Are neurologist being ageist when it comes to adopting new treatment paradigms? #MSBlog #MSResearch
“Although this study below is retrospective it does describe the behaviour of practicing neurologists when it comes to prescribing disease-modifying therapies (DMTs) in clinical practice. Treat-2-target of no evidence of disease activity (T2T-NEDA) is beginning to be adopted in healthcare environments were there is no restriction on prescribing, this is mainly in the U.S. In Europe, and particularly in the UK, we have national guidelines that prevent us adopting T2T-NEDA; in other words MSers have to really fail their current DMT with disabling clinical attacks before we can escalate their therapy. In other words, those of us doing routine monitoring MRIs on an annual basis, are being forced to watch smoldering MS shredding the brain. What is interesting about this study below is that it is US based and it clearly shows early adoption of T2T-NEDA, even though this study involves an epoch in which T2T-NEDA was not be widely discussed. It is also interesting that age affected decision making; younger MSers were more likely to get switched. Why? May be the younger MSers were more educated and asked questions more frequently; in other words they were actively involved in their clinical decision making about their treatment compared to older MSers. May be prescribing neurologists thought younger MSers had more to lose. Maybe older MSers were more reluctant to switch; habits die hard. It would be interesting to follow-up this study with a qualitative in-depth study to explore the reasons for the behaviors highlighted in this study.”
“You may be interested to hear that the second Cleveland Clinic NEDA meeting is happening this week in Las Vegas. I wonder if these softer social issues concerning prescribing behaviour will be discussed?”
Epub: Teter et al. Characteristics influencing therapy switch behavior after suboptimal response to first-line treatment in patients with multiple sclerosis.Mult Scler. 2013.
BACKGROUND: Factors driving disease-modifying therapy (DMT) switch behavior are not well understood.
OBJECTIVE: The objective of this paper is to identify MSer characteristics and clinical events predictive of therapy switching in MSers with suboptimal response to DMT.
METHODS: This retrospective study analyzed MSers with relapsing-remitting multiple sclerosis (MS) and a suboptimal response to initial therapy with either interferon β or glatiramer acetate. Suboptimal responders were defined as MSers with ≥1 MS event (clinical relapse, worsening disability, or MRI worsening) while on DMT. Switchers were defined as those who changed DMT within six to 12 months after the MS event.
RESULTS: Of 606 suboptimal responders, 214 (35.3%) switched therapy. Switchers were younger at symptom onset (p = 0.012), MS diagnosis (p = 0.004), DMT initiation (p < 0.001), and first MS event (p = 0.011) compared with nonswitchers. Compared with one relapse alone, MRI worsening alone most strongly predicted switch behavior (odds ratio 6.3; 95% CI, 3.1-12.9; p < 0.001), followed by ≥2 relapses (2.8; 95% CI, 1.1-7.3; p = 0.040), EDSS plus MRI worsening (2.5; 95% CI, 1.1-5.9; p = 0.031) and EDSS worsening alone (2.2; 95% CI, 1.2-4.1; p = 0.009).
CONCLUSIONS: Younger MSers with disease activity, especially MRI changes, are more likely to have their therapy switched sooner than MSers who are older at the time of MS diagnosis and DMT initiation.