Annette Okai, MD, FAAN

 State of the Science events are short meetings designed to educate neurologists and APPs on the clinical benefits associated with the new science driving new thinking. Our renowned faculty focuses on the most relevant topics to ultimately improve patient care.

In this recent event, held on July 21, 2022, a panel of experts in the care of multiple sclerosis (MS) convened to discuss the drastic evolution of MS therapeutic approaches in the past 30 years, as well as to detail some of the latest entrants into the treatment toolbox. This conversation included overviews of the recent oral medications and B cell depleters, and a look into what investigational treatments are on the horizon for the field.

The Evolving Landscape of Multiple Sclerosis - Mechanisms of Action and Targets of Treatment — Fernando Cuascut, MD, MPH

FDA Approved Oral Medications for MS — Lauren Tardo, MD

FDA Approved B Cell Depleting Medications for MS — Rebecca Romero, MD

Emerging Treatments for MS — Annette Okai, MD

Click the button below to watch the recent State of the Science Summit with Okai et al.

Videos

The medical director of the North Texas Institute of Neurology and Headache offered an overview of the State of the Science Summit that was held on July 21, 2022, with a variety of expert clinicians in MS care. [WATCH TIME: 3 minutes]

Getting Up to Speed on the Evolving Landscape of Multiple Sclerosis: Annette Okai, MD

 This is a very enjoyable conversation, and I hate to end it, but we have limited time. What are some of the take home messages that you have for health care providers treating relapsing remitting multiple sclerosis, and what advice also do you have for patients? So, for health care providers and patients, what are general take home messages that you greatly can share with us?

It’s been an enjoyable conversation and we could go on and on, but I know all good things have to come to an end. For my colleagues, other health care providers taking care of patients with MS [multiple sclerosis], I think it’s important to diagnose and treat early. Recognize progression and make the change at a very early time point in order to give the patient the best opportunity that they can in the long-term and decrease disability progression. So, be proactive and recognize and treat as indicated. For patients with MS, it’s the same thing but in different words, that you need to be on treatment because even though we may not see all the effects of MS on the outside, or clinically, the immune system is still ongoing, and it’s best that treatment is started and continued to control the disease, to improve quality of life, and reduce disability progression so that you have a good short-term and long-term outcome. So, work with your health care provider. Have a dialogue and not a monologue, and come to an understanding, be on the same page, and get the comprehensive care that you need to control your disease on this MS journey.

 Perfect. Thank you very much. So, it’s not only a shared decision on what medication, it’s a shared experience. It’s shared journey between the health care provider and the patient to make sure that there’s the right medication, right monitoring plan is being taken, and don’t be afraid from change. If a medication is not doing what it’s supposed to do for a particular patient, well, we have other options, right? Change. This is really important. Sometimes that’s where I’m like, “Oh it’s been too long on this medicine; maybe we can have change.” And early as possible, be proactive. I love these words. Thank you very much, Dr Okai. This has been great, and thank you for our audience for watching this 

 Peers & Perspectives. If you enjoyed the content please subscribe to our newsletter to receive upcoming Peers & Perspectives and other great content right to your inbox. Thank you everyone and thank you Dr Okai, again, it’s been a pleasure speaking to you today. Thank you.

Thank you for having me. It was a pleasure being here.

Drs Obeidat and Okai share clinical pearls for physicians taking care of patients with MS.

Clinical Pearls for MS Care

 No discussion can go without talking about vaccination these days. We’re still sadly within this pandemic, and hopefully things are improving, but really vaccination consideration in multiple sclerosis is a very important topic. Some of our medications are considered immune suppressive, and some vaccination considerations are important. We receive messages from our patients asking questions via phone calls, and during also the clinical visits we often discuss vaccination consideration not only for COVID-19, but also for many other diseases that we vaccinate for. Vaccination is one of the greatest things in mankind, I think, that prevents diseases and helps us to improve quality of life for people. We’d like to discuss some of these considerations in a brief discussion on vaccination and use of immunosuppressive disease-modifying therapies in multiple sclerosis.

