Clinician and Patient Preferences, Risk Tolerance Guide Relapsing Multiple Sclerosis Treatment Strategies

Patient characteristics and preferences and clinician risk tolerance are critically important guideposts in selecting among the various treatment choices for relapsing forms of multiple sclerosis, says Myla Goldman, MD, The director of the University of Virginia’s multiple sclerosis (MS) program spoke to a lively overflow crowd during an afternoon educational session at the American Academy of Neurology’s 2014 annual conference on April 30, 2014, in Philadelphia, PA.

Many strategies for treatment selection in MS have been proposed, and some were discussed in other talks at this session. Goldman’s presentation, however, differed by focusing on the balancing act that the bedside clinician faces when confronting a real patient. This individual, who has individual characteristics, needs, and preferences, is engaged in a therapeutic interaction with a physician who also brings experience, preferences, and a particular level of risk tolerance to the relationship.

Commonly understood criteria for treatment selection include efficacy and safety, and some longer-term data are still being collected on newer disease-modifying therapies (DMTs). When considering the safety profile of an MS drug, patient and provider risk tolerance can come into play. One patient may opt for a DMT with some cytotoxicity, preferring to pursue a high-risk, high-reward strategy, while a more risk-averse patient may opt to initiate treatment with a drug that has a more favorable side-effect profile.

Patient-specific characteristics influencing medication choice will include commonly considered aspects such as comorbidities and the patient’s need for non-MS medications. Positive serology for the John Cunningham virus (JCV) will preclude use of natalizumab, because of the risk of progressive multifocal leukoencephalopathy (PML). Many MS drugs have the potential to impact renal and hepatic function, so patients with comorbidities requiring other medications cleared through these pathways must be monitored closely.

Pregnancy plans must also be taken into consideration, necessitating a thorough and sensitive discussion on this topic. Beta interferon, natalizumab, dimethyl fumarate, and fingolimod are all pregnancy category C; teflunomide, however, is category X. Patients may balance disease severity and progression rate with their desire for pregnancy, and physicians should offer support through the process.

In addition to such commonly weighed considerations for treatment choice, Goldman highlighted several other real-world factors that often come into play. Geographic parameters are important: for physicians whose patients travel from distant or remote areas to receive MS treatment, frequent follow up, even for blood draws, may be challenging. This may make a more risk-averse patient or clinician reluctant to use a drug with a riskier safety profile.

In reality, third-party payers will often dictate many treatment choices, especially in the early stages of a patient’s MS treatment. Goldman noted that many insurers require patients to be treated with one or even two less expensive “first-line” drugs before receiving reimbursement approval for newer and more expensive DMTs. MS clinics can help patients understand and navigate this process while maintaining good documentation to expedite decisions.

During questions after Goldman’s presentation, an audience member asked whether the relative risk tolerance of the patient or the physician should take precedence, in her view. The answer, Goldman replied, is not clear cut: for example, a patient taking natalizumab might become JCV seropositive. This patient might have been having good results with the drug and wish to continue, despite the risk for PML. However, this option might exceed the treating physician’s risk tolerance; maintaining clear lines of communication and being honest about risk preference is important in this case, so patient preference can be respected within the bounds of ethical treatment.