Adherence and persistence to drug therapies for multiple sclerosis: A population-based study

Treatment Adherence in a Large Cohort of Turkish Multiple Sclerosis Population

OBJECTIVES

This study aimed to evaluate adherence to disease-modifying therapies (DMTs) among patients with multiple sclerosis (MS) and to identify factors influencing compliance, based on perceptions and preferences of both patients and neurologists.

METHODS

Questionnaires were designed by a team of experts, including MS specialists, psychologists, and statisticians, to capture data on treatment adherence and related factors. A total of 1021 MS patients and their neurologists participated. Patients' adherence to oral, injectable, and infusion DMTs was assessed alongside demographic and disease-related characteristics.

RESULTS

The study included 1021 MS patients with a mean age of 35.69 ± 9.07 years. Infusion therapies demonstrated the highest adherence rates (96.6%). Among all patients, 78.9% maintained treatment without interruption, while 56.7% of those who interrupted therapy informed their physicians. Patients with a disease duration of less than one year or more than 10 years exhibited lower rates of treatment interruption compared to those with a disease duration of 1-10 years (p = 0.032). In the injectable DMT group, significant differences in adherence were noted (p < 0.001). The lowest interruption rate (13.5%) was seen in patients with a disease duration of less than one year, whereas interruption rates were markedly higher (83%) in those with a duration exceeding 16 years.

CONCLUSION

Improving adherence requires a patient-centered, collaborative approach emphasizing shared decision-making between physicians and patients. Addressing factors that contribute to non-compliance is essential for optimizing treatment outcomes and enhancing long-term disease management in MS.

Comorbidities, safety and persistence in phase III clinical trials in multiple sclerosis

BACKGROUND

Associations between comorbidity and reduced persistence to disease-modifying therapies (DMTs) in multiple sclerosis (MS) have been identified. Limited information is available regarding the association of comorbidity with safety outcomes. The study objective was to evaluate the association of comorbidities with safety outcomes and persistence.

METHODS

We conducted a two-stage meta-analysis of individual participant data from phase III clinical trials of MS DMTs. Individual comorbidities and comorbidity burden, defined as the sum of all comorbidities (n=15), were examined. Safety outcomes, defined using adverse event (AE) data, were reviewed to identify specific AEs of interest, including infection; treatment-emergent autoimmune disease; cancer; elevated transaminases and lymphopenia. We also examined any early trial discontinuation.

RESULTS

We included 17 clinical trials representing 16 794 MS participants. Over a 2-year follow-up, the pooled proportion of AEs was 64% (95% CI 59.4% to 68.9%) and the majority were infection AEs. Increasing comorbidity burden was associated with an increased rate of AEs (rate ratio (95% CI) 1: 1.13 (1.09 to 1.17); 2: 1.19 (1.14 to 1.23); ≥3: 1.25 (1.18 to 1.33)) compared with those with no comorbidity. When pooled across trials, early discontinuation affected 17% of participants (95% CI 13.8% to 20.9%). A higher risk of trial discontinuation was associated with higher comorbidity burden (2: 1.23 (1.07 to 1.42); ≥3: 1.19 (1.01 to 1.40)) compared with those with no comorbidity. Psychiatric disorders were associated with trial discontinuation.

CONCLUSIONS

Higher comorbidity burden is associated with increased risk of experiencing safety outcomes and early DMT discontinuation among individuals with MS enrolled in clinical trials of MS-DMTs, highlighting the important role of comorbidities in the safety and persistence of DMTs.

Barriers and facilitators to medication adherence in chronic diseases: a scoping review

To guide the interventions of health professionals, it is necessary to identify the reasons for non-adherence to treatment. This scoping review aims to identify and discuss barriers and facilitators for adherence to pharmacotherapy in chronic diseases. Of the 3,482 eligible studies, it was observed that in the 114 studies that met the selection criteria, facilitators such as income, social support, older age, education, motivation to use pharmacotherapy, formation of a bond with the health professional, health education, believe in pharmacotherapy, realize the benefits of pharmacotherapy, motivation for self-care, and disease severity, were common to the various chronic health conditions. Regarding the common barriers, were: cost of the medication, complexity of pharmacotherapy; adverse drug reaction, greater number of prescribers and pharmacies used, greater number of visits to urgent and emergency services, believing that the medication is not necessary, and having depression. The analysis of these factors provides support for the health professional to identify the reasons that led to non-adherence and guide the interventions to be carried out, promoting adherence to treatment.

Appointment non-attendance is associated with disease modifying therapy persistence the following year

BACKGROUND

It is recommended that healthcare providers and persons with multiple sclerosis (MS) have discussions prior to discontinuing a disease modifying therapy (DMT). However, if these appointments missed, either as a no show (NS) or short-notice cancellation (SNC), these discussions do not take place and may result in premature discontinuation. This study aimed to explore whether appointment non-attendance was predictive of DMT persistence the following year.

METHODS

Electronic health record data from Veterans with MS (n = 3,742) in the Department of Veterans Affairs (VA) MS Center of Excellence Data Repository were examined during two time frames: January 2013 - December 2013 (Year 1) and January 2014 - December 2014 (Year 2). DMT non-persistence was defined as discontinuing a DMT and not restarting another one within 90 days. The proportion of each type of missed appointment in Year 1 was calculated by dividing the number of NS and SNC by the total number of scheduled appointments during that time frame, respectively. Logistic regressions were run for each appointment non-attendance behavior, with Year 2 non-persistence as the outcome and age, sex, race, number of comorbidities, time since initial DMT, and Year 1 non-persistence as covariates.

RESULTS

Veterans who were non-persistent in Year 2 (n = 563) had a higher proportion of NS (6.5 % vs. 4.6 %, p < .001) and SNC (6.7 % vs 5.7 %, p = .002) in Year 1. After adjusting for demographics and DMT history, both the proportion of NS (aOR = 5.01, 95 % CI: 1.82, 13.29, p = .001) and SNC (aOR = 3.86, 95 % CI: 1.09, 12.90, p = .032) in Year 1 were significantly associated with non-persistence the following year.

CONCLUSIONS

Appointment non-attendance was associated with DMT non-persistence the following year, with both higher proportions of NS and SNC being significant contributors after controlling for demographics and DMT history. These findings highlight the potential effects of disruption to care for persons with MS.

Treatment satisfaction with disease-modifying therapy is the only predictor of Adherence among multiple sclerosis patients from Upper Egypt

Despite the proven efficacy of the disease-modifying therapy (DMT) for multiple sclerosis (MS), the rates of non-adherence are frequently high. We aimed to evaluate the rate of non-adherence to the first DMT in Upper Egypt and identify different contributing factors. Out of 310 patients, ninety-seven adult patients with RRMS were recruited from three MS units located in Upper Egypt and were subjected to the following: complete clinical history, expanded disability status score (EDSS), Eight-item Morisky Medication Adherence Scale (MMAS-8), abbreviated Treatment Satisfaction Questionnaire for Medication-9 (TSQM-9), Hamilton depression scale, Fatigue Severity Scale (FSS) and the Pittsburgh Sleep Quality Index (PSQI). According to MMAS-8 scores, 63 (64.9%) of patients were non-adherent to their first DMT. Non-adherent patients are more likely to have longer disease duration (p = 0.002), longer duration on first DMT (p = 0.030), first DMT-start date before 2019 (p = 0.040), and lower treatment satisfaction scores (p = 0.016). However, there was no significant relation with physical disability, depression, fatigue, or sleep quality. On the regression analysis model, a lower treatment satisfaction score was the only predictor of DMT non-adherence (p = 0.012). Despite expanding DMT options, non-adherence among MS patients in Upper Egypt is high. Treatment satisfaction with DMT is the only predictor of adherence among MS patients of Upper Egypt. Adherence and satisfaction with the prescribed DMT should be assessed carefully to maximize DMT benefits.

[Adherence to treatment in the management of patients with multiple sclerosis]

Adherence to therapy largely determines the success of treatment interventions: low levels of adherence are associated with reduced treatment effectiveness. For many chronic diseases, the level of adherence to treatment is about 50% or less, which confirms the relevance of this topic and requires its research. The high costs of treatment, the need for long-term continuous use of drugs and the special socio-economic significance of a disease such as multiple sclerosis (MS) determine the importance of maintaining a high level of adherence to its treatment. An analysis of literature data on the concept of treatment adherence, methods of its definition and influencing factors was carried out, the values of the level of adherence in the treatment of MS, as well as measures to maintain it during the COVID-19 pandemic were considered. Increasing awareness of healthcare professionals about the problem of treatment adherence and ways to improve it helps to improve the efficiency of managing patients with MS. The paper considers the primary stage of the strategy to improve treatment adherence among patients with MS, namely the formation of expanded knowledge of the problem by specialists of a multidisciplinary team involved in the diagnosis and treatment of patients with MS.

Predictors of treatment switching in the Big Multiple Sclerosis Data Network

Background

Treatment switching is a common challenge and opportunity in real-world clinical practice. Increasing diversity in disease-modifying treatments (DMTs) has generated interest in the identification of reliable and robust predictors of treatment switching across different countries, DMTs, and time periods.