Awesome. That’s a hot topic these days. I was taught first that there are several general mantras or rules that we live by in MS [multiple sclerosis], and one is that we try to avoid live vaccines. We really do not recommend live vaccines to our patients, and so outside of that, when it comes to vaccination, we recommend that most of our patients get vaccinated if there aren’t any other contraindications. Now, let’s talk specifically about immunosuppressive medication and vaccination. As I said before, most of our treatments affect the white blood cells and lymphocyte count, and it lowers that—which is what we want—but speaking specifically to the oral therapies, when we look at the fumarates, teriflunomide, and cladribine, and why those affect the white blood cell count and lymphocyte count, they are not profoundly immunosuppressive when compared to the S1P, for which the blood count is way lower. What does this mean? That’s what my patient will say: “Well, Dr Okai, what does this mean?” Well, regardless of what medication you’re on, we recommend that you get vaccinated. Let’s talk about COVID-19; we recommend that you get the COVID-19 vaccination because it’s a public health issue, and it’s something that is protective for you. Now when it comes to the different forms of medication, and I’ll go through the fumarates, with which there are no issues in response to vaccination, nor with teriflunomide. With cladribine, there are no issues, and this was something that we found was surprisingly good in that there wasn’t an issue when it came to getting the vaccination with this medication that had this unique dosing, because everyone thought, “Well, surely if you’re giving something once a year for 2 years, it’s going to have profound immunosuppression and patients aren’t going to respond.” Studies were done and showed that the response was just as robust regardless of what time you took the medication in relation to when you were taking your pill. With the S1P, that is something that we also looked at, and we saw that while it may not be as robust, patients still needed to take the vaccination because there’s still some response to that, so the overarching message is, if you are on orals, regardless of which one you’re on, take the vaccine. The response is there. You also need a booster because we are affecting your immune system over time, but these medications are designed in a way that people have responded to the vaccine, and they need to be on it. Now, for other vaccines like the flu vaccine, we still recommend that. We now have a non-live shingle vaccine. We recommend it in the appropriate age group. So, as long as it’s not a live vaccine, it’s great, and if you are on the oral therapies, we recommend you get that because you can still mount a response to the vaccination.

 Thank you very much. This is kind of discussing more about the actual antibody response to the vaccination and sometimes in relation to the timing of when the medication, is given. One of the things to emphasize is while we see some immune responses or antibody responses, that does not sometimes equal full protection from the disease. There may still be some infection. Vaccinations are not perfect, and there might still be some T-cell responses that are being studied in some medications, where the antibody response may not be as robust. Overall, I like what you said; take the vaccination if you can as long as it’s not a live vaccine. Vaccinations are important in a global pandemic and in a public health situation. We would recommend people to take vaccines. We took vaccines, right? We want to make sure that our patients are also protected when they come to visit us in the clinic. We also need to be vaccinated. So, there are a lot of these concepts that are great and evolving, and those data that you referred to that were specifically for people living with MS on oral therapies are very important because we know that the majority of the vaccine clinical trials did not include patients with MS, right?

 We really needed this data. When this came, I remember a flood of messages to our clinic, and we really didn’t know what to say. We didn’t know. We needed some data and thankfully now we have enough evidence to see that there are some responses to the vaccine regardless of being on a therapy, with some therapies, as you mentioned, may have a more robust response of antibody mediated response to vaccination.

Two MS experts discuss use and efficacy of vaccinations in patients with MS, especially in patients who are on oral DMTs.

Vaccinations in MS

 You touched on some exciting emerging therapies in the pipeline. Since you do trials, what’s exciting? What's coming up, and what are you most excited about?

Well, the closest I will say that we have coming up right now is a new compound with a different mechanism of action. These compounds that are in late phase 3, so the last phase before it goes to the FDA to be approved, actually show that they are able to penetrate the central nervous system, or the brain-blood barrier where the damage is occurring. Those are called BTKIs [Bruton tyrosine kinase inhibitors]. So just the fact that we have a molecule that can have some effect within the central nervous system is exciting in itself, and that's something I'm looking forward to because this will be a new thing in terms of how we treat patients and how that is going to affect the trajectory of the disease over time. As always, people talk about stem cells, and it's something that we are continuing to look at, but the closest right now is the BTKI group that we're going to see come to the market first, so I’m looking forward to that over time.

