Oral Therapy Options for Relapsing-Remitting Multiple Sclerosis - Episode 13

Managing Patients With RRMS on Novel Oral Therapy

Key takeaways from a larger discussion surrounding the utilization of novel oral agents as therapy for patients with relapsing-remitting multiple sclerosis.

Jennifer Graves, MD, PhD, MAS: Let’s take a look back. What do you think is a take-home message for physicians treating relapsing-remitting patients with oral therapies? What big-picture advice would you give the treating physician or the patients about these classes of medications?

Gabrielle Macaron, MD: I’d tell the treating physicians that we have the chance to be able to treat MS [multiple sclerosis] in this new era of treatments, and we have over a dozen disease-modifying therapies that are available for our patients, and that’s a good thing.

Another key message is that treatment of MS remains complex and is becoming increasingly complex. There are unknowns regarding the best treatment approach and monitoring of treatment response. This is why treatment choice should always be individualized and take into consideration everything we said: the patient, their age, disease scores, disease characteristics, comorbidities, family planning, compliance, and patient preference. Understand that this is a dynamic process and might change each time we reassess the patients. And that oral DMTs [disease-modifying therapies]—because this is the subject of this discussion—have the advantage to be taken easily, and each has advantages and disadvantages that we should tailor to each patient.

Suma Shah, MD: I couldn’t have said it better. The only thing I’ll add is an expectation conversation between you and your patients as far as what your landscape looks like for future therapy choices and what your hopes are as far as clinical care. If that conversation can be had early and often, as far as what your goal is as their MS specialist or MS provider or neurologist in their care, that will help the patient know what to expect out of their oral DMTs and their relationship with you, and they’ll know that they can come to you. This is where your friendly neighborhood MS specialists can be helpful too. When it comes to these dizzying numbers of DMTs we have available, as Dr Graves mentioned, I always enjoy being part of the discussion about potential escalations in care if something doesn’t work out to the way the patient or provider expected.

Jennifer Graves, MD, PhD, MAS: In modern medicine, we’re doing a good job of educating physicians about shared decision-making and making sure that we’re moving forward as a team with the patients and the care provider individuals on MS medications. But I’m sure you’ve both had an experience that I’ve had, where I’ve laid everything out and tried to describe in detail the benefits, efficacy, and adverse effects, I’ve reviewed their history in detail, but we still have an open choice in front of us and the patient looks at me and says, “Dr Graves, what do you think I should do?” When you’re faced with that, what are a couple of key pearls you use to make that final decision? When the patient says, “I just want you to tell me what to take.”

Suma Shah, MD: I’ve definitely been in that position. Oftentimes it’s, “You’re the doctor, Dr Shah. You tell me.” That’s where getting to know the patient and having that discussion early is important. That’s where you have those family-planning conversations and talk about what life looks like outside the 4 walls of our clinic room and see whether twice-a-day medications are doable. I ask patients if they have children or if they’re on any other therapies and how well they do with taking medication, so that once a day vs twice a day may be a heavier consideration. I have patients who are truck drivers. For them, there are other considerations about storage and being able to travel with their medications and all that. Getting to know your patient well helps make that decision a little easier.

Gabrielle Macaron, MD: There’s also an advantage of laying down the options briefly. The more we go into details with the patients, the more it’s confusing for them, and then for us because they’re confused. It’s also important because when we have this conversation, then even the facial expression of the patient when we mention X or Y adverse effect automatically gives us a direction of what we can choose and what they’d feel more comfortable with.

Jennifer Graves, MD, PhD, MAS: You guys have eloquently said all these points. I would add that there’s usually a way to find a good fit, at least at the best first-pass decision-making on a disease-modifying therapy. The other thing I tell my patients is that the first decision we make isn’t a long-term marriage. We like to think of it as at least long-term dating. We want you to give your medication a real chance for 6 to 12 months, but the medication we choose isn’t one you have to be on forever.

As you both eloquently described, there are ways we can monitor patients, both for safety and efficacy, to make sure that we have a good fit. Most of the time, I’m lucky in that there are key factors either related to their intrinsic relapse rate or their risk-factor profile that allow us to make a best first pass. But all these medications have a role in multiple sclerosis, and there are ways to find a good fit for an individual.

In closing, thank you for watching this NeurologyLive® Peer Exchange. If you enjoyed the content, please subscribe to our e-newsletters to receive upcoming Peer Exchanges and other great content right in your in-box. I thank Dr Shah, Dr Macaron, and the NeurologyLive® group for allowing us to bring this conversation to you. Thank you.

Transcript edited for clarity.