Objective

The objective of this retrospective, observational study was to identify independent predictors of treatment switching in a population of relapsing-remitting MS (RRMS) patients in the Big Multiple Sclerosis Data Network of national clinical registries, including the Italian MS registry, the OFSEP of France, the Danish MS registry, the Swedish national MS registry, and the international MSBase Registry.

Methods

In this cohort study, we merged information on 269,822 treatment episodes in 110,326 patients from 1997 to 2018 from five clinical registries. Patients were included in the final pooled analysis set if they had initiated at least one DMT during the relapsing-remitting MS (RRMS) stage. Patients not diagnosed with RRMS or RRMS patients not initiating DMT therapy during the RRMS phase were excluded from the analysis. The primary study outcome was treatment switching. A multilevel mixed-effects shared frailty time-to-event model was used to identify independent predictors of treatment switching. The contributing MS registry was included in the pooled analysis as a random effect.

Results

Every one-point increase in the Expanded Disability Status Scale (EDSS) score at treatment start was associated with 1.08 times the rate of subsequent switching, adjusting for age, sex, and calendar year (adjusted hazard ratio [aHR] 1.08; 95% CI 1.07-1.08). Women were associated with 1.11 times the rate of switching relative to men (95% CI 1.08-1.14), whilst older age was also associated with an increased rate of treatment switching. DMTs started between 2007 and 2012 were associated with 2.48 times the rate of switching relative to DMTs that began between 1996 and 2006 (aHR 2.48; 95% CI 2.48-2.56). DMTs started from 2013 onwards were more likely to switch relative to the earlier treatment epoch (aHR 8.09; 95% CI 7.79-8.41; reference = 1996-2006).

Conclusion

Switching between DMTs is associated with female sex, age, and disability at baseline and has increased in frequency considerably in recent years as more treatment options have become available. Consideration of a patient's individual risk and tolerance profile needs to be taken into account when selecting the most appropriate switch therapy from an expanding array of treatment choices.

Switching to second line MS disease-modifying therapies is associated with decreased relapse rate

Background and objectives

While randomized, controlled trials (RCTs) are the gold standard for determining treatment efficacy, they do not capture the effectiveness of treatment during real-world use. We aimed to evaluate the association between demographics and multiple sclerosis (MS) disease-modifying therapy (DMT) exposure, including treatment adherence and switches between different DMTs, on the risk of subsequent MS relapse.

Methods

All persons with relapsing-onset MS (pwRMS) living in Manitoba between 1999 and 2014 were identified from provincial healthcare databases using a validated case definition. Use of DMTs was abstracted from the provincial drug database covering all residents of Manitoba, including use of any DMT, stopping/starting any DMT, switches between different DMTs and adherence as defined by cumulative medication possession ratios (CUMMPRs) of 50, 70, 80 and 90%. Time to first-treated relapse was used as the outcome of interest in logistic regression and Cox-proportional hazards regression models adjusting for demographic covariates including age and year of diagnosis, sex, socioeconomic status and number of medical comorbidities.

Results

1780 pwRMS were identified, including 1,510 who were on DMT at some point in the study period. While total DMT exposure was not associated with the time to subsequent treated relapse, individuals who switched between more than 2 DMTs had higher post-switch rates of relapse. Switching to second-line DMTs was associated with a longer time to treated relapse in comparison to those who remained on a first-line DMT (HR 0.44; 95%CI: 0.32-0.62, p < 0.0001).

Discussion

Switching to high-efficacy DMTs reduces the rates of subsequent MS relapse at the population level.

Factors Associated With Disease-Modifying Therapy Adherence and Persistence in Multiple Sclerosis: A Scoping Literature Review

BACKGROUND

Patients with multiple sclerosis (MS) receiving disease-modifying therapies (DMT) show published adherence rates of 27.0% to 93.8% and published persistence rates of 49.7% to 96.5%. Improvements in DMT adherence and persistence are key to optimizing MS care, and enhanced understanding could improve MS disease management and identify research gaps. This scoping literature review aims to examine the nature and findings of the literature evaluating factors associated with DMT adherence and persistence in patients with MS.

METHODS

Eligible articles included in the literature review were quantitative clinical studies written in English, included adherence or persistence as primary outcomes, and accounted for covariates/confounders. The articles were assessed to identify factors associated with adherence/persistence and analyzed according to DMT type (self-injectable, oral, infusion).

RESULTS

Fifty-eight studies (103,450 patients) were included. Study distribution by DMT type was self-injectable only (n = 41), oral only (n = 2), infusion only (n = 1), and more than 1 type (n = 14). Older age and previous DMT use were associated with increased adherence and/or persistence. Increased alcohol consumption, DMT adverse events, higher education, and higher body mass index were negatively associated with adherence and/or persistence. Greater number and severity of relapses was associated with increased adherence but decreased persistence.

CONCLUSIONS

Most studies examined factors associated with adherence and persistence to self-injectable DMTs. These factors should be evaluated further for oral and infusion DMTs. Insights into the modifiable factors associated with adherence and persistence could guide treatment decisions and help improve adherence and clinical outcomes.

Using an Intervention Mapping Approach to Improve Adherence to Disease-Modifying Treatment in Multiple Sclerosis

BACKGROUND

Up to 50% of individuals with multiple sclerosis (MS) who are prescribed disease-modifying treatments (DMTs) do not take them as advised. Although many studies report on DMT adherence rate, few studies report on interventions involving individuals with MS. The current paper describes the development of an intervention aimed at improving adherence to DMTs among identified nonadherent individuals with MS.

METHODS

An intervention was developed using an Intervention Mapping approach, recommendations from reviews on medication adherence, and input from individuals with MS. Its content was determined by theories of health behavior (specifically, a perceptions and practicalities approach), empirical evidence collected among the specific target population (an observational "needs assessment" stage [n = 186]), and other studies.

RESULTS

A personalized intervention was tailored to the reasons for nonadherence, uncovered during the observational needs assessment stage, to be delivered sequentially by a neurologist and a psychologist. After the intervention objectives were identified, components of the intervention were set: psychoeducation and ways of coping with adverse effects; modification of unhelpful treatment beliefs (such modifications were found predictive of adherence in the observational phase of the study); improving confidence and self-efficacy; and developing strategies for remembering to take DMTs. These components were embedded within motivational interviewing.

CONCLUSIONS

Intervention Mapping was useful in developing an intervention grounded both in the theoretical approach of perceptions and practicalities and in empirical evidence from the literature and the target sample; concurrently, identifying determinants that the intervention did not address. The effectiveness of the intervention-which could potentially improve adherence among individuals with MS-needs to be examined.

Effect of an educational intervention based on the theory of planned behavior on improving medication adherence in patients with multiple sclerosis treated with injectable disease-modifying drugs: randomized controlled trial

BACKGROUND

Adherence to prescribed treatment in chronic diseases, as occurs in multiple sclerosis (MS), is a critical factor for a successful therapeutic response. This study aimed to investigate the effect of educational program based on Theory of Planned Behavior (TPB) on treatment adherence in patients with multiple sclerosis (MS) receiving injectable immunomodulatory drugs.

METHODS

The present study is an educational randomized controlled trial research that was conducted on 100 patients with MS who had gone to MS clinic in Tehran city (Iran). The samples were randomly assigned to the intervention (N = 50) and control groups (N = 50). Data collection instrument was a researcher-made questionnaire based on TPB. Then, educational program was performed for the intervention group through four educational sessions. After three months, data collection was repeated for the two groups and data were analyzed.

RESULTS

The knowledge and performance of the intervention group on treatment adherence drugs increased from 56.25 ± 20.3 to 78.31 ± 15.57 and 56.22 ± 5.76 to 71.62 ± 12.01 after the education respectively (p < 0.001). The mean of construct of TPB in the intervention group also increased after the intervention (p < 0.05).

CONCLUSION

Applying the TPB model proved is very effective in developing an educational program for patients with MS, to enhance treatment adherence drugs. Besides such programs, follow-up education for controlling and monitoring are highly recommended.

TRIAL REGISTRATION

This trial has been registered at Iranian Registry of Clinical Trials, IRCT20210808052109N1. Prospectively registered at 12-Aug-2021, (12/8/2021) available at: URL: https://en.irct.ir/trial/57994.

Multiple sclerosis-related heat sensitivity linked to absence of DMT prescription and subjective hand impairment but not autonomic or corticospinal dysfunction

OBJECTIVES

Heat sensitivity (HS) describes a temporary worsening of multiple sclerosis (MS) symptoms with increased body temperature. The pathophysiology may relate to central nervous system conduction deficits and autonomic dysfunction. We conducted deep clinical phenotyping of a cohort of persons with MS to identify predictors of HS.

METHODS

We recruited 59 MS participants with HS or No HS. Participants self-reported symptom severity (Hospital Anxiety and Depression Scale, Multiple Sclerosis Impact Scale, and fatigue visual analog scale) and underwent maximal exercise and transcranial magnetic stimulation testing to characterize autonomic and corticospinal function. We examined associations with HS using binomial logistic regression.

