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Optimizing Treatment of Relapsing-Remitting Multiple Sclerosis with Oral Therapies - Episode 5

Monitoring and Risk Mitigation in MS

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

Ahmed Zayed Obeidat, MD, PhD: 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?

Annette Okai, MD, FAAN: 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.

Ahmed Zayed Obeidat, MD, PhD: This is a great way also of sometimes even monitoring adherence to treatment, right?

Annette Okai, MD, FAAN: Exactly.

Ahmed Zayed Obeidat, MD, PhD: 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?

Annette Okai, MD, FAAN: 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.

Transcript Edited for Clarity