Understanding Patient Preferences in the Treatment of Multiple Sclerosis: The Need for Switching Disease-Modifying Therapies

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.