RESULTS

People with HS (36/59) had significantly greater disability, depression, fatigue, and physical and psychological functional effects of MS. They also had significantly lower corticospinal excitability but not conduction. After controlling for disease-modifying therapy (DMT), disability, and disease type, self-reported difficulty using hands in everyday tasks was significantly associated with a large increase in the odds of HS. Autonomic and corticospinal dysfunction were not associated with HS. Lack of DMT use alone was also associated with a large increase in the odds of HS.

DISCUSSION

Following a comprehensive assessment of plausible contributors to HS, HS was most strongly associated with lack of a DMT prescription and self-reported hand dysfunction. Surprisingly, objective measurement of autonomic and corticospinal integrity did not contribute to HS.

The Effect of Exercise Training and Royal Jelly on Hippocampal Cannabinoid-1-Receptors and Pain Threshold in Experimental Autoimmune Encephalomyelitis in Rats as Animal Model of Multiple Sclerosis

Cannabinoid-1-receptors (CB1R) are therapeutic targets for both the treatment of autoimmune diseases, such as multiple sclerosis (MS), and some related symptoms such as pain. The aim of this study was to evaluate the effect of aerobic training and two dosages of royal jelly (RJ) on hippocampal CB1R and pain threshold (PT) in an experimental autoimmune encephalomyelitis (EAE) model. To this end, 56 female Sprague-Dawley rats with EAE were randomly assigned to one of the following eight conditions: (1) EAE; (2) sham; (3) 50 mg/kg RJ (RJ50); (4) 100 mg/kg RJ (RJ100); (5) exercise training (ET); (6) ET + RJ50; (7) ET + RJ100; and (8) not EAE or healthy control (HC). Endurance training was performed for five weeks, four sessions per week at a speed of 11–15 m/min for 30 min, and RJ was injected peritoneally at doses of 50 and 100 mg/kg/day). One-way analysis of variance and Tukey’s post hoc tests were performed to identify group-related differences in pain threshold (PT) and CB1R gene expression. Endurance training had no significant effect on PT and hippocampal CB1R in rats with EAE. CB1R gene expression levels in the RJ100 group were higher than in the EAE group. Further, PT levels in the ETRJ50 and ETRJ100 groups were higher than in the EAE group. The combination of ET and RJ50 had a higher impact on PT and CB1R, when compared to the ET and RJ50 alone. Next, there was a dose-response between RJ-induced CB1R gene expression and RJ dosages: higher dosages of RJ increased the CB1R gene expression. The overall results suggest that the combination of ET and increasing RJ dosages improved pain threshold probably related to CB1R in an EAE model, while this was not observed for ET or RJ alone.

Disease-Modifying Drugs for Multiple Sclerosis and Association With Survival

BACKGROUND AND OBJECTIVES

We examined the association between the disease-modifying drugs (DMDs) for multiple sclerosis (MS) and survival in a multiregion population-based study.

METHODS

We accessed multiple administrative health databases from 4 Canadian provinces. Persons with MS were identified and followed from the most recent of the first MS or demyelinating event or January 1, 1996 (index date), until death, emigration, or December 31, 2017. Association between the first-generation and second-generation DMDs and all-cause mortality was examined using stratified Cox proportional hazard models, reported as adjusted hazard ratios (aHRs). Timing of DMD initiation was explored, with findings reported at 2, 5, or 10 years postindex date, representing very early, early, or late initiation.

RESULTS

We identified 35,894 persons with MS; 72% were female. The mean age at index date was 44.5 years (SD = 13.6). The total person-years of follow-up while DMD-exposed was 89,180, and total person-years while unexposed was 342,217. Compared with no exposure, exposure to any DMD or to any first-generation DMD was associated with a 26% lower hazard of mortality (both aHRs 0.74; 95% CI 0.56-0.98), while any second-generation DMD exposure was associated with a 33% lower hazard (aHR 0.67; 95% CI 0.46-0.98). Earlier DMD initiation (beta-interferon or glatiramer acetate vs no exposure) was associated with a significant mortality effect (p < 0.05), while later initiation was not (95% CIs included 1). However, the survival advantage with earlier initiation diminished over time, no longer reaching statistical significance at 15 years postindex date.

DISCUSSION

Our study demonstrates an association between the DMDs for MS and improved survival in the real-world setting.

Multiple sclerosis patients and e-health system in Saudi Arabia

Purpose

Multiple sclerosis (MS) is a chronic autoimmune neurological disease. Disease-modifying therapies (DMTs) are mainstay lifelong treatment with no immediate benefits observed. Adherence to treatment is necessary, however, non-adherence is common problem in MS patients. This paper aims to evaluate patient-related factors and satisfactions affecting medication adherence in Saudi MS patients and their rights to discontinue them against medical advice.

Design/methodology/approach

In total, 409 patients diagnosed with MS, using self-administered DMT (oral and injectable), were randomly enrolled in a cross-sectional study. Electronic questionnaire was used in data collection.

Findings

Most participants (71.1%) did not know about their MS type. Average age of participants when diagnosed with MS was 27.9 ± 8 years (range 7–69), mean disease duration was 8.1 ± 6.6. Most patients received injectable therapy 363 (88%). Overall adherence in our sample was 67%. Age of participants and duration of disease had no impact on treatment adherence. No significant differences found between genders, educational level, marital status, and smoking in relation to treatment adherence. Route of administration did not reach statistical significance despite a higher percentage of adherence reported in patients on oral DMT [33% (n = 15)] versus injectable therapy [29% (n = 104)]. Conversely, there was significant difference between adherent and non-adherent patients according to anxiety (p = 0.002) and family history of MS (p = 0.011).

Originality/value

The results revealed that the age of the participants and the duration of the disease had no impact on adherence to treatment.

Factors affecting adherence to disease-modifying therapies in multiple sclerosis: systematic review

People with multiple sclerosis (MS) face challenges adhering to disease-modifying drug (DMD) treatment. Poor adherence to treatment reduces its clinical effectiveness which can adversely impact disease progression, MS-related hospitalisation, and mortality rates. Understanding the barriers to adherence is essential to addressing these issues in clinical practice and a consolidation of the literature had not yet been carried out. A systematic search was carried out using the electronic databases PsycINFO, and PubMed (Medline) using the search terms treatment compliance or treatment adherence and multiple sclerosis or MS. Studies included adults, with a diagnosis of relapsing-remitting MS (RRMS) (sample > 80% RRMS), taking a DMD. The studies used an adequate measurement of treatment adherence and analysed possible factors associated with adherence. A total of 349 studies were retrieved, of which 24 were considered eligible for inclusion. Overall adherence rates of the included studies ranged from 52 to 92.8%. Narrative synthesis revealed the most prevalent factors associated with adherence were age, gender, depression, cognition, treatment satisfaction, injection-site reactions, and injection anxiety. There was contradictory evidence for disability in association with treatment adherence. The findings should be used to inform the development of targeted patient support programs which improve treatment compliance. The review also highlights the opportunities for advancing research into treatment adherence in MS.

Interventions for Instrumental Activities of Daily Living Among Adults With Multiple Sclerosis: A Systematic Review

IMPORTANCE

Occupational therapy practitioners need updated information about interventions that may improve or maintain functional changes in instrumental activity of daily living (IADL) engagement caused by multiple sclerosis (MS).

OBJECTIVE

To conduct a narrative synthesis of updated evidence on interventions within the scope of occupational therapy to improve or maintain performance of and participation in IADLs among adults with MS.

DATA SOURCES

CINAHL, MEDLINE in PubMed, Cochrane, OTseeker, and PsycINFO. Study Selection and Data Collection: This systematic review followed the Cochrane Collaboration methodology and is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for conducting a systematic review. Inclusion criteria were Level 1 or 2 evidence, published in English, published from January 2011 to December 2018, intervention within the occupational therapy scope of practice, and at least one IADL outcome measure.

FINDINGS

Nineteen randomized controlled trials (including pilot and feasibility trials) and 1 preintervention-postintervention study met inclusion criteria. Results of this review show strong strength of evidence for coaching interventions in addressing physical activity (PA) routines and moderate support in addressing medication routines. Moderate strength of evidence was found with mixed results for interventions involving coaching plus prescribed PA in improving PA participation.

CONCLUSIONS AND RELEVANCE

This systematic review supports occupational therapy practitioners addressing PA and medication health management and maintenance IADLs through the use of coaching interventions when treating people with MS. Other IADLs were addressed by the articles in this review but require more evidence to make clinical recommendations. What This Article Adds: Occupational therapy practitioners' skills in promoting habits and routines paired with utilization of evidence-supported coaching interventions can support independence with health management and reduce the negative impact of MS on daily activity participation.

Predictors of adherence and persistence to disease-modifying therapies in Multiple Sclerosis

BACKGROUND AND AIMS

In multiple sclerosis (MS), non-adherence/non-persistence is related to suboptimal response to treatment, including disease relapses and the need for more expensive healthcare. The aim of this study was to identify predictors related to adherence to disease modifying therapies (DMTs) in a cohort of Argentinian MS patients.