 It's exciting, to your point, that this is a class, so now we are seeing multiple medications within a class in the pipeline already going on together. It's like a race. It's kind of interesting to see.

 That's right, and we're very eager, to your point, to see what the results and efficacy are. In early phase 2 studies, they are showing good efficacy, so we're excited about the results of phase 3 trials, and then there will be potentially another full class of medications available for our patients. This is really exciting, so I share your excitement, and I think it's great to have all these options coming.

Drs Okai and Obeidat share their excitement about an emerging new drug class for the treatment of MS.

Emerging Treatments in MS

 I want to first switch topics a little bit, staying with the oral therapies, but I want to go more into asking you directly about your practice and how have you adopted the recent advances in these new oral therapies to improve patient care in your own practice.

This is an exciting time to be in multiple sclerosis, and the advances that have been made have just been tremendous, not only for patients but also for us as providers. In my practice, I do a lot of clinical studies, so my familiarity with newer drugs before they come to the market makes it easier for me to discuss with patients by the time they reach to me, so what the drug is like, what to expect, how we monitor, and all of that. So, I will say an early adapter is important, and I think providing the patients the options early on is also something that's important, because we have medications that really change the trajectory of the disease. I like to see what we are doing in the field; I like what is out there and what is coming for us and our patients, taking into account that this is a game changer for most of them. With looking at just the mechanisms of action of the various therapies that we have, we have been able to offer someone a medication that they can take, and I can tell them based on the data that … the risk of relapse in the first 5 years may be 1 or even less versus someone who's having a relapse at 2 or 3 times a year. Or I can offer them a therapy where they have a total of 20 days in 2 years, and I can say the chances of you being stable for the next 2 years after that for the total of 4 years is very high over time. The different mechanisms that we have is just exciting, and not only that, but the effect that it has on the disease, improving the quality of life, that they don't have to deal with relapses, that MS [multiple sclerosis] is not interrupting their life, that they can go about their career, the family life, the social life, without having this intruder there every time, is very significant. With what we have right now, we've made great strides in the past 25 to 30 years that we have reduced disability rates and prolonged life span, and what we have coming is very exciting for me and what I have to offer to my patients.

 That's great to know, and as you mentioned, every time now we are aiming for more disease control. Now we even aim for neither, not having disease activity and we strive to reach that, and we are trying to achieve the best personalized approach for each patient.

Annette Okai, MD, FAAN, discusses how she is utilizing the newer oral therapies and treatment advances in her practice.

Newer Oral DMTs in Clinical Practice

 I want to pick on clinical trials a little because I run several clinical trials, and I’m often looking for ideal situations. We look at inclusion and exclusion criteria, and we have to go through them, and patients have to qualify to be in a clinical trial. But when we are in our clinic day-to-day, many of our patients would not qualify for clinical trials based on several comorbidities, disease duration, relapse rates, or prior treatment. So having real-world data is of great importance to learn about how people we see mostly in clinics would do with these therapies if they were not included in clinical trials. That’s another value of real-world data, more, I would say, generalizability of what we find in those studies. Any more comments on real-world data related to efficacy and even safety?

Definitely. With clinical trials, we both do them and love to do them, but we know that we cherry-pick these patients. But when it comes to the real world, there’s no cherry-picking. If the patient is in your exam room, you have to choose a medication, and they may not fit the ideal patient from the trial. So real-world data are where we get our information to make that decision. How do we get real-world data? We look at databases, we look at registries, and we draw conclusions from that. When it comes to the group of therapies, and speaking of oral therapy specifically, let’s talk about some of the real-world data that we have seen. One thing I’d like to point out is that most of these medications have not gone head-to-head in clinical trials. We cannot compare them in terms of, oh, this medication is better than this medication, because we do not have the data for that. But what we can do is look at real-world data and say, how did it perform in this group, and how did this other medication perform in this group?

