Current Series: Treatment Of Multiple Sclerosis Relapses

Thomas P. Leist, MD, PhD: Is making a decision to go on treatment sufficient to ensure that the patient remains on therapy? I think that all of you who hear this segment would immediately say, “No, it’s not.” It is very important to openly discuss adherence to medication with the patient, including the burden of adverse effects. Fiscal burdens are also important to recognize: Can they get the medication? Has their insurance changed? How is the co-pay affecting them? It’s important to explore all the barriers that actually lead to reduced adherence and compliance with the medication.

One of the very important considerations around most of the medications that we have available is the fact that once ongoing therapy compliance goes below about 80%, the disease activity of multiple sclerosis [MS] returns to its natural-history course for that particular patient. We all want to afford the patient the best possible outcome from treatment, from management to consideration of adherence. Appropriate questioning of adherence is a very important part of follow-up visits with the practitioner.

How can one potentially ensure that the patient is adherent to medication regimen? Obviously, this is only possible if the patient actually gets the medication. Very often, many of us get letters from the pharmacy benefit provider indicating that the patient hasn’t refilled medication.

If one has a question, there is also the possibility of getting a printout or a readout of the patient’s refill history from the pharmacy benefit provider. This is an integral part of the considerations we address during every follow-up visit. Are you taking your medication? How many doses have you missed? If you have missed doses, why did you miss them? What was the problem surrounding it? Is it that you don’t want to take the medication? Do you have adverse effects? Could you not refill the medication because you have co-pay issues associated with it? Have you changed your insurance plan and the old medication is no longer covered?

All of these are very important points, and there are different approaches, from the electronic health records to the pharmacy benefit records. However, the patient history itself is also very important. Obviously, this is slightly different for medications that are administered at an infusion center or for medications that are administered at very infrequent courses of treatment.

When we have a patient in front of us and we consider potential MS relapse, 1 of the cardinal points is to first ensure that the patient doesn’t have a pseudo-relapse. When I use the word pseudo, I don’t mean that this doesn’t look, feel, or have the characteristics of a relapse for the patient. It’s more a recrudescence, or a return of prior symptoms that the patient has experienced because of an infection.

Very often, when patients go to the emergency [department], the first thing that is done is they are given a dose of steroids. Very often, a urinary tract infection is not ruled out. In patients with new activity, it is very important to ensure us that the symptoms are, in fact, new by history and that the same symptoms are not due to an infection. Subsequently, if the patient has 2 new symptoms, it is also indicated to image the appropriate part of the central nervous system where the lesion is suspected. Showing new lesions, particularly in patients on treatment, will open a conversation with the patient regarding adherence to current therapy. If adherence is present, a discussion with the patient regarding switching medication to 1 with an alternative mode of action may be warranted.

Multiple sclerosis is a lifelong illness. It requires seeing the patient at regular intervals to get to know them. It is important to understand where they stand in their disease process. With that, it’s also important to understand how the patient is at baseline in their neurological functioning. This will allow us to evaluate the patient when they present with changes in their neurologic functioning. This makes it easier for us.

It is also important to encourage patients to contact the practice if they incur new symptoms so that we can see them earlier, because again, if a patient had symptoms that started 3 or 4 weeks ago and they are already on their plateau, it may be less helpful to consider treatment for an acute lapse in this particular patient.

As always, when a patient presents with new symptoms, it’s important to ensure that we are treating a truly new event and that we are not just treating the adverse effects of an infection.

It is important to keep in mind that multiple sclerosis patients go through periods of relative quiescence followed by periods of more disease activity. It is important to monitor the patients who appear clinically stable for subclinical progression of their disease. It is helpful if certain standard measures can be performed in practice. The Timed 25-Foot Walk Test can be integrated into the vital signs, the 9-Hole Peg Test, or perhaps the Symbol Digit Modalities Test can also be performed to provide a formal assessment of every patient with a quantitative measure that can be followed over time.

If a patient comes in and has a clear change in their 25-foot walk time, this may lead to a completely different flow in that care visit. If the patient comes in and has vision that has clearly changed based on a Snellen test, this will affect how we look at the patient’s stability. If the patient has a significant decrement in the Symbol Digit Modalities Test, this will also lead to a discussion with the patient. It will be important as we look forward to value-based care to integrate measures that are quantitative rather than just qualitative evaluations of patients with multiple sclerosis.