Current MS Treatment Paradigms


Key opinion leaders highlight the MS treatment landscape.

Ryan Haumschild, PharmD, MS, MBA: Now that we’ve talked about the background of multiple sclerosis [MS] in detail, I think it’s important for us to review the treatment landscape and the treatment paradigms for MS. Amanda, as we get started, I’d like for you to review some of the treatment goals for patients with MS, how are those established, and what are the goals from a treatment perspective clinically and from a patient’s perspective as well?

Amanda Montague, Ed.M.: Sure, I think it’s a great question. Certainly, I think at the top of our minds is delaying progression. That’s what everyone is trying to do. I think that goes hand in hand with maintaining quality of life. For those living with MS, I think there is this fear that they are going to get robbed of the things that matter to all of us in life, like being able to walk their child down the aisle for their wedding, or going to their kid’s baseball game in the hot sun. There are so many things that MS can take away from folks. So, trying to maintain a quality of life that incorporates all of the meaningful stuff is I think at the pinnacle of how right now, patients are expecting their MS to be managed and treated, and I think clinicians are more and more looking out for it. This symptom management piece plays a big part. Delaying progression, that’s more of a disease-modifying therapy conversation. But then on quality of life, there’s a lot that can be done around symptom management that I think we’ve gotten better as an MS community of recognizing and trying to tackle.

Mitzi Joi Williams, MD FAAN: I would add to that, when we think about our clinical research trials, there has been a shift from looking at things individually to looking at things as a whole. We look at MRI activity, we look at disease progression, we look at relapses. And traditionally it’s been, if one therapy performed really well at 1 or 2, we were very happy. But now there’s this concept of no evidence of disease activity. As clinicians, our goal is we don’t want any changes in the MS. So, no relapses, plus no MRI changes, plus no disease progression. The other thing that’s been very interesting is that in some of our newer trials, we’re looking at clinically definite improvement…now can we look and see if we can improve disease and improve symptoms with our disease-modifying therapy? So, it’s a very exciting time because we are going beyond trying to stop it from getting worse to see if we can make it better.

Amanda Montague, Ed.M.: To Mitzi’s point, the other piece that’s super exciting for patients is the inclusion of patient-reported outcomes in a lot of clinical trials.

Mitzi Joi Williams, MD FAAN: Yes.

Amanda Montague, Ed.M.: Because that’s the stuff that matters, right? Of course, we want to see relapse rates go down. But for what matters in someone’s life, it’s a lot of the stuff that we can find out through the inclusion of patient-reported outcomes in clinical trials.

Mitzi Joi Williams, MD FAAN: Like fatigue, right?

Amanda Montague, Ed.M.: Yes.

Amanda Hickman, PharmD, MPH, MSCS: Absolutely.

Dana McCormick, RPh: And not just clinical trials, but the more we have real-world evidence being generated through post-marketing trials and studies and things like that, I think we’ll get to more of that being able to report on patient-reported outcomes.

Amanda Montague, Ed.M.: Absolutely.

Ryan Haumschild, PharmD, MS, MBA: Excellent. When we’re talking about that initial diagnosis, we’ve talked about the goals for the patients. But Dr Williams, after that initial MS diagnosis, we know a lot of different diagnoses could come up, it could be relapsing remitting, clinically isolated. Once you finalize that, what patient factors do you consider to determine which agent you want to prescribe for a patient?

Mitzi Joi Williams, MD FAAN: Yes, there are several different buckets of factors that we take into consideration. Certainly patient factors in terms of their lifestyle, what type of therapy could they be best compliant with? Because to me, the best therapy is one you can take on a regular basis, otherwise it won’t work. We also take into consideration their risk aversion, because as we’re having more effective disease-modifying therapies, there are particular risks that we have to make sure they’re aware of and educated about to determine what the best option is. It really is a shared decision-making process. The way I personally approach it is, we talk about several different therapies, we may narrow it down to 1 or 2. I have my patients go home, do their homework, and then we come back and have another conversation to make that decision. Other things we take into account are things that Dr Hickman spoke about earlier, such as prognostic factors. Do they have poor prognostic factors, how active is their disease? And then, of course, we look at the mechanism of action of their medication, we look at adverse effects. We try to weigh all of those things together and come up with the best treatment that’s right for the person sitting in front of us.

Ryan Haumschild, PharmD, MS, MBA: You talked about so many factors that are important, and they’re really patient-centric. I want to build upon that with a follow- up question. When we think about social determinants of health, and we think about transportation vulnerability, and as you mentioned, the ability of a patient to stay adherent, how much are you starting to analyze those factors just as much as some other criteria when you’re designing that unique care plan for a patient?

Mitzi Joi Williams, MD FAAN: Yes, it’s extremely important. Gone are the days where we say, “You’re going to take this,” and they go home and take it. I don’t point my finger at anyone. But it is about what is feasible. We want to remove as much burden as possible. You have someone with a chronic disease, disability associated with that, the fear, the concern, particularly early in the diagnosis. We want to try to make that transition to treatment as seamless as possible and as easy as possible for the person with that condition. For instance, for patients who may live 4 or 5 hours away, maybe an infusion at our center is not the best idea for them, so we may choose a therapy they can do at home. Or even if someone lives close by and they have a significant disability, and they have difficulty with transportation, we say, “OK, here are a couple of options with home therapies.” The other piece is if the plan is not working, then we switch gears and come up with a new plan. Things may change over time, and we have to be willing to reassess that plan regularly.

Transcript edited for clarity.

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