Treatment Planning and Shared Decision-Making in RRMS


Best practices for talking about treatment goals and options with patients who have relapsing-remitting multiple sclerosis.

Jennifer Graves, MD, PhD, MAS: How do you approach discussing treatment options? You’ve made the diagnosis and let someone know they have relapsing-remitting disease. You have the opportunity to interact with them at the beginning of their story with MS [multiple sclerosis]. What are your first conversations like about therapeutic options?

Suma Shah, MD: The hallmark is trying to understand a little about behavioral economics and shared decision-making as we sit in the room with our patients. The truth is there’s no wrong answer, especially when it comes to how many medications we have approved. However, we want to be sure that people are treated with the best option available for them for what’s going to fit into their lives. Because of our multitude of options, that’s a conversation we can have. It can get challenging, but it’s one that we have to make sure we know how to navigate. There are various options as far as oral, infusion, and injectable therapies, and they all have varying levels of efficacy. Based on your risk tolerance and my recommendations from what I’ve seen, how can we come to a place that’s meeting in the middle?

Jennifer Graves, MD, PhD, MAS: Dr Macaron?

Gabrielle Macaron, MD: I agree with everything that was just said, but I’d also like to add that it’s very important to talk about compliance and optimizing treatment response. It’s important to say to the patient that there’s no right and absolutely perfect disease-modifying therapy for them, and that the choice should be individualized. Part of this individualized treatment choice is compliance and patient preference. Patient preference is definitely not the most important part, because we need to orient the patient and recommend what is best for their disease. But it’s also very important, because if we have noncompliant patients, then we don’t have a good treatment response.

Jennifer Graves, MD, PhD, MAS: Absolutely. I’d add that there are a few other things I look at. I look at their presenting features of disease and try to give them my scientific opinion about the level of medication that they might require, along with the timeframe. I always bring up how fast the medications work. That’s an important distinguishing feature. Some of our medicines work within the hours that you get them, others take about a month to be fully protective, and others might take 3 to 6 months to be protective. Depending on your estimate of their relapse activity, you may want to take that into account as well.

The other things I ask include family planning. If it’s a woman, I like to know up front if she’s planning on getting pregnant in the next 1 to 2 years. I don’t think we have to make our decision today based on apersonal life decision 5 years down the road, but if it’s within the next 1 to 2 years, that should be taken into account. For men, there are a few medication choices we may want to avoid if they’re planning on a pregnancy in their family as well. Other things that are important include figuring out how you can reduce social determinants of health barriers. Some people express concern about their ability to get to appointments, including appointments for infusion therapies. Other people say their lives are so busy juggling 2 jobs and 8 kids that they’re not going to remember a daily medication. I try to understand those factors so we can, as you both pointed out, improve compliance.

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Transcript edited for clarity.

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