Balancing Efficacy, Equity, and Shared Decision-Making in MS Care: Fred Lublin, MD

Effective multiple sclerosis (MS) treatment requires thinking carefully about therapy sequencing, deescalation, equity of access, and the infrastructure needed to deliver complex care consistently across settings.

As high-efficacy therapies have reshaped the treatment paradigm, a new set of questions has moved to the forefront: When should clinicians consider de-escalating therapy? How should patient preference factor into infusion versus injection decisions? And who is being left behind?

Fred D. Lublin, MD, the Saunders Family Professor of Neurology at the Icahn School of Medicine at Mount Sinai and director of the Corinne Goldsmith Dickinson Center for Multiple Sclerosis, addresses those questions in this interview with The American Journal of Managed Care^® (AJMC^®).

Lublin also discussed racial and social disparities in MS care, the role academic centers can play in supporting community neurologists, and the potential and limitations of digital tools to extend the reach of quality MS care.

This interview was lightly edited for clarity.

AJMC: As high-efficacy disease-modifying therapies have moved earlier into the treatment paradigm, how has that influenced how clinicians decide on sequencing in relapsing MS?

Lublin: We talked about this a little bit in terms of when to escalate. Now we're thinking about it, but there hasn't been much work done yet on de-escalation. But I think, as I mentioned earlier, it's something we need to think about, because I don't know that we need to keep people on some of the high-efficacy therapies as long as we are now. We have to think about who would be the right individual to de-escalate. When would be the right time to de-escalate—at what age, at what level of activity, what to de-escalate to, and even when to stop? These are all things that we don't have a lot of data for yet, but we need to try and collect

AJMC: What factors should clinicians consider when deciding on the use of infusible therapies?

Lublin: With the infusibles, you have some that are every 4 weeks, some that are every 6 months, and then you have injections that you can give monthly, and it's really a matter of patient preference. And when we have the conversation, say, around the anti-CD20 therapies, where you can either get it every 6 months or get it as a self-injection every month, we pretty much leave that up to the patient. It's purely a matter of: do you want to take the time off to go in and get the infusion and then not have to think about it for the next 6 months, or do you just want to take this autoinjector every month? It's preference, whatever works for them.

AJMC: You recently coauthored a study on social determinants of health and health inequity in MS. Where do you see the greatest disparities in MS care today, and what systemic changes are needed to address them?

Lublin: We looked at some different racial differences and severity of disease, and it turns out to be a combination of both biological and social determinants. And of course, this depends on where you are and what the access is, but it speaks to the difficulties in our system—and even our insurance system, where we have people getting their drugs that they need denied or delayed, and it's caused us an enormous amount of grief and headache and caused incredible amounts of patient anxiety. I think that it all needs to be addressed beyond the biological and neurobiological reasons why there are differences in severity and the genetic reasons why there are differences in severity, but we have to make sure that we're taking care of the entire population and that they all have access to what are really life-saving medications.

AJMC: How can academic MS centers support community neurologists and health systems in delivering consistent, evidence-based care?

Lublin: This is a great question. We do this. There are lots of regions where people don't have access to MS centers or people who, due to traveling distance or even because of their insurance, can only go see certain doctors. We work hard to partner with our colleagues in the community. I have an enormous amount of respect for the general neurologists out in the community because they not only have to know about MS, but they also have to know about headaches and Parkinson disease and strokes and all these other things that we don't necessarily have to deal with. We're happy to partner with them and maybe see someone once a year and then have them out in the community and seeing their doctors there.

There is a challenge for community practice for some of these complex therapies because they're time-consuming, and the patients may have a lot of phone calls and questions and such, and we're set up to do that. We have fellows, and we have nurse practitioners and things like that, and we're set up to get comprehensive care. But we do that and, in the same frame, support the providers out in the community and make it easier for them to care for the patients and make it easier for the patients to get their care in a convenient setting.

AJMC: How do you see the role of newer digital tools to remotely monitor patients? Do they have the potential to increase access and equity of treatment?

Lublin: It's something we're getting involved with. We're going to start a protocol testing that this year. The digital tools have an interesting potential because they can measure things more long-term—just things like steps, distance walked in a week, and pace, and things like that. Even falls or balance—these are all things that can be picked up. The difficulty comes when people study this; one of the things that they see is that the individual's interest wanes over time in maintaining the data and such. That's going to be one of the challenges. But I think the potential for providing important long-term data is there.

AJMC: Looking ahead, what unanswered questions in MS research or care delivery do you believe will most influence how we manage relapsing MS in the next decade?

Lublin: For relapsing MS, we'd like to have safer high-efficacy therapies. We'd like to know when we can modulate therapy, de-escalate, or even stop. But more importantly, we need better therapies for progressive disease. And then looking to the future, we want to get some repair strategies to repair the damaged nervous system.