The soaring in prices of disease-modifying therapies (DMTs) for multiple sclerosis (MS) over the last several years has resulted in significant increases in the costs of MS-related care. In a new study, published in Neurology, researchers outlined five strategies neurologists can use to employ cost-saving measures while maintaining quality MS care:
• Avoid treating patients with “improbable MS” with DMTs. It is estimated that 5% to 13% of patients diagnosed with MS do not actually have MS, and nearly half of misdiagnosed patients receive DMTs. Observational studies found that patients without clinical history, neurologic deficits, or lesions characteristic of MS rarely, if ever, progress to MS. Therefore, these patients should not be prescribed DMTs, which, in addition to high costs, are associated with potentially severe side effects such as progressive multifocal leukoencephalopathy.
• Customize treatment of relapses based on patient factors and severity. A recent randomized trial of high-dose methylprednisolone (1000 mg daily for 3 days) for MS relapses was noninferior to intravenous administration of the same dose. Some relapses are mild and self-limited, and may be difficult to differentiate from the transient worsening due to physiologic or psychologic stressors. Mild relapses may not require treatment, which carries the risk of adverse events. For severe MS, patients may benefit from plasmapheresis.
• Develop alternative dosing strategies for currently approved DMTs. A multicenter, observational study suggested that decreasing natalizumab dosing to every 8 weeks is safe and more effective for reducing relapses and new T2 lesions than every 4-week dosing. Small studies of glatiramer acetate 20 mg every other day showed similar efficacy, but better tolerability, of alternate-day dosing compared with daily dosing.
• Consider off-label DMTs. The average annual DMT cost in the United States now exceeds $60,000 per patient year. Rituximab is significantly less expensive than approved DMTs, has demonstrated efficacy in MS in several studies, and has been shown to significantly reduce relapses compared with fingolimod in a recent observational study. Leflunomide is an inexpensive generic drug. Upon ingestion, leflunomide is converted into the approved DMT teriflunomide; however, no studies on its safety and efficacy in MS have been published.
• Determine whether DMTs can be discontinued in certain patient populations. Discontinuing DMTs in younger patients aged ≤ 55 years with highly active disease has been shown to result in disease reactivation within months of stopping the medicine, but the effects of discontinuing DMTs in older patients who are at lower risk of relapses are unclear. A randomized trial evaluating DMT discontinuation in patients aged ≥ 55 years without active disease is scheduled for enrollment in 2017.
Investigators Ilya Kister, MD, NYU Multiple Sclerosis Center (New York, NY) and John R Corby, MD, Rocky Mountain MS Center (Aurora, CO), noted that their suggestions “should not be viewed as practice guidelines…but as an effort to set a patient-centered, neurologist-driven agenda for clinical research in MS that could help improve outcomes and decrease costs.”—Eileen Koutnik-Fotopoulos
