RRMS: Introducing Oral Therapy into Clinical Practice


Considerations that affect recommendations for novel oral treatment for relapsing-remitting multiple sclerosis vs a more conventional option.

Jennifer Graves, MD, PhD, MAS: If a patient ends up saying they’re not into needles, they don’t want to do injections or infusions, and you’ve deemed that one of the oral therapies may be appropriate for them, can you describe the conversation you might have with a patient who expresses interest in an oral therapy? Dr Macaron, maybe you can start us this time.

Gabrielle Macaron, MD: I’d tell my patients that oral therapies have some advantages. They’re obviously more convenient than injectables, and they’re generally better tolerated. They put less stigma on the patient. When you take a pill, it’s different from when you inject yourself. I also explain the difference between continuous or DMT [disease-modifying therapy], such as fingolimod, dimethyl fumarate, and teriflunomide, which have to be taken daily vs pulsed, or therapies such as cladribine, which is used in 2 treatment cycles separated by a year and has the advantage of improving adherence to treatment. It’s also important for patients to know what follow-up is needed when taking these medications. This is an inherent part of adherence. They should be able to also do the follow-up that is needed to optimize the safety and efficacy of the medication.

Jennifer Graves, MD, PhD, MAS: That’s such an important point, that there’s adherence to taking the medication, but we also need patients to adhere to safety monitoring and protocols. That’s an excellent point. Dr Shah, do you want to add to that?

Suma Shah, MD: The other part of the discussion that often comes up and what I think patients take into account more personally is often the tolerability and adverse effect profile. If there are oral pills, whether they’re once a day or twice a day, they want to get a sense of what possible adverse effects they’re signing up for. For a fair part of my patients who have diagnoses of MS [multiple sclerosis], they might be thinking of transitioning care from their injectables. They’ve got needle fatigue and want to go to an oral therapy. For those patients, particularly with some of the adverse effects they may have experienced previously, they’re interested to see, “How is this going to affect me day-to-day and what should I look out for?” That would be the last part of that conversation for me.

Jennifer Graves, MD, PhD, MAS: We’ll go into the details of different oral drugs in a moment, but how do you paint the options in that framework in terms of adverse effects? Sometimes I like to distinguish them by saying, “These are the adverse effects you’ll feel, and these are the adverse effects you might not notice on a day-to-day basis but are things you and I have to monitor for.” How do you approach painting that picture for them when you’re providing a framework for oral therapy?

Suma Shah, MD: I try to paint broad strokes. I try to share my experience with what I have seen on the whole with the majority of these therapies, and I’m fairly honest about the fact that rare things can happen and we don’t know what a medication is going to do to someone individually until they take it. But with that said, I use broad strokes with how this might affect their day-to-day. I like to ask a little about their own background. If they’re someone who tends to have more IBS [irritable bowel syndrome] symptoms, certain oral medications might not be right for them. If they’re patients who have concerns about vision changes because of a history of optic neuritis, they tend to shy away from certain oral medications for that reason. One of my patients a few years ago was getting married and came to me for a second opinion. She had a fair amount of hair loss happening in the setting of stress prior to wedding planning. The hair loss and specific adverse effect profiles can really weigh on someone’s individual decision-making.

Jennifer Graves, MD, PhD, MAS: Dr Macaron, do you have anything to add?

Gabrielle Macaron, MD: Yes. I also think it’s important. I usually like to emphasize the fact that some medications have more pretreatment workup and there are a lot of things to do before starting treatment, and some have a lot of follow-up. Sometimes there’s monthly blood work. This also makes it easier for them to understand, because sometimes—especially with S1P [sphingosine 1-phosphate] inhibitors—when we explain to them how many things have to be done before starting treatment, they freak out. But when we mention that it’s preventive to avoid any problems with the medication, that makes it much easier for them to accept and they feel more comfortable taking this medicine because they know that they have it all in check. This is also important.

Jennifer Graves, MD, PhD, MAS: You both made some excellent points. Coming back to the topic of pregnancy, which is one of my interests in MS, I remind people that if we go with an oral option, they can’t get pregnant on any of the oral options. That’s one rule of thumb in family planning and MS. I also have a discussion about birth control if we’re heading toward an oral therapy and I make sure they’re going to use a reliable form of birth control.

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Transcript edited for clarity.

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