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The 2015 Annual Meeting of the Consortium of Multiple Sclerosis Centers
Abundance of agents adds choice in choosing MS therapy
INDIANAPOLIS – With the emergence of 11 Food and Drug Administration–approved treatments for clinically isolated syndrome and/or relapsing forms of multiple sclerosis since 1993, patients have more choices for disease-modifying therapy than ever before. Dr. Mitzi Joi Williams describes choosing the right disease-modifying therapy as a balancing act that considers efficacy, safety, and tolerability.
“As we have more medications for MS, especially with different mechanisms of action, there may be some side effects that we may not be familiar with,” Dr. Williams, a neurologist at the Multiple Sclerosis Center of Atlanta, said at the annual meeting of the Consortium of Multiple Sclerosis Centers. “You want a drug that you and the patient feel comfortable with and find tolerable. In the past when we only had injections, we’d say, ‘you have to tough it out; we don’t have anything else.’ ”
Other considerations, she said, include non–neurologic side effects, sequencing of therapies, and compliance with monitoring. “Some medications require blood work every month for 6 months, others require blood work every month for 4 or 5 years,” Dr. Williams said. “That’s a lot for patients to keep up with.”
The two most recent drugs approved for MS are alemtuzumab and pegylated interferon beta-1a. Alemtuzumab, which is indicated for the treatment of relapsing-remitting MS, is a monoclonal antibody to CD52 and has been previously used in patients with chronic lymphocytic leukemia. Dosing is 12 mg/day delivered intravenously for 3-5 days once a year. Possible adverse effects include profound lymphopenia, autoimmune thyroid disease, immune thrombocytopenic purpura, infusion reaction, and increased susceptibility to infections.
The other newcomer, pegylated interferon beta-1a is a recombinant interferon beta-1a protein attached to a polyethylene glycol molecule that reduces proinflammatory cytokines and inhibits T-cell migration and is indicated for relapsing MS. Dosing is 125 mcg subcutaneously every 2 or 4 weeks. Common adverse events include flulike symptoms, infection-site reactions, fever, and headache.
Another drug that has been submitted to the FDA for approval is daclizumab, a humanized monoclonal antibody that binds to CD25, decreasing activated T cells. It is intended for the treatment of relapsing MS. The dosing schedule would be 150 mg delivered subcutaneously every other week at home. Data from the SELECT trial, a year-long, phase II study of the agent, showed a 50%-54% decrease in annualized relapse rate (ARR), a 43%-57% decrease in confirmed disability, a 79%-86% reduction in new gadolinium (Gd)-enhancing lesions, and a 70%-79% reduction in new or enlarging T2 lesions. A phase II extension trial called SELECTION showed a 59% decrease in ARR, a 54% decrease in confirmed disability, a 86% reduction in new Gd-enhancing lesions, and a 74% reduction in new or enlarging T2 lesions. Potential adverse side effects include increased risk for infection, abnormal liver function tests, diarrhea, constipation, and swelling of the extremities. It has previously been used in rheumatoid arthritis and in kidney transplant patients.
Another promising agent in phase III studies is ocrelizumab, which is being studied in doses of 600 mg or 2,000 mg in patients with relapsing-remitting MS and primary-progressive MS. “It’s an anti-CD20 molecule that is similar to rituximab, which has been used in MS for some time, but it’s a more humanized antibody,” Dr. Williams said. She noted that a multicenter phase II study showed that ARR decreased by 73% with the 2,000-mg dose and by 80% with the 600-mg dose (Lancet 2011;378:1779-87). It also showed that Gd-enhancing lesions decreased by 96% with the 2,000-mg dose and by 89% with the 600-mg dose. “Potential adverse events reported in the trial include infusion-site reactions and increased risk of infection,” she said. “One study participant died from systemic inflammatory response of unknown cause.”
Other drugs for relapsing MS in earlier phases of research included ofatumumab, S1P receptor modulators, Tcelna, statins, antibiotics, and vitamin D3. Agents being investigated for progressive MS include S1P receptor modulators, masitinib, and ibudilast. “The more options we have for our patients, the better, because there’s no one drug that’s right for everyone,” Dr. Williams said.
Potential therapies could eventually come via more studies of drugs and mechanisms for myelin repair, including anti-LINGO-1 and stem cell therapies, as well as hormone therapy in the form of estrogen and testosterone. Other avenues of research include gene and DNA studies, personalized medicine and biomarkers, and monitoring progression of disease.