Recently we had an MS [multiple sclerosis] conference that showed several posters with real-world data looking at the different oral therapies in the absence of head-to-head clinical trials. It’s hard to do an accurate comparison, but what you can do with real-world data is that you can match cohorts. We use a technique called propensity score matching, where cohorts of patients on different therapies are matched as closely as they can be, accounting for different variables, to have a good set of data to compare to. So, when you use propensity score matching, you are in a way mimicking a trial with 2 sets of patients and looking at them on different sets of drugs. With that, I can speak to the fact that one showed that cladribine compared to fingolimod, dimethyl fumarate, and teriflunomide had an improved annualized relapse rate compared to those 3. Another poster showed that with patients on cladribine, the time to first relapse was also sustained longer and was significant compared to fingolimod. This is one example of where, while we do not have head-to-head data, we can look at patients, match them in terms of their demographics, and see how they do on the various medications, and then use that information to direct how we prescribe our medication to patients over time.

 Thank you for bringing this up, because propensity score matching has been utilized now multiple times, especially in multiple sclerosis and some other fields. As you mentioned, we don’t have many head-to-head clinical trials, so the use of propensity score matching is another way for us to look at real-world data and big registries and databases, like the MSBase and some of the other databases, to get some idea on how we can have some comparative efficacy and even comparative safety, sometimes, between existing medications post approval. It’s a good method, and it’s as good maybe as it can get to for us to be able to compare with real-word data. Again, clinical trials are the gold standard, but there are things like this so that we can have some comparative data we can employ in our practice. Thank you very much for bringing this up.

Propensity score matching is a biostatistical process, and they match the score, as you mentioned, based on several factors. And then, comparably scored patients can be compared on each of the drugs. And we have to compare to 1 drug, so we get scores for 1 drug, and then get another patient with a similar score on another drug and compare, which is something that’s been used in several publications. When I first read this, it was very complex for me to understand, and then later I’m like, “OK, now I get it.” I think this helped me to understand more and more of these publications as they come out to help us and guide in clinical practice.

It also helps us to eliminate most of the biases that may come in when you take 2 separate groups that are not in a controlled randomized trial. When you try to use real-world data and put these patients into groups, there are a lot of biases that may creep in, and this is one way to eliminate most of those and try to get as clean a data set as possible.

Two MS experts discuss how the field is benefiting from availability of real-world data, given the absence of head-to-head trials.

Real-World Data in RRMS With Oral Therapies

 Clinical trials are a great way of learning about medications, a great way to bring medications to market, and a great way for us to understand efficacy, major safety concerns, and also tolerability of the medication. Yet clinical trials are shortly timed: 2 or 3 years. Long-term data are really important, and often, long-term data stem from clinical trial programs where you have the open-label extension and are collecting data over years. People, and even patients, ask me sometimes, “How many years has this medication been approved?” Or, “How many years do we have of data?” What really defines long term is a hard question because it 5 years long term or 10 years long term? We don’t know. What I always tell my patients is that the more years we have, the more it is long term, but 1 extra year of knowledge is important. This is something we use to help us to decide on treatments, but also to understand monitoring, needs, and efficacy data. So long-term data are of immense importance. I want to ask you to discuss some of the long-term data we have on oral medications that are approved for relapsing-remitting multiple sclerosis.

This is a very important topic for patients, because like you said, they want to know how long the medication has been out and if they are going to be tested with this new therapy. My response is, before the medication comes to market, you have at least 5 years of clinical data. One thing you mentioned, Dr Obeidat, is that in the clinical trials, it only goes for a certain period of time. Is that really long term? Do we consider that long-term? What I must point out here is that, even when the clinical trial ends, there is still an extension phase in which these patients are followed, and then new studies are also opened to look at the medication in the real world, as we call it. We need to look at the medication in the real world and not a pristine clinical environment.

