Drug therapy in multiple sclerosis: a study of Nova Scotia senior citizens

Multiple Sclerosis Disease-Modifying Therapy Prescribing Patterns in Ontario

Background:

Differences in Multiple sclerosis (MS) disease-modifying therapy (DMT) prescribing patterns between different groups of neurologists have not been explored.

Objective:

To examine concentrations of prescribing patterns and to assess if MS-specialists use a broader range of DMTs relative to general neurologists.

Methods:

We conducted a cross-sectional study using administrative claims databases in Ontario, Canada to link neurologists to 2009 DMT prescription data. MS specialization was defined using both practice location and prescription patterns. Lorenz curves and Gini coefficients were constructed to examine prescribing patterns, separating neurologist characteristics dichotomously and separating Avonex from the other standard DMTs (Betaseron, Rebif and Copaxone). Gini coefficient 95% confidence intervals (CIs) were derived using jack-knife statistical techniques.

Results:

Prescriptions were highly concentrated with 12% of Ontario neurologists prescribing 80% of DMTs. There was a trend towards Avonex being more commonly prescribed relative to the other DMTs. When MS specialization was defined by DMT prescribing, high-volume prescribing neurologists showed a broader range of DMT prescribing (Gini 0.38-0.44) in comparison to low-volume prescribers (Gini 0.57-0.66).

Conclusions:

The majority of DMTs are prescribed by a small subset of neurologists. High-volume prescribing MS-specialists show more variability in DMT use while low-volume prescribers tend to individually focus on a narrower range of DMTs.

Symptomatic medication use in multiple sclerosis

Multiple sclerosis (MS) is one of the most studied neurological diseases, although scarce attention has been placed on symptomatic therapy. The aim of the study was to evaluate the frequency of medication prescription for the major symptoms related to MS in order to better understand the needs of patients. The study was conducted during an epidemiological survey in the province of Genoa, Italy. Out of 856 patients with MS in the study area, 665 agreed to participate in a structured interview. Two hundred and forty-nine (37%) subjects, with a mean age of 53 years and a mean Expanded Disability Status Scale (EDSS) score of 5.2, were taking at least one symptomatic medication. Four hundred and sixteen (63%) subjects, with a mean age of 49 years and a mean EDSS score of 4.5, were not using symptomatic therapy. The most commonly treated symptoms were pain (28%), spasticity (27%) and mood disorder (16%), while bladder dysfunction (8%) and fatigue (3%) were less frequently treated with medication. Seventy-seven patients (12%) were taking medications for reasons not directly related to MS. This cross-sectional study underlines the frequency of medication prescription for symptoms such as spasticity and pain, while other common symptoms, such as bladder dysfunction and fatigue, may perhaps be undertreated. The present findings also underline the need for clinical trials on symptomatic therapies.

L’évaluation médico-économique dans la sclérose en plaques

In multiple sclerosis, evaluation of quality of life is important because the patients are usually confronted with a decrease in physical, cognitive and social functioning. Apart from the personal suffering, the financial consequences for these patients and their family and the economic burden for society are enormous. Measurement of health related quality of life is important for the understanding of disease burden and the impact of specific MS treatments. Rising costs associated with new treatments and spending limits have prompted a search for gratter efficiency. Although health economics research can suggest ways to maximize health benefits within fixed budgets it is currently underused in MS. The purpose of this review of the literature is to explain some of the basic principles underlying both quality of life and economic evaluations, and analyse their contribution to understanding and managing patients with MS. Neurologists should not underestimate how dramatic their contributions can be to this maturing field that will influence the future of MS patients care.

Prescribing for multiple sclerosis patients in general practice: a case-control study

OBJECTIVES

To examine the prescribing patterns for multiple sclerosis (MS) patients resident in Wales by general practitioners (GPs), compared to an age, gender and GP surgery matched control population.

METHODS

Anonymised data for 1996 were obtained for all patients from 24 GP practices in the all-Wales General Practice Morbidity Database (GPMD). This covered 220 538 patient years at risk for 1996. Cases were selected as those with a Read code of MS at some point from 1993 to 1996 (therefore had consulted the GP at least once during this time). The controls were age, gender and surgery matched patients randomly selected from the GPMD.

RESULTS

A total of 216 cases were identified, giving a prevalence of 97.9 per 105. Cases were prescribed a mean of 15 drugs each in 1996 compared to eight drugs for controls (P < 0.0005). Compared with controls, MS patients were prescribed significantly more laxatives, diuretics, hypnotics and anxiolytics, antidepressants, antiepileptics (mainly carbamazepine), corticosteroids, oxybutynin, vitamin B12 and skeletal muscle relaxants (predominantly baclofen; P < 0.05). Certain 'MS specific' drugs were not frequently prescribed, such as cytotoxic immunosuppressants (two cases), amantadine (one case) and isoniazid (no cases). No case was prescribed medication for erectile dysfunction. Over 80% (44/53) of corticosteroid prescriptions for MS were for oral prednisolone. Over one-third (39%, 9/23) of cases prescribed a corticosteroid received a 'chronic' course. Over one-third (5/14) of courses of selective-serotonin re-uptake inhibitors (SSRI) for cases were identified as subtherapeutic.