Dr. Williams disclosed that she is a consultant and speaker for Biogen Idec, Teva Neuroscience, EMD Serono, Mallinckrodt Pharmaceuticals, Novartis, Genzyme, and Acorda Therapeutics.
INDIANAPOLIS – With the emergence of 11 Food and Drug Administration–approved treatments for clinically isolated syndrome and/or relapsing forms of multiple sclerosis since 1993, patients have more choices for disease-modifying therapy than ever before. Dr. Mitzi Joi Williams describes choosing the right disease-modifying therapy as a balancing act that considers efficacy, safety, and tolerability.
“As we have more medications for MS, especially with different mechanisms of action, there may be some side effects that we may not be familiar with,” Dr. Williams, a neurologist at the Multiple Sclerosis Center of Atlanta, said at the annual meeting of the Consortium of Multiple Sclerosis Centers. “You want a drug that you and the patient feel comfortable with and find tolerable. In the past when we only had injections, we’d say, ‘you have to tough it out; we don’t have anything else.’ ”
Other considerations, she said, include non–neurologic side effects, sequencing of therapies, and compliance with monitoring. “Some medications require blood work every month for 6 months, others require blood work every month for 4 or 5 years,” Dr. Williams said. “That’s a lot for patients to keep up with.”
The two most recent drugs approved for MS are alemtuzumab and pegylated interferon beta-1a. Alemtuzumab, which is indicated for the treatment of relapsing-remitting MS, is a monoclonal antibody to CD52 and has been previously used in patients with chronic lymphocytic leukemia. Dosing is 12 mg/day delivered intravenously for 3-5 days once a year. Possible adverse effects include profound lymphopenia, autoimmune thyroid disease, immune thrombocytopenic purpura, infusion reaction, and increased susceptibility to infections.
The other newcomer, pegylated interferon beta-1a is a recombinant interferon beta-1a protein attached to a polyethylene glycol molecule that reduces proinflammatory cytokines and inhibits T-cell migration and is indicated for relapsing MS. Dosing is 125 mcg subcutaneously every 2 or 4 weeks. Common adverse events include flulike symptoms, infection-site reactions, fever, and headache.
Another drug that has been submitted to the FDA for approval is daclizumab, a humanized monoclonal antibody that binds to CD25, decreasing activated T cells. It is intended for the treatment of relapsing MS. The dosing schedule would be 150 mg delivered subcutaneously every other week at home. Data from the SELECT trial, a year-long, phase II study of the agent, showed a 50%-54% decrease in annualized relapse rate (ARR), a 43%-57% decrease in confirmed disability, a 79%-86% reduction in new gadolinium (Gd)-enhancing lesions, and a 70%-79% reduction in new or enlarging T2 lesions. A phase II extension trial called SELECTION showed a 59% decrease in ARR, a 54% decrease in confirmed disability, a 86% reduction in new Gd-enhancing lesions, and a 74% reduction in new or enlarging T2 lesions. Potential adverse side effects include increased risk for infection, abnormal liver function tests, diarrhea, constipation, and swelling of the extremities. It has previously been used in rheumatoid arthritis and in kidney transplant patients.
Another promising agent in phase III studies is ocrelizumab, which is being studied in doses of 600 mg or 2,000 mg in patients with relapsing-remitting MS and primary-progressive MS. “It’s an anti-CD20 molecule that is similar to rituximab, which has been used in MS for some time, but it’s a more humanized antibody,” Dr. Williams said. She noted that a multicenter phase II study showed that ARR decreased by 73% with the 2,000-mg dose and by 80% with the 600-mg dose (Lancet 2011;378:1779-87). It also showed that Gd-enhancing lesions decreased by 96% with the 2,000-mg dose and by 89% with the 600-mg dose. “Potential adverse events reported in the trial include infusion-site reactions and increased risk of infection,” she said. “One study participant died from systemic inflammatory response of unknown cause.”
Other drugs for relapsing MS in earlier phases of research included ofatumumab, S1P receptor modulators, Tcelna, statins, antibiotics, and vitamin D3. Agents being investigated for progressive MS include S1P receptor modulators, masitinib, and ibudilast. “The more options we have for our patients, the better, because there’s no one drug that’s right for everyone,” Dr. Williams said.
Potential therapies could eventually come via more studies of drugs and mechanisms for myelin repair, including anti-LINGO-1 and stem cell therapies, as well as hormone therapy in the form of estrogen and testosterone. Other avenues of research include gene and DNA studies, personalized medicine and biomarkers, and monitoring progression of disease.