METHODS

We conducted a cross-sectional study at the National Medical Care Program from Argentina. MS patients with at least one claim for a DMT from 1 January 2017 to 1 October 2017 were identified. A telephone survey was performed to assess clinical and demographic factors. The medication possession ratio (MPR) was used to estimate adherence; MPR <80% defined non-adherence. Associations were studied using a logistic regression model.

RESULTS

Our database included 648 MS patients. A total of 360 patients (60% females, mean age 55.3 years) accepted to participate. Of these, 308 (85.5%) patients were receiving DMT at the time of the survey. Some 198 (63.7%) were receiving injectable therapies. Optimal adherence was 47.7%. Adherence was associated with oral medication [odds ratio (OR) 1.83 95% confidence interval (CI) 1.13-3.00, p = 0.014]. A factor related to oral drugs was higher educational level (OR 2.86 95%CI 1.41-5.81, p = 0.004).

CONCLUSION

This real-world study showed better adherence and persistence on treatment with oral therapies in MS patients in Argentina.

Comorbidity and persistence of disease-modifying therapy use in relapsing remitting multiple sclerosis

BACKGROUND

Comorbidity decreases the likelihood of initiating disease-modifying therapy (DMT) for multiple sclerosis (MS). Our objective was to characterize the relationship between comorbidity and initial DMT persistence along with reasons for DMT discontinuation.

METHODS

We identified individuals with relapsing remitting MS or clinically isolated syndrome starting a platform DMT (interferon-β, glatiramer acetate, dimethyl fumarate, teriflunomide) as initial therapy in the Canadian province of Nova Scotia from 2001 to 2016. Cases were identified using a clinic database for the only clinic providing specialty MS care in a province with universal publicly-funded health care. Comorbidity was determined by linkage of MS cases to provincial health administrative data using validated case definitions for mental health disorder, hypertension, hyperlipidemia, diabetes, chronic lung disease, ischemic heart disease, epilepsy, and inflammatory bowel disease. Cox proportional hazards models explored the relationship between comorbidity, as a count or individual comorbidities, and time to discontinuation of initial DMT. Logistic regression models explored reasons for DMT discontinuation.

RESULTS

Among 1464 individuals starting platform therapy as initial DMT, the median duration on first DMT was 4 years (95% CI 4 - 4). Comorbidity count (0, 1, ≥2) was not associated with time to discontinuation of initial DMT. However, the presence of a mental health disorder was associated with an increased hazard of discontinuing DMT (hazard ratio 1.22, 95% CI 1.03-1.44). Comorbidity count was not associated with discontinuation for lack of efficacy or lack of tolerability after adjusting for covariates.

CONCLUSION

Individuals with mental health comorbidity may have unique challenges that affect persistence on DMT after treatment initiation.

Objective medication adherence and persistence in people with multiple sclerosis: a systematic review, meta-analysis, and meta-regression

BACKGROUND: Medication adherence is critical for the realization of pharmacotherapy benefits and reduced healthcare expenditure. Studies have shown up to 60% of people with Multiple sclerosis (MS) experience suboptimal medication adherence, which is associated with poorer health outcomes and subsequent discontinuation. The current systematic review reported on objectively measured adherence and discontinuation rates for self-administered oral and injectable disease-modifying therapies (DMTs). OBJECTIVES: To identify whether, in people with MS, the introduction of oral DMTs has improved medication adherence when compared with injectable DMTs. The secondary aim was to report synthesized objectively measured medication adherence and persistence rates for both oral and injectable DMTs in MS across varying study durations. METHODS: Literature searches were conducted through PubMed, Web of Science, Scopus, and PsycINFO. Inclusion criteria were limited to English, peer-reviewed, objective, self-administered DMT articles, published between July 1993 to December 2019. Publications reporting combined intravenous and self-administered DMT data, or that did not account for DMT switching in discontinuation rates, were excluded. Data were synthesized into observation lengths ranging from less than 8 months to greater than 36 months. Meta-analysis and meta-regression were undertaken on both oral and injectable 12-month adherence and discontinuation data. RESULTS: In total, 61 articles were included; 46 articles examined adherence and 26 examined discontinuation. Twelve-month adherence ranged between 53.0% to 89.2% for oral (N = 7) and 47.0% to 77.4% for injectable DMTs (N = 7). Results from the meta-analysis and meta-regression show significantly higher pooled mean medication possession ratio (MPR) adherence for oral DMTs (91.0%) when compared to injectable DMTs (77.0%) over 12 months (β = -0.146; 95% CI: -0.263 to -0.029). Results indicate major asymmetry across studies (LFK index: -5.18), proposing the presence of significant publication bias. Mean discontinuation over 12 months was between 10.5% to 33.3% for oral (N = 7) and 15.2% to 50.8% for injectable DMTs (N = 10), with meta-analysis results indicating the presence of significant heterogeneity (I2 Injectable: 99.5%; I2 Oral: 93.1%) between studies included in each subgroup. However, no appreciable difference in mean discontinuation rates across groups (Injectable: 27%; 95% Cl: 19.0%-34.0%; Oral: 24%; 95% CI: 17.0%-31.0%) was found. CONCLUSIONS: Medication adherence for oral DMTs suggests a significant improvement compared to adherence for injectable DMTs. No significant difference in discontinuation rates between oral and injectable DMTs was found. Oral DMT adherence and persistence studies are limited, given their relatively recent introduction. Suboptimal medication adherence and discontinuation issues remain present for both oral and injectable DMTs. Future studies would benefit from improved consistency in methodology, such as comparable adherence and persistence definitions. DISCLOSURES: The authors did not receive any funding for this study. Mardan and Hussain have nothing to disclose. Grech reports grants from Merck Pharmaceutical, outside the submitted work. Allan reports grants received from Merck Pharmaceutical outside the submitted work. Allan holds advisory board and consulting positions with Merck and advisory board positions for Bristol Myers Squibb and Novartis, for which Monash Institute of Neurological Diseases receives consulting fees.

Effectiveness, Healthcare Resource Utilization and Adherence to Subcutaneous Interferon Beta-1a According to Age in Patients With Multiple Sclerosis: A Cohort Study Using a US Claims Database

Background: It is thought that older patients with multiple sclerosis (MS) may present with a different clinical disease phenotype, and therefore respond to subcutaneous interferon beta-1a (sc IFN β-1a) differently to younger patients. However, few real-world data are available concerning the effectiveness of sc IFN β-1a according to age. Using data from US claims databases, this cohort analysis aimed to determine the differences in relapse rates, healthcare utilization, treatment adherence, and discontinuation according to pre-defined age groups.

Methods: Patient data were pooled from the IBM® MarketScan® Commercial Claims Database and Medicare Supplemental Database. Patients with a confirmed MS diagnosis who initiated treatment with sc IFN β-1a between July 01, 2010 and December 31, 2015, along with at least 6 months continuous enrolment in a healthcare plan, were followed from first prescription (index date) until date of discontinuation, treatment switch, or end of observation period (1 year after index date).

Results: Of the 5,340 patients included in the analysis, there was a high proportion of patients free from relapse across all age groups (range: 94.1–95.4%), with a numerical decrease in the number of MRI performed by age (mean: 0.25, 18–30 years; 0.20, 31–40 years; 0.16, 41–50 years; 0.14, ≥51 years). Adherence (≥80%) was seen to increase with age (77.6%, 18–30 years; 79.6%, 31–40 years; 81.3%, 41–50 years; 84.0%, ≥51 years), at the same time as a non-significant decrease in discontinuation (incidence rate: 79.91, 73.01, 71.75, 68.71%).

Conclusion: The effectiveness of sc IFN β-1a does not appear reduced as a consequence of age in this real-world setting. Older patients had lower discontinuation rates and reduced disease activity, reflected in lower relapse rates and fewer MRI scans compared with younger patients.

Exploring the Cost Effectiveness of Shared Decision Making for Choosing between Disease-Modifying Drugs for Relapsing-Remitting Multiple Sclerosis in the Netherlands: A State Transition Model

Background

Up to 31% of patients with relapsing-remitting multiple sclerosis (RRMS) discontinue treatment with disease-modifying drug (DMD) within the first year, and of the patients who do continue, about 40% are nonadherent. Shared decision making may decrease nonadherence and discontinuation rates, but evidence in the context of RRMS is limited. Shared decision making may, however, come at additional costs. This study aimed to explore the potential cost-effectiveness of shared decision making for RRMS in comparison with usual care, from a (limited) societal perspective over a lifetime.

Methods

An exploratory economic evaluation was conducted by adapting a previously developed state transition model that evaluates the cost-effectiveness of a range of DMDs for RRMS in comparison with the best supportive care. Three potential effects of shared decision making were explored: 1) a change in the initial DMD chosen, 2) a decrease in the patient’s discontinuation in using the DMD, and 3) an increase in adherence to the DMD. One-way and probabilistic sensitivity analyses of a scenario that combined the 3 effects were conducted.

Results

Each effect separately and the 3 effects combined resulted in higher quality-adjusted life years (QALYs) and costs due to the increased utilization of DMD. A decrease in discontinuation of DMDs influenced the incremental cost-effectiveness ratio (ICER) most. The combined scenario resulted in an ICER of €17,875 per QALY gained. The ICER was sensitive to changes in several parameters.

