Overview of Multiple Sclerosis

A multidisciplinary panel of experts provide an overview of the progressive nature of multiple sclerosis (MS) and discuss how clinicians, payers, and pharmacists approach management of the disease.

Neil Minkoff, MD: Hello and welcome to the American Journal of Managed Care® Stakeholder Summit. Our program is titled “New Treatment Landscapes in MS: Preventing Long-Term Disability Through High Efficacy Treatments in Early MS.” I’m Dr Neil Minkoff, the chief medical officer of Coeus HealthCare and Consulting. Joining me today in this virtual discussion are my colleagues, Dr Thomas Leist, the director of the Comprehensive Multiple Sclerosis Center at the Thomas Jefferson University in Philadelphia, Pennsylvania; Dr Darin Okuda, professor in the Department of Neurology at the University of Texas Southwestern Medical Center; Dr Maria Lopes, chief medical officer at AMC Health; and Dr Nancy Ross, clinical pharmacist at the Multiple Sclerosis Center of Atlanta. Today, our panel of experts will explore opportunities for improving long-term patient outcomes in MS [multiple sclerosis] through earlier use of high efficacy therapies, including clinical and payer considerations. Thank you for joining. With that, we’ll begin.

To make sure we’re all getting settled in the same place and our audience is in the same position as we are, let’s get an idea of the progressive nature and clinical burden of MS and how that changes as the disease progresses. Dr Okuda, could you address some of that to help us get started?

Darin Okuda, MD: Multiple sclerosis is an autoimmune condition in which a person’s immune system misrecognizes components within the human body. With rheumatoid arthritis, the target may be joints. In the case of multiple sclerosis, the target can be the brain, the optic nerve, or the spinal cord. What’s really interesting is that this condition has a high degree of heterogeneity. Not all patients progress, but a meaningful number do. In fact, there are some people who can remain asymptomatic for their entire life, which punctuates how the management of multiple sclerosis can be very difficult in that setting, because we basically treat people on probabilities of having an outcome that we think is suboptimal. As a person with MS evolves in their experience, they may require a higher degree of care. This could involve treatments; there could be a switch in the therapies they’re on. There could be supportive therapies or even the use of symptomatic agents. One thing is for sure: the disease itself is significant. It is still the No. 1 reason young people are impaired neurologically.

Neil Minkoff, MD: There’s a lot to unpack there. I’d like to draw some other folks into the conversation. I’ll address my first follow-up question to Dr Lopes. There needs to be some confluence between the way payers and active clinicians who are seeing the patients are approaching MS. From your point of view as a payer, could you speak a little about how you look at that and where those opportunities for convergence occur?

Maria Lopes, MD, MS: Absolutely. What Dr Okuda said is very important. It’s a very serious disease. It’s not always predictable. There’s a high degree of heterogeneity. Not everyone responds to treatments. Treatments may need to be individualized based on patient characteristics, patient preferences, administrative alternatives: oral, subcutaneous, or IV [intravenous]. Payers need to recognize this. These are expensive treatments. The most expensive treatment is the one that’s not adhered to. We recognize the value of shared decision-making and individualizing patient need for choice.

On the other hand, it may not be endless choice. As we think about treatment options, between oral medications, injectables, and IV products, we need to offer choice with different mechanisms of action. Also ensuring through a prior authorization or having specialty preferred agents vs specialty nonpreferred products, which reflects the cost and contracting that we would have, helps us ensure choice. There’s choice among the S1Ps [sphingosine-1-phosphates] and preferred options, choice among dimethyl fumarates, especially now that we have generic options. Some of these are becoming a bit crowded in terms of the number of products within each mechanism of action. Ensuring choice meets outpatient needs, and reflecting what Dr Okuda said, is necessary.

Neil Minkoff, MD: Dr Ross, let me pull you in here, because it feels like your role as a clinical pharmacist at a major MS center is somewhat to balance those things. Does that sound appropriate? On some level, you’re caught between the Scylla and Charybdis of the payer and the prescriber in terms of what they want to accomplish. You have a very important role in the patient’s MS journey, and you could help us understand how that works in a center of excellence and how you help tailor therapies to patients.

Nancy Ross, PharmD, BCACP, MSCS, CSP: It’s a fairly unique role. I feel like it’s an important role because I’m an advocate for both causes. I’m an advocate for my prescribers to make sure their patients are getting treated quickly and effectively with the medication they deem most favorable to keeping their MS from progressing. At the same time, I need to convince the patient that this is important, that they need to continue on therapy and to stay adherent. At the same time, I work with the payers to convince them that this particular treatment for this patient is the best course of action. How do we balance all of that to make sure a patient gets the medication they need in a timely manner and stays on treatment?

Transcript edited for clarity.

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