Speaking about some of the long-term data we have with the oral therapies, there have been several, and I will start with the fumarates. Like I mentioned before, the first one that came into the market was dimethyl fumarate, and there have been long-term data. What is encouraging with most of these long-term data, for physicians, we want to see that safety is maintained. That what we saw in the clinical trial is the same thing that we are seeing in the real world, and we are not seeing new issues pop up over time. We also want to make sure efficacy is sustained over a long period. We also want to make sure that tolerability is not an issue. Several of these medications, the fumarates, have shown that safety has been maintained over time, and in certain cases, efficacy has also been shown to be the same. There hasn’t been a big difference from what we saw in the clinical trials compared to what we see in the real world with a long-term extension follow-up, as we call it.

With the S1P [sphingosine-1-phosphate] class, we have fingolimod, which was the first one approved. Over time, the safety signals have also remained the same. We saw the same with teriflunomide. The safety signals are the same and efficacy is comparable to that of the clinical trials. The newer one to oral therapy is cladribine. Cladribine was recently approved, but I’d like to say that the trials were done a long time ago. So, even though it’s 2 or 3 years on the market, we have data up to 9 years that show there have not been any new safety signals. The efficacy data we saw in 2009 are the same as we are seeing now. Patients respond to these medications over time, and this has remained the same. So, I think when it comes to long-term data and how we see them in the real world, it’s important to look at the studies. We need to look at extension data and what we can get from real-world experience by looking at databases from various places to draw a conclusion on the safety, tolerability, and efficacy of these medications.

 This is a great summary of real-word data, and also long-term data. You mentioned cladribine studies were done earlier, with short dosing and then treatment-free periods, but showed sustained efficacy. It’s interesting to talk about these medications. 

Drs Obeidat and Okai discuss long-term data with oral DMTs that were recently presented at ACTRIMS 2022.

Long-Term Data With Oral DMTs in MS

 I like the way you mentioned that, yes, there are risks. We understand the risks, but we have to focus on safety and efficacy. But also those risks that we understand, we can mitigate. This is really important, and this is something, to your point, when I meet my patients, I say, “Well, there are some risks and you may not develop any of them, but you may develop some of them.” But what we would do is we are going to monitor. And the word monitor is of great importance, because that also keeps the patient engaged in their care because they know that there is some laboratory testing they would do and maybe some other testing that we need to be doing. Can I ask you to talk more about monitoring of medications and oral therapies?

Sure. I will say, when we start patients on treatment, like you said, monitoring is key, and this also keeps the patient engaged. I think with the level at which we monitor, this ensures that the safety of the patient is also the utmost priority. With all of the classes that I mentioned before, the first thing that’s common with all of them is we have to do blood monitoring. What are we looking for in the blood? We’re making sure that liver function is stable and is processing the medication like it should, and it’s not overworking. So, we monitor liver function. Another thing we also monitor for is white blood cell count and its subsets, most especially lymphocyte count. Why is that important, as well? The white blood cells and lymphocytes are what we are targeting as MS [multiple sclerosis] physicians, we want to keep that low to reduce the risk of inflammation. These are the cells that we have identified as the cause of attacking the nerve cells in MS, so we want to keep them very low. When I say that, most patients are curious, saying, “Well, is that going to affect me? Am I going to be more susceptible to infection?” I have to assure them that this is only one part of the immune system. This is not your entire immune system. You still have the ability to fight off infections if needed, and not all of our treatments are putting your cells at very low levels. We are lowering it, but you still have enough to do the job that’s needed. Those are the 2 main things that are common across these 4 groups.

Now, when we take the groups and break them down, we still have some other monitoring to do prior to starting treatment. This is great because we do testing prior to starting to make sure you are appropriate for the treatment, and then prescribe it. So, if in that pretesting phase we see that one is abnormal, then we know that this is not the medication for you, and we have another choice. One of the things we do prior to starting treatment is to make sure that there aren’t latent infections, such as TB [tuberculosis], herpes, or shingles. We also want to rule out any HIV as well. This is important, once again, because of the white blood cells and what we are doing to them. Once we make sure that all of those things are in line, or if you need a vaccine before you start, then we get that in line, and then we prescribe the medication for you. Afterward, once again, we monitor the liver, blood counts and see how those levels are. For some of the medication, even though the blood count might be low, it gives us as providers a certain level of comfort because we know the medication is working as we want it and as it’s supposed to be.