Conclusion

This study suggests that shared decision making for DMDs could potentially be cost-effective, especially if shared decision making would help to decrease treatment discontinuation. Our results, however, may depend on the assumed effects on treatment choice, persistence, and adherence, which are actually largely unknown.

Epidemiology, treatment patterns and healthcare utilizations in multiple sclerosis in Taiwan

“Real-world” data on the nationwide epidemiology and treatment patterns of multiple sclerosis (MS) is very scarce in Asia. This study is aim to evaluate the 10-years trends in epidemiology and treatment patterns of MS with Taiwan’s National Health Insurance Database (NHIRD). Patients aged 20 years or older and were newly diagnosed with MS between 2007 and 2016 were identified. The crude incidences of MS were presented annually and stratified by sex and age. Baseline characteristics and treatment patterns, particularly disease-modifying drugs (DMDs), were also analyzed. This study included 555 MS patients (mean age was 36.9 and 74.4% were female). The crude incidence rate of MS decreased slightly from 0.43 per 100,000 persons in 2007 to 0.24 per 100,000 persons in 2015. The female to male ratios remained mainly between 2 to 3. Approximately 80% of MS patients received initial DMDs, with interferon β-1a as the dominant one. Furthermore, 37.5% of MS patients received subsequent DMDs, with fingolimod being the most frequently used. The median times from diagnosis to initial and to subsequent DMDs were 77 and 1239 days, respectively. This nationwide study provides up-to-date and sophisticated estimates of MS epidemiology and treatment pattern in “real-world” setting in Taiwan.

Beliefs about medication as predictors of medication adherence in a prospective cohort study among persons with multiple sclerosis

BACKGROUND

Though adherence to disease-modifying therapies (DMTs) among persons with multiple sclerosis (PwMS) varies and is often below 80%, only few prospective studies on adherence examined predictors beyond demographic and clinical characteristics.

OBJECTIVES

Identify antecedents to adherence and persistence to DMT in a prospective design among PwMS.

METHODS

PwMS (n = 186) were prospectively assessed at three time points: baseline, 6 (Time 1) and 12 months later (Time 2). Clinical, demographic information and patient-reported medication beliefs, illness perceptions, medication habits, perceived health and affect were surveyed in-person. Adherence and persistence were assessed by a combination of self-reports and retrospective review of medication claims.

FINDINGS

PwMS were 69.9% (Time 1) and 71% (Time 2) adherent to their DMTs and 64.5.9% were persistent. Beliefs about Medications were consistently predictive at both time points (baseline to Time 1 and Time 1 to Time 2) of medication adherence and persistence whereas other perceptions were predictive in some analyses; clinical and demographic characteristics were mostly not predictive of adherence nor persistence. The prospective association of beliefs about medication with adherence held also in multivariate analyses (OR = 0.88, 95% CI 0.78-0.99, p = 0.029).

CONCLUSIONS

Adherence and persistence are predicted by medication beliefs of PwMS. As medication beliefs are modifiable, they should be assessed periodically and targeted as a focus of tailored interventions aimed to improve adherence and consequently health outcomes in PwMS.

REGISTRATION

Clinical trials registry # NCT02488343 , date: 06/08/2015.

Treatment Switching and Discontinuation Over 20 Years in the Big Multiple Sclerosis Data Network

Background: Although over a dozen disease modifying treatments (DMTs) are available for relapsing forms of multiple sclerosis (MS), treatment interruption, switching and discontinuation are common challenges. The objective of this study was to describe treatment interruption and discontinuation in the Big MS data network. Methods: We merged information on 269,822 treatment episodes in 110,326 patients from 1997 to 2016 from five clinical registries in this cohort study. Treatment stop was defined as a clinician recorded DMT end for any reason and included treatment interruptions, switching to alternate DMTs and long-term or permanent discontinuations. Results: The incidence of DMT stopping cross the full observation period was lowest in FTY (19.7 per 100 person-years (PY) of treatment; 95% CI 19.2-20.1), followed by NAT (22.6/100 PY; 95% CI 22.2-23.0), IFNβ (23.3/100 PY; 95% CI 23.2-23.5). Of the 184,013 observed DMT stops, 159,309 (86.6%) switched to an alternate DMT within 6 months. Reasons for stopping a drug were stable during the observation period with lack of efficacy being the most common reason followed by lack of tolerance and side effects. The proportion of patients continuing on most DMTs were similarly stable until 2014 and 2015 when drop from 83 to 75% was noted. Conclusions: DMT stopping reasons and rates were mostly stable over time with a slight increase in recent years, with the availability of more DMTs. The overall results suggest that discontinuation of MS DMTs is mostly due to DMT properties and to a lesser extent to risk management and a competitive market.

Medication adherence in multiple sclerosis as a potential model for other chronic diseases: a population-based cohort study

OBJECTIVE

To determine whether better medication adherence in multiple sclerosis (MS) might be due to specialised disease-modifying drug (DMD) support programmes by: (1) establishing higher adherence in MS than in other chronic diseases and (2) determining if higher adherence is associated with patient-specific or treatment-specific factors.

DESIGN

Retrospective cohort study with data from 1 January 1996 to 31 December 2015.

SETTING

Population-based health administrative data from three Canadian provinces.

PARTICIPANTS

Individual cohorts were created using validated case definitions for MS, epilepsy, Parkinson's disease (PD) and rheumatoid arthritis (RA). Subjects were included if they received ≥1 dispensation for a disease-related drug between 1 January 1997 and 31 December 2014.

MAIN OUTCOME MEASURES

Proportion of subjects with optimal adherence (≥80%) measured by the medication possession ratio 1 year after the index date (first dispensation of disease-related drug).

RESULTS

126 478 subjects were included in the primary analysis (MS, n=6271; epilepsy, n=55 739; PD, n=21 304; RA, n=43 164). Subjects with epilepsy (adjusted OR, aOR 0.29; 95% CI 0.19 to 0.45), PD (aOR 0.42; 95% CI 0.29 to 0.63) or RA (aOR 0.26; 95% CI 0.19 to 0.35) were less likely to have optimal 1-year adherence compared with subjects with MS. Within the MS cohort, adherence was higher for DMD than for chronic-use non-MS medications, and no consistent patient-related predictors of adherence were observed across all four non-MS medication classes, including having optimal adherence to DMD.

CONCLUSIONS

Subjects with MS were significantly more likely to have optimal 1-year adherence than subjects with epilepsy, RA and PD, and optimal adherence appears related to treatment-specific factors rather than patient-related factors. This supports the hypothesis that higher adherence to the MS DMDs could be due to the specialised support programmes; these programmes may serve as a model for use in other chronic conditions.

Knowledge Is Power, but Is Ignorance Bliss? Optimising Conversations About Disease Progression in Multiple Sclerosis

Communication about multiple sclerosis (MS) disease progression between healthcare professionals (HCPs) and people with MS (PwMS) has historically been considered difficult, and attention to improving it has been neglected. However, a growing number of studies have shown that this is a key area to get right, since negative experiences can affect patient satisfaction, treatment adherence, and clinical outcomes. This article reports on a symposium at the European Charcot Foundation, 2018, led by a panel of leading clinicians and patient experts from MS in the 21st Century, who debated the benefits, drawbacks, and challenges of communicating about disease progression, for both HCPs and PwMS, and potential ways to optimise these discussions. PwMS' preferences and priorities regarding conversations about disease progression vary widely. While the majority want to have these conversations, some will be reluctant and/or emotionally unready. Communication therefore needs to be personalised, and HCPs should always be prepared to have such conversations in an appropriate and sensitive manner. Clinical information can be opaque for PwMS, so HCPs also need to use language that is clear, easily understandable, and patient-friendly. MS in the 21st Century is in the process of developing several resources and programmes to help improve disease progression communication between HCPs and PwMS. FUNDING: Merck KGaA, Darmstadt, Germany. Plain language summary available for this article.

Modeling the impact of patient treatment preference on health outcomes in relapsing-remitting multiple sclerosis

Aims: Model how moving from current disease-modifying drug (DMD) prescribing patterns for relapsing-remitting multiple sclerosis (RRMS) observed in the United Kingdom (UK) to prescribing patterns based on patient preferences would impact health outcomes over time.Materials and methods: A cohort-based Markov model was used to measure the effect of DMDs on long-term health outcomes for individuals with RRMS. Data from a discrete choice experiment were used to estimate the market shares of DMDs based on patient preferences (i.e. preference shares). These preference shares and real-world UK market shares were used to calculate the effect of prescribing behavior on relapses, disability progression, and quality-adjusted life-years (QALYs). The incremental benefit of patient-centered prescribing over current practices for the UK RRMS population was then estimated; scenario and sensitivity analyses were also conducted.Results: Compared to current prescribing practices, when UK patients with RRMS were treated following patient preferences, health outcomes were improved. This population was expected to experience 501,690 relapses and gain 1,003,263 discounted QALYs over 50 years under patient-centered prescribing practices compared to 538,417 relapses and 958,792 discounted QALYs under current practices (-6.8% and +4.6%, respectively). Additionally, less disability progression was observed when prescribed treatment was based on patient preferences. In a scenario analysis where only oral treatments were considered, the results were similar, although the magnitude of benefit was smaller. Number of relapses was most sensitive to how the annualized relapse rate was modeled; disability progression was most sensitive to mortality rate assumptions.Limitations: Treatment efficacy estimates applied to various models in this study were based on data derived from clinical trials, rather than real-world data; the impact of patient-centered prescribing on treatment adherence and/or switching was not modeled.Conclusions: The population of UK RRMS patients may experience overall health gains if patient preferences are better incorporated into prescribing practices.

