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                                                                                                                                       Reviewed June 2022