 This is a great way also of sometimes even monitoring adherence to treatment, right?

 We know the patient is taking the medicine, it’s showing an effect. One other aspect is sometimes when primary care physicians or other doctors are taking care of the patient, they may be aware that these changes are expected from the medications. That’s sometimes important. That prevents further testing to rule out other issues that one may think are going on, but it’s because of the medicine. That’s also a big part of our education, right?

Exactly. We also have to educate the primary care physicians. I tell patients as well, “If your primary care draws this and sees that your white blood cell count is low, tell them you are on this medication that causes it.” That way there isn’t an unnecessary referral to a hematologist or something for an abnormally low white blood cell count. Education is important for not only the patient from the provider, but also the other providers taking care of patients as well.

MS experts highlight the value of monitoring and use of risk mitigation strategies when taking care of patients with MS.

Monitoring and Risk Mitigation in MS

 We’re going to transition to oral therapies in multiple sclerosis [MS] and focus on this for the rest of the episode. Nowadays we talk about classes, but back in the day we’d talk about medications. We talk about full classes of medications, and within each class we have several medications, which is a great problem to have. It’s great because sometimes within the class, there’s some small intricacy that for a specific patient, 1 medication from the class may be better than the other. This can help us select and personalize the treatment approach. I’d like to ask you to discuss with our audience and provide an overview, it can be brief, on the classes of oral medications used for relapsing-remitting multiple sclerosis.

I’m happy to do that. Long gone are the days when you have 1, 2, 3, or 4 medications and then make a decision. Each class has more than 1 medication at this time. In terms of the oral medications available for multiple sclerosis, we have 4 classes, meaning that the mechanism of each class is different from 1 class to the other. The first class I’d like to touch on is called fumarates. Within that you have dimethyl fumarate, monomethyl fumarate, and so on. This class of medication has 1 common mechanism of action. When you have that in a class, you also see that the potential adverse effects may be the same, with a little variation.

Fumarates are in a class that work on oxidation, or oxidated stress as we call it in MS. But there are potential adverse effects. There may be GI [gastrointestinal] issues, and you have to counsel the patient regarding how to take the medication to reduce these potential adverse effects. I keep saying 

 because that doesn’t mean that the patient is going to develop these adverse effects. It’s an effective class of medications, and we’ve seen this in several studies proven over time.

The second class I’d like to talk about is S1P. I’m using the initials as opposed to the long name, but it’s the sphingosine 1-phosphate class. This class has 4 medications: fingolimod, ponesimod, siponimod, ozanimod. They all carry that same thing. They’re also very effective in their own class. We’ve seen that with the initial drug fingolimod, the potential for lowering the heart rate below a certain threshold was high, and patients needed to be monitored to take the first dose. With the newer drug in that class, there isn’t a requirement for monitoring because the cardiac effects are fewer.

I caution patients that even though we’re talking about potential adverse effects associated with the drug, the first thing we should think about is efficacy. Then I weigh that in terms of the benefit-risk profile. As time goes by, we seeing improvements in our medication with the risk is being lowered, in terms of how we’re monitoring and making sure that the patients are on a good process and following a certain protocol to make sure this medication is the best for them.

The third class is pyrimidine inhibitor, and this is where teriflunomide comes in. This works in a different way in that it restricts this type of amino acid from actively dividing cells, and that’s supposed to control the inflammatory rate. Once again, all these medications have been proven to be effective. The fourth class is purine synthesis inhibitor, and that’s where cryoglobulin is in. This has a unique mechanism of dosing: 10 days a year for 2 years, and then you monitor after 2 years.