Magnetic Resonance Imaging of Spinal Cord Lesions in Patients with Multiple Sclerosis in Saskatchewan, Canada

Background

Spinal cord lesions (SCLs) contribute to disability in multiple sclerosis (MS). Data in Saskatchewan, Canada, concerning SCLs and their association with disability levels in patients with MS are lacking. The study objectives were to identify clinicodemographic profiles of patients with MS with respect to spinal cord magnetic resonance imaging (MRI) involvement; determine the frequency of individuals with MRI SCLs; and explore differences between patients with MS with and without SCLs with respect to disability and disease-modifying therapy status.

Methods

A monocentric, cross-sectional, retrospective review of prospectively collected data from 532 research-consented patients seen at Saskatoon MS Clinic was performed. Data were collected from a database and electronic medical records.

Results

Of the 356 patients (66.9%) with an SCL, 180 (50.6%) had only cervical cord lesions. Median Expanded Disability Status Scale (EDSS), ambulation, and pyramidal scores of patients with SCLs were higher than those of patients without SCLs. Of patients with EDSS scores of at least 6, those with SCLs were younger than those without SCLs (P = .01). Patients with SCLs were 55% less likely to have been on continuous disease-modifying therapy since diagnosis than patients without SCLs (adjusted odds ratio, 0.45; 95% CI, 0.25-0.81; P = .008).

Conclusions

Prevalence and association with disability of SCLs in patients with MS are comparable with existing literature. Patients with MS with SCLs have higher levels of disability and attain EDSS scores of at least 6 at a younger age.

Changing therapeutic strategies and persistence to disease-modifying treatments in a population of multiple sclerosis patients from Veneto region, Italy

BACKGROUND

The availability of new disease-modifying treatments (DMTs) in the last years has changed the therapeutic strategies used in Multiple Sclerosis (MS). We aimed to describe trend in DMTs utilization and persistence to treatment in a large sample of patients attending 10 MS centres from four provinces of Veneto, Italy.

METHODS

Demographic, clinical and DMTs information of patients regularly followed from January 2011 to August 2018 were recorded and analysed. Persistence at 12, 24 months and at last follow-up was assessed by Kaplan Meier survival analysis. Multivariable Cox- proportional hazard model was used to identify predictors of persistence.

RESULTS

Of 3025 MS patients 65.7% were in treatment al last follow-up. Dimethylfumarate (DMF) was the most prescribed single drug among first-line and fingolimod among second-line DMTs. In the cohort of 1391 cases starting any DMT since 2011 12.9% stopped within 6 months, 24% within 12 and 40.3% within 24 months. Disease duration > 5 years at therapy start was predictive of greater risk of discontinuation, while age and sex were not. DMF use was predictive of higher persistence at 12 and 24 months, but not at last follow-up when azathioprine and glatiramer acetate showed the highest persistence compared to other DMTs. Side effects represented the main reason of discontinuation.

CONCLUSION

The use of the new oral DMTs greatly increased since their approval but persistence in the long-term is not better than with old drugs. The treatment choice is still a challenge both for patients and their doctors.

Multiple modality approach to assess adherence to medications across time in Multiple Sclerosis

BACKGROUND

Medication adherence is especially challenging in a chronic condition such as Relapsing Multiple Sclerosis (RMS). Medication adherence among persons with MS (PwMS) is usually assessed via a single measure, mostly electronic pharmacy records.

OBJECTIVES

Assess medication adherence in multiple modes across time among PwMS; examine consistency across time and associations between measures.

METHODS

PwMS (N = 194) were surveyed prospectively at three time points (baseline, 6 and 12 months later) and their health records and medication claims were retrospectively obtained. Adherence score was based on medication possession ratio (MPR) and two patient-reported outcome (PRO) measures. Electronic monitoring devices assessing medication adherence were also initiated.

RESULTS

MPR of each nonadherent PwMS, once compared to medical records containing prescription changes, was found as underestimating adherence. MPR was between the two PROs in identifying nonadherence and associations between the measures and across time was moderate (Kappa ranged 0.37-0.42). The use of electronic monitoring devices was not adopted by patients. A score indicated adherence as 66% and 64.9% at Time1 and Time 2, respectively, with 21.1% of PwMS nonadherent at both time points. Adherence did not vary significantly by DMT type.

CONCLUSIONS

Being a dynamic behavior, medication adherence should be repeatedly monitored by using multiple modalities and focused on in clinician-patient encounters, especially in chronic diseases such as MS, which requires long-term treatments. Applying PROs in monitoring medication adherence would facilitate implementation of Participatory Medicine and patient-centered strategies in MS care.

Monitoring, Switching, and Stopping Multiple Sclerosis Disease-Modifying Therapies

PURPOSE OF REVIEW

This article reviews appropriate monitoring of the various multiple sclerosis (MS) disease-modifying therapies, summarizes the reasons patients switch or stop treatment, and provides a framework for making these management decisions.

RECENT FINDINGS

With the increasing number of highly effective immunotherapies available for MS, the possibility of better control of the disease has increased, but with it, the potential for side effects has rendered treatment decisions more complicated. Starting treatment early with more effective and better-tolerated disease-modifying therapies reduces the likelihood of switching because of breakthrough disease or lack of compliance. Clinical and radiographic surveillance, and often blood and other paraclinical tests, should be performed periodically, depending on the disease-modifying therapy. Helping patients navigate the uncertainty around switching or stopping treatment, either temporarily or permanently, is one of the most important things we do as providers of MS care.

SUMMARY

Ongoing monitoring of drug therapy is a crucial component of long-term MS care. Switching treatments may be necessary for a variety of reasons. Permanent discontinuation of treatment may be appropriate for some patients with MS, although more study is needed in this area.

Time to recurrence after first-ever ischaemic stroke within 3 years and its risk factors in Chinese population: a prospective cohort study

OBJECTIVE

This study aimed to estimate the time of recurrent ischaemic stroke events among the first 3 years of follow-up after hospitalisation discharge.

STUDY DESIGN

A prospective cohort study.

SETTING

The research was conducted in the Department of Neurology at a tertiary hospital, Chengdu of China, from January 2010 to June 2016.

OUTCOME MEASURES

We estimated the restricted mean survival time (RMST) of ischaemic stroke recurrence for the first 3 years after discharge. Basic sociodemographic characteristics and major potential risk factors for recurrence were collected using a semistructured questionnaire. Regression analysis of RMST was used to identify risk factors of recurrent stroke.

PARTICIPANTS

Patients hospitalised with first-ever ischaemic stroke were eligible for this study. Patients with severe cognitive impairment were excluded.

RESULTS

We included 641 surviving patients who were followed up for 3 years. Stroke recurrence occurred in 115 patients, including 16 patients who died of stroke recurrence. The cumulative risk of stroke recurrence rate was 11.51% (9.20%-14.35%) at 1 year, 16.76% (13.96%-20.05%) at 2 years and 20.07% (17.00%-23.61%) at 3 years. Modified Rankin Scale (mRS) score ≥3 thus resulted in the recurrence time loss, which was 0.22 months (p=0.008) at 6 months, 0.61 months (p=0.004) at 1 year, 1.49 months (p=0.007) at 2 years and 2.46 months (p=0.008) at 3 years. It is similar with the effects of drug adherence after stroke. The recurrence time of patients ≥75 years at 3 years was 2.02 months (p=0.220) less than that of those aged <55 years.

CONCLUSION

In China, the time of first recurrence varies among different patients with ischaemic stroke. The mRS and the level of drug adherence after stroke are important risk factors of stroke recurrence.

Risk Factors for Suboptimal Medication Adherence in Persons With Multiple Sclerosis: Development of an Electronic Health Record-Based Explanatory Model for Disease-Modifying Therapy Use

OBJECTIVE

To determine which factors are associated with suboptimal disease-modifying therapy (DMT) adherence and to develop an explanatory model that could be used to identify individuals at risk and potentially inform interventions.

DESIGN

Cross-sectional cohort study using electronic health records.

SETTING

Veterans Health Administration (VA).

PARTICIPANTS

Veterans with multiple sclerosis (MS) (N=2939; 79.69% men) who received care through the VA and were included in the VA MS Center of Excellence Data Repository.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Suboptimal DMT adherence (<80%), demographics, co-occurring conditions, and health care use.

