Early use of high-efficacy therapies in people with MS: What is holding us back?

Join us for an honest discussion looking at the latest evidence for early, intensive treatment of MS –Safety of high-efficacy DMTs: has COVID-19 changed things? How can MS services cope with widespread use of high-efficacy therapies and what are the barriers to early use of high efficacy disease modify therapy

Objectives:

• Provide evidence for and safety of high efficacy treatments.
• Identify barriers to early use of high efficacy therapies - including unit capacity & availability of screening OPAs. strategies to overcome these? eg data collection / business cases
• Discussions around how can we plan for the widespread use of high-efficacy therapies in MS

CPD accreditation

Early use of high-efficacy therapies in people with MS: What is holding us back? has been approved by the Federation of the Royal Colleges of Physicians of the United Kingdom for 1 category 1 (external) CPD credit(s).

Please note CPD does not include satellite symposia sessions.

Summary

Early use of high-efficacy therapies in people with MS: What is holding us back?

Unit capacity and the availability of screening outpatient appointments are among the practical barriers impeding the early use of high-efficacy therapies in everyday MS practice.

Speaking at this latest MS Academy webinar, Dr David Paling, Consultant Neurologist at Sheffield Teaching Hospital, Aoife Shields, MS Principal Pharmacist at University College London Hospitals NHS Foundation Trust, and Carolyn Cairns, MS Nurse at Liverpool’s Walton Centre, outlined strategies to overcome these common obstacles, and discussed how teams can plan for the widespread use of these treatments.

Latest evidence: Has COVID-19 changed things?

There is data to suggest that early treatment with a highly efficacious disease modifying therapy (DMT) can improve medium- to long-term outcomes in some patients. Yet how these drugs interact with SARS-CoV-2 has been a topic of much discussion over the last few years.

David said data from the MS Register were “largely reassuring”, and that, with most DMTs, people who were on treatment were less likely to be hospitalised with COVID-19 than those who were not.^[1]

Rituximab and alemtuzumab are the only exceptions to this. However, David highlighted that progressive MS, higher EDSS, cardiac and respiratory comorbidities, and male gender were more important factors in this group. “These have a significantly greater effect upon your odds ratio of hospitalisation than the DMT that you're on,” he said.¹

Barriers to early use

Each stage of the patient and prescription pathways presents its own barrier to early treatment with highly efficacious DMTs, said Aoife.

Information gathering

Gathering all the patient information necessary to make a diagnosis or settle on an indication can be a lengthy first step, she said. “Patients can take months to recognise and report symptoms, and, at diagnosis, there may be lost referrals or waiting lists. Those already on treatment may not report mew symptoms right away, and new lesions may not be discovered until a person’s next routine MRI,” she said.

Educating patients on identifying and reporting new symptoms, making “every touch point” with the wider MS team count, and improving communication among MDT members can help to reduce these delays.

Eligibility

Eligibility guidelines guide rational cost-effective prescribing, but they have become confusing over time, due to differing definitions of MS, changing diagnostic criteria, and advice on prescribing criteria.

“In an ideal world, the MDT should be the people to decide what is best for the patient. That is certainty what we try to encourage, but that does mean an expert MDT needs to keep in touch with NHS England,” said Aoife.

Drug selection

Choosing the right drug is “probably one of the hardest decisions”, she went on, adding that it should be a shared decision, between the physician and the patient.

Considerations should include family planning, and side effects. Potential adverse effects on comorbidities can sometimes tip the risk/balance profile towards lower efficacy medications that have less immune suppression.

Aoife said: “MDT meetings can provide clinicians with a forum to discuss decision making, giving them confidence to make decisions, particularly around more complex patients. They also give the wider MDT the opportunity to ask questions and understand the reason behind choice of treatment.”

Availability

MS services are specially commissioned, meaning only certain hospitals can provide certain medications. This will, inevitably, lead to bottlenecks and increased waiting times.

Increasing patient numbers reduce the number of available screening, education, and infusion appointments, while staff shortages, including those related to COVID, can increase delays further.

“I think there is an opportunity to explore pharma funds and support for services such as home phlebotomy, to support patients access to treatment,” said Aoife.

Adherence

Patient engagement and adherence are also barriers worth noting. “When the decision for treatment is made by the medical team, then it's down to the patient to engage and continue on their treatment,” said Aoife, “and we can all think of patients who have continually declined treatment, which is quite frustrating.”

Teams may be able to support engagement and adherence through education and shared decision making, she said.

Can MS services cope with widespread use of high-efficacy therapies?

MS nurse services have been adapting to accommodate new treatments since the introduction of fingolimod back in 2011, said Carolyn. In much the same way, it is down to individual centres to reconfigure themselves to meet the demands of widespread high-efficacy DMT use.

“When NHS England and NICE approve these drugs, it doesn’t come with any additional funding or guidance. It just says these drugs are approved, and we get three months to get our services set up to deliver them,” said Carolyn, adding that most MS nurse services cared for “significantly more” than the 315-person caseload recommended by the MS Trust.

Drawing on the Walton Centre’s experience, Carolyn said the bulk of paperwork and coordination was now done by an administration team, which had freed up a lot of clinical time. When setting up such a team, people need to think about the level of expertise needed for each task, and assign appropriately.

When building business cases for additional staff, there are a number of pieces of key data that teams will need. This includes the overall clinic capacity, current and anticipated demand by DMT, and the workloads associated with each treatment.

Teams also need to consider how additional nursing capacity will impact on other areas, such as MRI, infusion suites, and neurologist appointments. MDT working is key here.

Clearly defined processes, which clearly articulate how services will be run to managers and other team members, are essential. Teams can also look to see if there are rooms for efficiency within existing standard operating procedures.

Carolyn also pointed to pharma support programmes, such as remote phlebotomy and pre-screening services, which can free up nursing time while also delivering care closer to home. In addition, working more closely with the wider MDT, including pharmacy, can help to ease the load of prescription management.

Overall, teams need to “have their numbers” and “understand their service”, she said, before going on to list a number of useful resources. These included the MS Trust, the MS Academy, the UKMSSNA, and the pharmaceutical companies.

[1] https://pubmed.ncbi.nlm.nih.gov/34653949/

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