In terms of what could potentially occur, we have to clear the patient for any type of malignancy and make sure there are no latent viruses before we initiate therapies. As you can see, I have 4 classes, and I have 9 to 10 medications in just 4 classes of older drugs. It’s exciting that we have these options in MS and can offer them to patients. We know how to monitor and treat these patients regardless of everything we see listed in terms of adverse effects. Because we’re familiar with it, we choose the right patient for the medication, thereby decreasing any risk to that patient. This is what we call risk mitigation, and this has helped us in the past. Most patients do quite well when we choose medication that’s aptly suited to their disease.

 This is a superb summary of the existing oral therapies that we have for multiple sclerosis.

Dr Okai provides an overview of oral DMTs available to patients with RRMS.

Oral Therapies in MS

 We have 21 medications, including generics, approved for relapsing-remitting multiple sclerosis [MS]. When you think about choosing a disease-modifying therapy, what patients or disease factors, or both, do you consider for your patient before and when you select treatment?

MS is a very complicated disease as it is. There are various factors that we as providers have to look for in selecting the most appropriate therapy for patients. Specifically, I look at how effective the therapy will be for the patient. The likelihood that the patient will respond to treatment or tolerate treatment is also the impact on the quality of life. There are several other factors I take into consideration. How is the patient presenting? What does the MRI look like? Did they present with 1 symptom or multiple symptoms at once? Did they fully recover from that event that they had, or do they have residual symptoms occurring? What other comorbidities do they have that are going to impact my choice for them? Clinically, I have to put all that into context.

I also have to look at it from the patient perspective. How is this going to impact them? Are they going to tolerate it? Is this medication something they can afford for an extended period of time without breaks and treatment? Is this is something they can take in addition to any other medications they’re on? Several factors come into play. There isn’t a single 1 that I use, but we have to look at the totality of the presentation of the patient at that time and what you hope to achieve in the short term and long term. As you said before, invest in the short term for the long term, because we want to reduce disability. That’s the goal for both providers and patients when this discussion is being held.

 This is great, and you’re alluding to the concept of shared decision-making. This is a topic of very high importance because with the number of medications we have and the various ways the medications work, the various administration routes, and things like that, shared decisions are very important. In my clinic, I say, “If we have a medication that we reach mutually with shared decision-making, that’s a medication that most likely will be successful.” That’s because the patient will be taking the medicine. They’ll be following the recommendation because they participated in that decision. I’d like to hear your perspective on shared decision-making. Also, a recent poster presented at ACTRIMS [Americas Committee for Treatment and Research in Multiple Sclerosis] has some interesting findings about how commonly shared decision-making is utilized in clinical practice.

Exactly. I like to think that if someone had a stake in the decision-making, the likelihood that they’re compliant with treatment is very high, but you also have to involve the patient in this decision-making. As I mentioned earlier, MS is a complicated disease. The choices aren’t as simple as we’d like it to be. As a provider, my goal is to explain what the disease is and a little biology behind it, and then bring into that the medication and how it affects the biology of the disease and why we think this may be the best.

Then I take the patient perspective and say, “I’ve given you the reasons why I think this may be the right medication for you based on these factors that you’re showing, but how does this play into your lifestyle?” Let the patient have a say. I can choose what I think is the best medication for the patient, but if that patient has adverse effects from treatment or comes in with some type of misconception that this medication may cause this, I don’t want to deal with that. Without proper explanation or education on what it is, that patient may leave the office and be noncompliant with the medication. Then your best treatment option really isn’t that. Give the patient a role in the decision-making process and help them understand why you chose what you did and how it plays into their lifestyle. Coming to a agreement on what’s best in terms of the treatment plan enhances medication compliance and understanding of the disease.

 This is great. You understand patient preferences, risk tolerance, the goals of therapy, and the lifestyle. Based on these factors, you recommend what you think is the best medication. Then the patient agrees to it because they understand why you’re recommending this medicine. That results in a successful journey with MS while on these therapies.

Two MS experts discuss shared decision-making and other considerations in choosing MS treatment.