RESULTS

Nearly 31% of participants had suboptimal adherence. Flags for suboptimal adherence included >20% missed appointments (odds ratio [OR], 3.78; 95% CI, 2.45-2.82), traumatic brain injuries (OR, 1.55; 95% CI, 1.12-2.14), age younger than 59 years (OR, 1.47; 95% CI, 1.23-1.74), ≥1 emergency department visits (OR, 1.40; 95% CI, 1.18-1.67), mood disorders (ie, depressive and bipolar disorders) (OR, 1.40; 95% CI, 1.18-1.66), and service connection (OR, 1.22; 95% CI, 1.01-1.47). Hyperlipidemia (OR, 0.77; 95% CI, 0.65-0.92) and being issued a wheelchair (OR, 0.83; 95% CI, 0.70-1.00) were associated with lower risk.

CONCLUSIONS

Suboptimal adherence to DMTs continues to be an issue. Interventions that focus on person-level barriers should be urgently explored to increase adherence and improve self-management abilities.

Association between disease-modifying therapies for multiple sclerosis and healthcare utilisation on a population level: a retrospective cohort study

OBJECTIVE

Disease-modifying therapy (DMT) use in multiple sclerosis (MS) has increased significantly. However, the impact of DMTs on healthcare use is limited and conflicting, and rarely examined at a population level. This study examined the association between DMTs and healthcare utilisation at the population level.

DESIGN

Retrospective cohort.

SETTING

Health administrative data from Saskatchewan, Canada (1997-2016).

PARTICIPANTS

To test for associations at the population level, we identified two cohorts. The general population cohort included all Saskatchewan residents ≥18 years who were drug plan beneficiaries. The MS cohort included individuals ≥18 years, identified using a validated definition (≥3 hospital, physician or drug claims for MS).

MAIN OUTCOME MEASURES AND METHODS

To test for an association between the total number of DMT dispensations per year and the total number of hospitalisations we used negative binomial regression fitted with generalised estimating equations (GEE); only hospitalisations that occurred after the date of MS diagnosis (date of first claim for MS or demyelinating disease) were extracted. To test for an association between the number of DMT dispensations and physician claims, negative binomial distributions with GEE were fit as above. Results were reported as rate ratios (RR), with 95% CIs, and calculated for every 1000 DMT dispensations.

RESULTS

The number of DMT dispensations was associated with a decreased risk for all-cause (RR=0.994; 95% CI 0.992 to 0.996) and MS-specific (RR=0.909; 95% CI 0.880 to 0.938) hospitalisations. The number of DMT dispensations was not associated with the number of all-cause (RR=1.006; 95% CI 0.990 to 1.022) or MS-specific (RR=0.962; 95% CI 0.910 to 1.016) physician claims.

CONCLUSION

Increased DMT use in Saskatchewan was associated with a reduction in hospitalisations, but did not impact the number of physician services used. Additional research on cost-benefit and differing treatment strategies would provide further insight into the true impact of DMTs on healthcare utilisation at a population level.

Persistence and adherence to interferon and glatiramer acetate in patients with multiple sclerosis

Objectives

To analyse persistence and adherence in patients with multiple sclerosis receiving first-line treatment with subcutaneous glatiramer acetate 20 mg (GA), subcutaneous interferon β1a (IFNβ1a-sc), intramuscular interferon β1a (IFNβ1a-im) and subcutaneous interferon β1b (IFNβ1b-sc) and to identify associated factors and reasons for discontinuation.

Methods

An observational retrospective study was performed between January 1999 and November 2014. Persistence was defined as the time from treatment initiation until discontinuation, and adherence as the number of units dispensed since treatment initiation until its interruption divided by the theoretical number of units needed to cover said period as a percentage. A patient was considered adherent if ≥95%. Persistence was measured using the Kaplan-Meier method and univariate Cox regression; adherence was measured using a univariate binary logistical regression model.

Results

The study included 224 patients. The median persistence was 1349 days (95% CI 1017.4 to 1680.6). Patients receiving IFNβ1a-im continued treatment for a longer time (1720 days; 95% CI 1196.8 to 2243.2), while patients treated with IFNβ1a-sc had the lowest persistence (771 days; 95% CI 377.4 to 1164.6) (HR=1.7; 95% CI 1.02 to 2.72). Patients with Expanded Disability Status Scale (EDSS) 1.5-6 discontinued treatment earlier than those with EDSS 0-1 (HR 1.5; 95% CI 1.01 to 2.25); 94.4% of patients discontinued treatment due to medical decision, primarily due to lack of efficacy (24.6%) and adverse effects (17.4%), while 80.8% of patients had good adherence. GA had the highest adherence, with no major difference from IFNβ1a-im, while IFNβ1b-sc showed the highest non-adherence (OR 3.5; 95% CI 1.29 to 9.28).

Conclusions

The persistence levels obtained were lower than in similar studies. EDSS was identified as an independent predictor of treatment interruption. Acceptable adherence was achieved among the population, comparable to other studies and influenced by the drug.

Adherence to disease-modifying treatments in patients with multiple sclerosis in Spain

PURPOSE

Adherence to disease-modifying treatments is essential in order to maximize the beneficial effects of treatment for multiple sclerosis (MS). There are numerous treatments that have been approved. Treatment selection is essential in patient adherence. In addition, patient preference plays an increasingly significant role in treatment decision-making. This study aims to evaluate the degree of adherence, along with other variables that may influence this adherence, in Spain.

METHODS

A cross-sectional study was conducted with 157 MS patients with disease-modifying treatments. Adherence was assessed using the Morisky Green scale, and other related factors were measured using a questionnaire that addressed demographics, disease characteristics, global perception of pathology, impact of medication on patient's life, and treatment decision-making.

RESULTS

The adherence rate was 71% and was associated with the following variables: older age, more treatments received, time to diagnosis 5-10 years, absence of exacerbations, better cognitive status, being married/in a union, clear information about the disease, and higher treatment satisfaction. The main cause for non-compliance was forgetfulness (27%).

CONCLUSION

The adherence rate is acceptable. It is widely known that treatment satisfaction is related to adherence. In our study, patients' level of satisfaction was higher with oral treatments. However, oral administration showed a greater lack of adherence. The main cause of lack of adherence was forgetfulness. In relation to other variables, cognitive status and family support showed a correlation with treatment adherence.

Patient Power Revolution in Multiple Sclerosis: Navigating the New Frontier

A debate on shared decision making in multiple sclerosis (MS) was led by a patient advocate and leading neurologists from the MS in the 21st Century Steering Group. Key themes and salient points which emerged from the debate and audience discussions are reported in this article. Arguments against shared decision making included the fact that physicians study and practice for years to reach their level of expertise, and that the level of understanding required to make these decisions may not be possible to communicate to patients within time-limited consultations. Furthermore, unreliable online information, information overload or information with marketing bias may also cloud patients' judgements. Arguments for patient engagement focussed on how ownership of decisions can lead to improved adherence and outcomes, and a strengthening of the physician-patient relationship. Shared decision making requires educating patients to make informed decisions and to understand the risks and consequences of their choices. However, shared decision making may not be the correct option for every patient, and the level of involvement must be driven by the patient. To support patients' engagement and promote responsible management of their condition, physicians need to (1) foster and maintain a positive, ongoing relationship with their patients, and (2) provide patients with timely, accurate, and understandable information. There was broad agreement that the patient voice should be heard more in discussions around the future of MS care. MS in the 21st Century offers a model for patient involvement in partnership with MS healthcare specialists, and the steering group is currently considering these issues and developing tools and solutions to enhance patient-physician communication and relationships. Funding Merck KGaA, Darmstadt, Germany.

Persistence and adherence to the new oral disease-modifying therapies for multiple sclerosis: A population-based study

OBJECTIVE

To examine persistence and adherence to the oral disease-modifying therapies (DMTs) for multiple sclerosis (MS).

METHODS

Population-based health administrative databases in British Columbia, Canada were accessed to identify all individuals filling an oral DMT prescription for MS (fingolimod, dimethyl fumarate, teriflunomide) between January 2011 and December 2015. Predictors of persistence and adherence at 6 and 12 months were assessed using logistic regression, with estimates expressed as adjusted odds ratios (aORs), and 95% confidence intervals (CIs).

RESULTS

Of 858 individuals with ≥6 months of follow-up, the mean age at first prescription was 43.0 (SD:10.3) years; 74.2% were women. By 6 months 11.0% (94/858) had discontinued their initial oral DMT; by 12 months the proportion was 19.6% (113/577). Over 6 and 12 months, among those persisting with their oral DMT, 82.5% (630/764) and 81.7% (379/464) exhibited optimal adherence (proportion of days covered ≥80%). Age, sex, calendar year and comorbidity were not associated with persistence or adherence. Individuals with higher neighbourhood-level socioeconomic status had higher odds of discontinuation within 6 months (aOR = 2.2; 95%CI:1.3-3.7). Those who had previously used another DMT had higher odds of optimal adherence (6 months aOR = 2.4;95%CI:1.6-3.6, and 12 months aOR = 2.4; 95%CI:1.5-3.9).

CONCLUSION

Approximately 1 in 10 individuals discontinued their first oral DMT within 6 months, and 1 in 5 did so within one year. However, among those who did continue drug, a high proportion (>80%) exhibited optimal adherence. Predictors of persistence or adherence with immediate practical application were lacking; this highlights the challenges in optimizing drug therapy.

