Navigating the Expanding MS Treatment Landscape: Kavita Nair, PhD

The treatment landscape for multiple sclerosis (MS) has transformed dramatically in recent years, with the number of available disease-modifying therapies continually growing. But with greater choice comes greater complexity, as clinicians must weigh efficacy, safety, cost, access, and patient preference to chart the right course for each individual.

Kavita Nair, PhD, of the University of Colorado Anschutz Medical Campus, spoke with The American Journal of Managed Care^® (AJMC^®) about how providers are navigating these decisions, what innovations in care delivery and data hold the most promise, and why policy changes could put hard-won treatment gains at risk.

This interview was edited for length and clarity.

AJMC: With the expanding landscape of MS disease-modifying therapies, how are clinicians balancing efficacy, safety, patient preference, and the goal of long-term disease control when selecting treatments for relapsing forms of MS?

Nair: The clinician's job is not just to pick a drug, because we have so many drugs to choose from. MS therapy has really come down to a couple of things. One is, what is the most accessible, and what do you have the access to, and what will the patient consistently be able to have access to? We have so many choices, so in some ways it's very good news for the patient and the provider for relapsing forms as well. Until 2020, we had drugs that were for symptom management, interferons, that had horrible adverse effects, which is very hard for patients to tolerate. Now, we've moved way past that.

If we look from a clinical standpoint, what we can start with is a risk stratification model. We look at features of a disease-modifying therapy—and keep in mind that, with MS, it's so unique because we have orals, we have infusions, we have self-injectables, we have generics, and we have biosimilars. We've got the entire menu of options, and that increases access. But it's not as simple as that. The first thing is safety, but we also want to make sure that there's great access.

I'm going to talk a little bit about the access aspect, because we have some drugs that are generics, and also about monitoring. First, you have oral medications, which are the easiest for a patient to take—but with some of these orals, they do have some intense initial cardiac monitoring, and because there are generics now, there's no support from the pharmaceutical manufacturers of generics. The pharmaceutical company used to do it, now they don't. So, who does that monitoring initially to make sure that you're okay to take it? No one really knows. That takes away some of the high-efficacy generics as options, because no one really wants to find out.

Some of the other generics, despite being generics, are not your $4 or $5 generics, or your $0 generics that more health plans are moving toward. If you go to Cost Plus Drugs, for example, and you put in these drugs, the cheapest prices for them are around $200 a month, and you think, “Well, that's $200 a month, so I don't want to take these drugs, even though they're generics. I'd rather get on a brand name drug where my co-pay is only $50 a month.” You can see how that informs choice. Of course, I want to know that clinically it makes sense, but also cost does inform the clinical decision.

Now, we get into the brand name drugs, and with brand name drugs, we go almost instantly into some of the higher efficacy ones, which are infusions, and then we start getting into these drugs that are immunosuppressants. For them to work, they do suppress the immune system. They require patients to get vaccinated, and patients must have their labs monitored so certain lab values don't reach a critical point showing, for example, severe immunosuppression.

Then we get into what I call the “infusion dance.” You have to get infused twice a month, or once every month, depending on the type of drug that you're taking. It's a level of comfort. We have found that patients who eventually get on infusion drugs and then are presented with a self-injectable version that becomes available actually like to get infusions because they have infusion buddy systems, and all end up finding friends that go to infusion centers at the same time. They have a buddy support system, so they socialize, especially for some of our older patients. When we tell them they can switch to maybe an oral drug at the same efficacy level or a self-injectable, they're like, “No, we like the support.” They enjoy the camaraderie, and they don't want to break up their camaraderie.

The choice comes down to, of course, your type of MS—and this is relapsing MS we’re discussing, so your choices are a lot more varied. If this was progressive MS, the choices would be much more limited. It also comes down to out-of-pocket costs and what your insurance covers. And it comes down to area. If you're living in one of these rural areas, you may not have some of these other choices as well. And then, of course, safety, in terms of monitoring—how soon can you get these labs, and those kinds of things?

Once those decisions are made, we see how patients are doing. Ideally, you want to see a patient once a year and you want to get an MRI once a year. But the reality is, that's all great on paper: We want to get monitoring labs every time they have an infusion. But if the infusions are happening outside of the system, the integration of the electronic medical records [EMRs] is not smooth because our systems don't talk to each other.

