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Optimizing Treatment of Relapsing-Remitting Multiple Sclerosis with Oral Therapies - Episode 3

Treatment Considerations in MS

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

Ahmed Zayed Obeidat, MD, PhD: 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?

Annette Okai, MD, FAAN: 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.

Ahmed Zayed Obeidat, MD, PhD: 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.

Annette Okai, MD, FAAN: 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.

Ahmed Zayed Obeidat, MD, PhD: 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.

Transcript Edited for Clarity