Cladribine tablets' potential role as a key example of selective immune reconstitution therapy in multiple sclerosis

Multiple sclerosis (MS) is one of the most important, disabling, and prevalent neurological disorders of young adults. It is a chronic inflammatory and neurodegenerative disease when autoreactive B and T cells have downstream effects that result in demyelination and neuronal loss. Anti-inflammatory disease-modifying therapies do have proven efficacy in delaying disease and disability progression in MS. While the progress in MS treatments has already improved the prognosis and quality of patients’ lives overall, there are some clear shortcomings and unmet needs in the current MS treatment landscape. The most promising means of MS treatment is selective immune reconstitution therapy (SIRT). This therapy is given in short-duration courses of immunosuppression, producing durable effects on the immune system and preventing nervous tissue loss. This review discusses the mechanisms of action and the data of clinical trials of cladribine tablets as an example of SIRT in MS. The clinical benefits of cladribine tablets in these studies include decreased relapse rate and disability progression with large reductions in lesion activity, and protection against brain volume loss. Whether all of these neurological findings are direct results of lymphocyte depletion, or if there are downstream effects on other, unknown, neurodegenerative processes are yet to be determined, but these clearly point to an interesting area of research.

Establishing the Incidence and Prevalence of Multiple Sclerosis in Saskatchewan

OBJECTIVE

To validate a case definition of multiple sclerosis (MS) using health administrative data and to provide the first province-wide estimates of MS incidence and prevalence for Saskatchewan, Canada.

METHODS

We used population-based health administrative data between January 1, 1996 and December 31, 2015 to identify individuals with MS using two potential case definitions: (1) ≥3 hospital, physician, or prescription claims (Marrie definition); (2) ≥1 hospitalization or ≥5 physician claims within 2 years (Canadian Chronic Disease Surveillance System [CCDSS] definition). We validated the case definitions using diagnoses from medical records (n=400) as the gold standard.

RESULTS

The Marrie definition had a sensitivity of 99.5% (95% confidence interval [CI] 92.3-99.2), specificity of 98.5% (95% CI 97.3-100.0), positive predictive value (PPV) of 99.5% (95% CI 97.2-100.0), and negative predictive value (NPV) of 97.5% (95% CI 94.4-99.2). The CCDSS definition had a sensitivity of 91.0% (95% CI 81.2-94.6), specificity of 99.0% (95% CI 96.4-99.9), PPV of 98.9% (95% CI 96.1-99.9), and NPV of 91.7% (95% CI 87.2-95.0). Using the more sensitive Marrie definition, the average annual adjusted incidence per 100,000 between 2001 and 2013 was 16.5 (95% CI 15.8-17.2), and the age- and sex-standardized prevalence of MS in Saskatchewan in 2013 was 313.6 per 100,000 (95% CI 303.0-324.3). Over the study period, incidence remained stable while prevalence increased slightly.

CONCLUSION

We confirm Saskatchewan has one of the highest rates of MS in the world. Similar to other regions in Canada, incidence has remained stable while prevalence has gradually increased.

Adherence to disease-modifying therapies in patients with multiple sclerosis

BACKGROUND

Multiple sclerosis (MS) is a chronic, inflammatory progressive demyelinating disease of the central nervous system. MS is one of the main causes of disability among young adults, and its management is a serious challenge for the healthcare system.

PURPOSE

The main purpose of this study was to examine adherence to first-line disease-modifying therapy (DMT) in MS patients using the self-report Multiple Sclerosis Treatment Adherence Questionnaire (MS-TAQ).

MATERIALS AND METHODS

The participants consisted of 226 MS patients (166 women and 60 men) who were treated with first-line immunomodulatory DMT. This study used a questionnaire designed by the authors, which contained questions about sociodemographic data, and the Polish version of the MS-TAQ.

RESULTS

The overall adherence was 76.5% according to the first criterion (missed ≥1 injection or tablet). There were no statistically significant differences due to sociodemographic variables between adherent and nonadherent patients. However, patients taking Avonex^® significantly more often belonged to the adherent group (P=0.042). The most frequently mentioned reasons why nonadherent patients forget to take the drug included the following: too busy in their daily activities, indisposition to take the drug, unwillingness to take the drug, interference with daily activities, and dissatisfaction with the drug. The degree of adherence among MS patients treated with immunomodulatory drugs is high; however, some patients do not take medications regularly.

CONCLUSION

Due to the utility of the MS-TAQ, the caregivers of MS patients are able to quickly and easily assess the occurrence of side effects, ways to cope with them, and the occurrence of barriers to taking medication.

Effect of adherence to the first-generation injectable immunomodulatory drugs on disability accumulation in multiple sclerosis: a longitudinal cohort study

OBJECTIVE

To examine the association between optimal adherence to the first-generation injectable immunomodulatory drugs (IMDs) for multiple sclerosis (MS) and subsequent disability accumulation.

METHODS

We accessed prospectively collected linked clinical and administrative health data from British Columbia, Canada. Subjects with MS treated with a first-generation injectable IMD at an MS clinic (1996-2004) were followed until their last clinic visit before 2009. Adherence was estimated using the proportion of days covered (PDC). The primary outcome was disability accumulation, defined as an increase in the Expanded Disability Status Scale (EDSS) score as recorded during each year of follow-up. Generalised estimating equation models, adjusted for baseline sex, age, EDSS and time between scores, were used to measure associations between optimal adherence (≥80% PDC) during the first year of treatment and subsequent disability accumulation. The relationship between early IMD adherence and the secondary outcome, time to sustained EDSS 6, was examined using Cox proportional hazards regression.

RESULTS

Among 801 subjects, 598 (74.7%) had optimal adherence over the first year of IMD treatment and 487 (39.0%) demonstrated one or more instances of disability accumulation. Early optimal adherence was not associated with disability accumulation (adjusted OR 0.94; 95% CI 0.78 to 1.15), nor with time to sustained EDSS 6 (adjusted HR 0.91; 95% CI 0.57 to 1.44).

CONCLUSION

Almost three-quarters of subjects with MS had optimal early adherence to their first-line injectable IMD. There was no evidence that this was associated with disability accumulation in the following years.

A qualitative study assessing patient perspectives in the process of decision-making on disease modifying therapies (DMT's) in multiple sclerosis (MS)

Background

Physicians commonly advise patients to begin disease modifying therapies (DMT’s) shortly after the establishment of a diagnosis of Multiple Sclerosis (MS) to prevent further relapses and disease progression. However, little is known about the meaning for patients going through the process of the diagnosis of MS and of making decisions on DMT’s in early MS.

Objective

To explore the patient perspective on using DMT’s for MS. Methods: Ten participants with a recent (< 2 years) relapsing-remitting MS diagnosis were interviewed. Seven of them were using DMT’s at the time of the interview. All interviews were transcribed and analyzed using a hermeneutical-phenomenological approach.

Results

The analysis revealed the following themes: (1) Constant confrontation with the disease, (2) Managing inevitable decline, (3) Hope of delaying the progression of the disease, and, (4) The importance of social support. The themes show that patients associate the recommendation to begin DMT’s (especially injectable DMT’s) with views about their bodies as well as their hopes about the future. Both considering and adhering to treatment are experienced by patients as not only matters of individual and rational deliberation, but also as activities that are lived within a web of relationships with relatives and friends.

Conclusion

From the patient perspective, the use of DMT’s is not a purely rational and individual experience. More attention to the use of DMT’s as relational and lived phenomena will improve the understanding of the process of decision-making for DMT’s in MS.

Disease-Modifying Therapies and Adherence in Multiple Sclerosis: Comparing Patient Self-Report with Pharmacy Records

BACKGROUND

Self-report and pharmacy records are often used to measure adherence rates to disease-modifying therapies (DMTs) in multiple sclerosis (MS), but little is known about how the sources compare.

OBJECTIVE

Compare self-report and pharmacy records for assessing DMT use and adherence rates.

METHODS

Demographic information, self-reported DMT use, and missed DMT doses in the previous 30 days were obtained from consecutive MS patients attending an MS clinic and linked to pharmacy records. A medication possession ratio (MPR) was calculated using pharmacy records for the year before and after the visit; MPR <80% defined nonadherence. Agreement between self-report and pharmacy records was assessed using Cohen's kappa (κ).

RESULTS

Of 326 participants, 135 reported using an injectable DMT. There was near-perfect and perfect agreement between self-report and pharmacy records for DMT use (κ = 0.95; 95% CI 0.91-0.98) and DMT agent (κ = 1.00). Nonadherence was estimated at 13% (17/128) from the 30-days self-report compared to 30% (34/113) and 43% (53/123) in the year pre- and post-clinic visit from pharmacy records, indicating moderate to fair agreement (year prior: κ = 0.41; 95% CI 0.22-0.59; year post: κ = 0.22; 95% CI 0.09-0.36).

CONCLUSIONS

Patients self-reports closely reflected pharmacy records when assessing DMT use and product. Moderate to fair agreement was found when comparing adherence rates between sources.