Using a Deliberative Approach to Decide on an MS Therapy

Joseph Berger, MD

One of the biggest challenges for neurologists treating multiple sclerosis (MS) is the process of deciding on which of the more than a dozen therapies is best for a particular patient.

With numerous factors going into the decision, it can make the process convoluted, and with the complexity of treating MS increasing, it only makes this venture more challenging. To help alleviate this, Joseph Berger, MD, and Clyde Markowitz, MD, penned a viewpoint in JAMA Neurology to express their preferred approach to making the decision about a specific treatment.¹

While the pair did not seek to aid their peers in coming to a decision on a specific therapy, they explained why this “deliberative" approach is the most beneficial considering the landscape of treating MS.

Berger, a professor of neurology at the Hospital of the University of Pennsylvania and the chief of the Multiple Sclerosis Division at the Perelman School of Medicine, spoke with NeurologyLive in an interview to discuss this strategy and why it came to be.

NeurologyLive: What’s the main takeaway from this viewpoint for the clinician community?

Joseph Berger, MD: The takeaway message had nothing to do with helping physicians come to a decision as to which medication a patient should be on. Rather, it's the approach of how they should decide what medicine somebody should be on. The reason behind it was, in my experience, many patients—and this is true of a lot of MS neurologists—a lot of patients come to the MS neurologists having been placed on a medication that they selected. This is because the neurologist who’s caring for the patients, who's made the diagnosis, rather than coming to some decision based on a variety of parameters as to what would be best for the patient, will give them 13 brochures supplied by the drug companies and say, “Here. Go home, read this, come back in two weeks and tell me which one of these you want to be on.”

It's surprising how often that happens. That is an approach that both [myself and Clyde Markowitz, MD] thought was inaccurate and incorrect. There's another approach in which individuals are told what medication they need to be on without there being much interaction. They're both ends of the spectrum, and neither of them are the ideal way to practice, be it the practice of prescribing MS medications, or for that matter, any other in our opinion.

Then we are left with two other models. One is where you go through all the medications and you collaborate with the patient and, in that fashion, arrive at something. That is impractical as far as I'm concerned because the number of medications that we have available to us is quite broad, and the amount of time that we have with the patient is short, and increasingly shorter as were driven to generate more and more [Relative Value Units]. Some of the medications are clearly inappropriate for certain patients, so if you have somebody with very active disease, you're not likely to want to put them on a platform therapy. Or if you have somebody with very benign disease, you're not very likely to put them on an infusion therapy. So, it doesn't make sense to go through all the medications with every patient, and therefore we arrived at the deliberative approach, which is one way you say to yourself as a physician, “Look, this is somebody who has a rather benign disease. I can use this set of medications,” or “This is somebody with aggressive disease and I can use this set of medications,” or “This is somebody who has these comorbidities and I want to avoid these medications.” You can pare that down to maybe 2 or 3 medicines that you discuss with the patient, and then, in collaboration with the patient, arrived at what you both think is best.

Was this approach developed as a reaction to an issue in the field, or has this been a long-held belief?

This is sort of a reaction to an issue. One of the issues is this: there are now estimates that there are as many as a million people with MS in the United States. It used to be 400,000 but that number has been jacked up with these recent analyses. From my own experience, I believe that that's likely to be the case because even when it was 400,000, we thought that was an underestimate based on the reports of people who were claiming disability for MS to the Social Security Administration, and based on the number of people claim they had spinal cord problems from MS and had been reported to the Christopher Reeves Association.

Well, there aren't that many MS neurologists to care for a million people, and the complexity of the drugs that we are now providing patients with MS has increased substantially. Unfortunately, the general neurologist, in many instances, finds it hard to keep up—and this is true of all of us. Don't ask me what the best epilepsy drugs are, or Parkinson's drugs are anymore. This is true for everybody, that it's hard to keep up in every one of these fields. MS is one of those fields where the advances have been rather rapid. The expansion of our pharmacopeia has been very broad in a very short period of time, and many of these drugs carry with them significant adverse events. You need to be able to parse out what is important and what isn't when you talk to patients about what sort of drugs they need to be on, and you need to have a comfort level with the administration of that drug.

My belief is that the ideal person to be doing that would be somebody who has a familiarity with all the drugs and functions as an MS neurologist. However, because of the large numbers of patients with MS in the nation, that's not very practical. If you live in North Dakota or Montana, who are you going to see about your MS? Or if you live in north-central Pennsylvania, I have no idea you'd see unless you travel long distances. The bottom line is that some of the practices that people are using in order to decide on a drug are predicated on what they're most comfortable with or allowing the patient to make the decision, and that may not be the very best for the patient. The ideal situation would be to train up more MS neurologists.

REFERENCES

1. Berger JR, Markowitz C. Deciding on the best multiple sclerosis therapy: tough choices. JAMA Neurol. 2018;75(12):1461-1462. doi:10.1001/jamaneurol.2018.2689