AJMC: Looking ahead, what innovations in care delivery or data use do you believe will most improve relapse prevention, care continuity, and long-term outcomes for patients living with MS?

Nair: I love this question, and we are really living in the Gilded Age of MS, so to speak. The number of available therapies went from 4 to 23, and they keep coming. MS is not a great disease to have, but we have options now.

In terms of care delivery options, I think these models where we are training providers in areas where patients live to at least be a first point of contact can improve care delivery. You don't have to be an MS specialist to treat MS, but if you are a neurologist or you are a primary care provider and a patient comes to you and has symptoms that you suspect are MS, you can then form a relationship with an MS specialist in an academic center in a large private practice so the triaging can happen, and that care pathway can start at the first line of defense. That is the way to get a patient and their family on a good path.

We don't need providers to know everything, but to have some kind of support system and backup system and a little bit of training to say, “I think this is what it might be,” and have a sort of hub-and-spoke model that is truly integrated across the state without taking patients away [from their primary provider]. We also have patients who come from out of state, and that's sort of a different level of experience. But within a state, we should be able to get people placed through a pathway that goes from first point of contact all the way to specialists. Telehealth absolutely facilitates some of these assessments for physical mobility that are used in trials, like the EDSS [Expanded Disability Status Scale]. There are ways to do it electronically.

I also never thought I would say this, but I think we need to take advantage of some of these newer technological advancements. With our imaging criteria that have now expanded, if there was one area that artificial intelligence [AI] can really work the best, it's identifying things in imaging, because it's all data points. Maybe AI can be used for different diagnostic aspects, even using just a simple MRI report, so let's take advantage of that—although the details of that process, I couldn't tell you.

Also, how can payers simplify some of these processes? If you're going to a neurologist and you're getting an MRI, maybe reduce some of the prior authorization burden. We hear about “gold carding” policies, where if your practice has achieved a 90% approval rate for their prior authorizations or for certain services, they can participate and get some of these things waived. Maybe we can start implementing some of these policies for approval of these drugs, because no one is really treating patients with the older drugs. To avoid new evidence of disease activity and to keep patients in a stable state, maybe we don't have to go through hoops of step therapy, because the evidence is very clear that the older symptom management drugs are just that—symptom management drugs. Maybe it’s working with the American Academy of Neurology to come up with different policies to say, “This is evidence-based, so let's get rid of some of these kind of archaic methods.” It’s not going to cost more money if people are treated sooner and less likely to be on disability, because when they're on disability, you as a payer have to pay more. Ten years ago, maybe there was less evidence, but the evidence is so compelling now. The innovation can be this notion of payers, providers, and societies working together to get rid of some of these outdated concepts in MS.

In terms of data right now, providers will only look at data that they can pull in their EMR, and our EMRs are pretty outdated. We should be able to pull down and see an MRI report, what drugs they were on, and some patient-reported outcomes as part of the dashboard. Especially when we're looking at some of the intermediate continuum aspects of MS, consistently capturing those outcomes can help identify some of these continuum types as they’re happening vs after the fact. We are still developing drugs and the phenotype of MS is changing rapidly, and we should be able to do it in real time.

While we have come a long way, we still have a ways to go, but it's a gilded age for MS.

AJMC: How can health care policy better support optimal care for patients with MS?

Nair: On a policy basis, if we want patients with MS to be successfully treated, we do have to look at a really coordinated model, all the way from pharmacy to long-term care to services for disability paperwork. It really has to be a lot of care. Now, not every practice can afford that, but if we can have coverage, it’s ideal. And it's ironic to talk about increased coverage at a time when coverage is being slashed. I worry about the Medicaid requirements going into effect in 2027 where Medicaid patients who are able-bodied will have to prove eligibility twice a year and will have to do 80 hours of work or community service per month. That worries me tremendously, because you can be an MS patient and you can look healthy, but if you have tremendous fatigue, and it's not an outward and you're not in a wheelchair, that doesn't mean you don't have the disease.

We have to work hard as a community, as advocates, and as leaders, to emphasize that MS sometimes can be invisible because the functioning of it, like with fatigue and other aspects that don't present themselves outwardly. If they're not in a wheelchair, it doesn't mean they don't have MS or that their MS is not debilitating, especially for this disease. We need to work a little bit more on some of these measures that are so central to a patient's functioning but that we can't always see.