CONCLUSIONS

MS patients were high users of prescribed medicines, having almost twice as many prescriptions from the GP compared to controls. GP prescribing often reflected available evidence from published controlled trials, hence cytotoxic immunosuppressants, drugs for fatigue and tremor were seldom prescribed, whereas drugs such as oxybutynin and skeletal muscle relaxants were frequently prescribed. However, the increased use of certain drugs compared to controls such as diuretics, vitamin B12, hypnotics and anxiolytics were unsubstantiated in the literature. Furthermore, no published well-controlled clinical trials were found utilizing oral prednisolone or assessing the possible therapeutic benefit of chronic courses of corticosteroids in MS, both of which were prescribed by the GP. The absence of medication for sexual dysfunction (prelicensing of sildenafil), a reportedly common MS problem, was discussed. The relatively high incidence of subtherapeutic courses of SSRIs needs further investigation, given the increased incidence of depression and suicide associated with MS.

Nonprescription medicine use in a multiple sclerosis clinic population

AIMS

To determine the use of nonprescription medicines in a cohort of multiple sclerosis (MS) patients and to identify a subgroup of patients liable to spend more on nonprescription medicines

METHODS

A questionnaire was given to MS patients attending a neurology out-patients clinic during the previous year. Medicines from a General Practitioner (GP), pharmacy and 'other' sources utilized in the last month were determined, along with demographic data. Additional information was obtained from hospital notes.

RESULTS

One hundred and seventeen MS patients responded to the questionnaire, giving a response rate of 79% (117/148). Responders differed from nonresponders only in age, with responders being significantly older than nonresponders (P = 0.011). Over one-third of medicines taken in the last month were nonprescription medicines (35%; 219/627). A gamolenic acid containing preparation was the most popular, purchased by 28% of patients. Fifteen percent (17/117) of MS patients had exceeded the recommended daily allowance of a vitamin (frequently vitamins A, D and E), and one exceeded the upper safe level for daily self-supplementation of vitamin A and D. Females spent significantly more than males in the previous month ( pound10. 09 compared with pound5.53, respectively; P = 0.022). Patients who were older, reported worsening MS symptoms in the last year and those who exhibited greater disability were more likely to have been prescribed medicines by a GP (P < 0.0005), although they were not more likely to self-prescribe or take alternative remedies (P > 0. 05). However, those with poorer mobility were significantly less likely to have purchased a pharmacy medicine in the last month (P = 0.033).

CONCLUSIONS

MS patients were high users of nonprescription medicines. A typical subgroup of MS patients that spent more on nonprescription medicines could not be identified, aside from females. Furthermore, the strong predictors for increased use of prescription medicines (increasing age, severity of symptoms in the last year and poorer mobility) were not found for nonprescription medicines. Excessive intake of the fat soluble vitamins could lead to hypervitaminosis, the effects of which could exacerbate or mimic MS symptoms. Health professionals should be aware of these issues and counsel the MS patient accordingly, particularly as the majority purchased products from 'other' sources where typically there is no health-professional available to give advice. The limited use of pharmacy medicines by the more disabled patient could indicate a problem with access to the pharmacy, or could reflect the greater use of prescription medicines.

The population's use of pharmaceuticals

OBJECTIVES

In this study, population-based analysis is used to study the extent to which characteristics such as age, sex, socioeconomic status, and region of residence are associated with different patterns of pharmaceutical use. It also includes an examination of whether pharmaceutical use is responsive to differential health needs across the population.

RESEARCH DESIGN

Indicators of access, intensity of use, and total expenditures are used to describe Manitobans' use of pharmaceutical agents, consistent with the POPULIS framework.

MEASURES

Several rate-based measures have been developed for this purpose: the number of residents who are pharmaceutical users; the number of prescriptions dispensed; the number of different drugs dispensed; the total number of defined daily doses (DDDs) dispensed; and expenditures for pharmaceuticals. The DDD measurement provides a cumulative assessment of total drug use (i.e., across multiple drug categories) and is a useful indicator of a population's total drug exposure.

RESULTS

Patterns of use of pharmaceuticals follow patterns similar to those patterns in earlier POPULIS studies on health care access, intensity, and expenditures. In areas where health is generally poorer, a greater number of prescriptions are dispensed. The highest use of pharmaceuticals also was found in the lower-income quintiles and among those at greatest socioeconomic risk, traditionally those with the poorest health status.

CONCLUSIONS

This kind of population-based pharmaceutical information can help monitor the effectiveness of policy initiatives, as well as serve to better manage pharmaceutical use within the health care system.