The cost of multiple sclerosis (MS) care is rising due to escalating prices of disease-modifying therapies (DMTs) over the last several years. Insurers have responded by passing some of the cost to the patient in the form of denying costly therapies or limiting payment, which may have a negative effect on MS care.
To address the dilemma of maintaining quality MS care while containing costs, Ilya Kister, MD, of NYU Langone Medical Center and John R. Corboy, MD, of the University of Colorado School of Medicine outlined 5 strategies that neurologists can employ to provide their MS patients with medically sound and cost-effective care. These strategies were recently published in Neurology.
- Avoid treating patients with “improbable MS” with DMTs. Up to 13% of patients diagnosed with MS do not actually have MS, and nearly half of misdiagnosed patients receive DMTs. Patients without neurologic deficits and without lesions characteristic of MS almost never progress to MS, while DMTs in these patients can lead to adverse events such as progressive multifocal leukoencephalopathy (PML).
- Treat relapses according to patient factors and severity. Recent data showed that for MS relapses, oral methylprednisolone given at a dose of 1000 mg daily for 3 days was non-inferior to intravenous administration of the same dose. Mild relapses are sometimes self-limited and may not require treatment, which carries the risk of adverse events. Patients with severe MS relapse may benefit from plasmapheresis.
- Investigate alternative dosing strategies for currently approved DMTs. Recent data suggest that decreasing natalizumab dosing to every 8 weeks is safe and more effective for reducing relapses and new T2 lesions than monthly dosing. There are reasons to believe that alternate day dosing of fingolimod may also be effective, given this drug’s long half-life (6 days), but no trials to test this hypothesis have been carried out.
- Consider off-label DMTs. Rituximab is significantly less expensive than approved DMTs, has demonstrated efficacy in MS in several studies, and has been shown to reduce relapses to a greater extent than fingolimod in a recent observational study. Leflunomide, which after ingestion is converted into the FDA-approved DMT teriflunomide, is available as an inexpensive generic drug, although no studies on its efficacy in MS have been published.
- Evaluate whether DMTs can be discontinued in certain populations. Discontinuing DMTs in younger patients (≤55 years) with highly active disease has been shown to result in increased relapse rates, but the effects of discontinuing DMTs in older, nonrelapsing patients are unclear. A randomized trial evaluating DMT discontinuation in older MS patients without evidence of active disease is scheduled for 2017.
While these strategies may help reduce the cost of MS care, they are not all based on rigorous evidence, so more research is needed. “Our medical system is stacked against studies which are not profitable to the pharmaceutical industry, but can lead to large savings to the health care system,” Dr Kister told Neurology Advisor. “We need to develop a mechanism to ‘level the field’ for studies that make both economic and medical sense. Clinicians should advocate for far greater funding for investigator-initiated clinical trials from not-for-profit sources, especially from the government, that could yield considerable savings to the system without compromising – and, ideally, enhancing – quality of medical care.”
“Clinicians can also identify promising management strategies from their own experience and collect the data that they acquired in their practice for conference presentations and publications,” he added. “Although such retrospective, observational studies have a low level of evidence, they help generate hypotheses for more rigorous studies and enrich the clinical literature with new ideas.”
Kister I, Corboy JR. Reducing costs while enhancing quality of care in MS. Neurology. 2016;87:1-6.