Dr. Williams disclosed that she is a consultant and speaker for Biogen Idec, Teva Neuroscience, EMD Serono, Mallinckrodt Pharmaceuticals, Novartis, Genzyme, and Acorda Therapeutics.
INDIANAPOLIS – With the emergence of 11 Food and Drug Administration–approved treatments for clinically isolated syndrome and/or relapsing forms of multiple sclerosis since 1993, patients have more choices for disease-modifying therapy than ever before. Dr. Mitzi Joi Williams describes choosing the right disease-modifying therapy as a balancing act that considers efficacy, safety, and tolerability.
“As we have more medications for MS, especially with different mechanisms of action, there may be some side effects that we may not be familiar with,” Dr. Williams, a neurologist at the Multiple Sclerosis Center of Atlanta, said at the annual meeting of the Consortium of Multiple Sclerosis Centers. “You want a drug that you and the patient feel comfortable with and find tolerable. In the past when we only had injections, we’d say, ‘you have to tough it out; we don’t have anything else.’ ”
Other considerations, she said, include non–neurologic side effects, sequencing of therapies, and compliance with monitoring. “Some medications require blood work every month for 6 months, others require blood work every month for 4 or 5 years,” Dr. Williams said. “That’s a lot for patients to keep up with.”
The two most recent drugs approved for MS are alemtuzumab and pegylated interferon beta-1a. Alemtuzumab, which is indicated for the treatment of relapsing-remitting MS, is a monoclonal antibody to CD52 and has been previously used in patients with chronic lymphocytic leukemia. Dosing is 12 mg/day delivered intravenously for 3-5 days once a year. Possible adverse effects include profound lymphopenia, autoimmune thyroid disease, immune thrombocytopenic purpura, infusion reaction, and increased susceptibility to infections.
The other newcomer, pegylated interferon beta-1a is a recombinant interferon beta-1a protein attached to a polyethylene glycol molecule that reduces proinflammatory cytokines and inhibits T-cell migration and is indicated for relapsing MS. Dosing is 125 mcg subcutaneously every 2 or 4 weeks. Common adverse events include flulike symptoms, infection-site reactions, fever, and headache.
Another drug that has been submitted to the FDA for approval is daclizumab, a humanized monoclonal antibody that binds to CD25, decreasing activated T cells. It is intended for the treatment of relapsing MS. The dosing schedule would be 150 mg delivered subcutaneously every other week at home. Data from the SELECT trial, a year-long, phase II study of the agent, showed a 50%-54% decrease in annualized relapse rate (ARR), a 43%-57% decrease in confirmed disability, a 79%-86% reduction in new gadolinium (Gd)-enhancing lesions, and a 70%-79% reduction in new or enlarging T2 lesions. A phase II extension trial called SELECTION showed a 59% decrease in ARR, a 54% decrease in confirmed disability, a 86% reduction in new Gd-enhancing lesions, and a 74% reduction in new or enlarging T2 lesions. Potential adverse side effects include increased risk for infection, abnormal liver function tests, diarrhea, constipation, and swelling of the extremities. It has previously been used in rheumatoid arthritis and in kidney transplant patients.
Another promising agent in phase III studies is ocrelizumab, which is being studied in doses of 600 mg or 2,000 mg in patients with relapsing-remitting MS and primary-progressive MS. “It’s an anti-CD20 molecule that is similar to rituximab, which has been used in MS for some time, but it’s a more humanized antibody,” Dr. Williams said. She noted that a multicenter phase II study showed that ARR decreased by 73% with the 2,000-mg dose and by 80% with the 600-mg dose (Lancet 2011;378:1779-87). It also showed that Gd-enhancing lesions decreased by 96% with the 2,000-mg dose and by 89% with the 600-mg dose. “Potential adverse events reported in the trial include infusion-site reactions and increased risk of infection,” she said. “One study participant died from systemic inflammatory response of unknown cause.”
Other drugs for relapsing MS in earlier phases of research included ofatumumab, S1P receptor modulators, Tcelna, statins, antibiotics, and vitamin D3. Agents being investigated for progressive MS include S1P receptor modulators, masitinib, and ibudilast. “The more options we have for our patients, the better, because there’s no one drug that’s right for everyone,” Dr. Williams said.
Potential therapies could eventually come via more studies of drugs and mechanisms for myelin repair, including anti-LINGO-1 and stem cell therapies, as well as hormone therapy in the form of estrogen and testosterone. Other avenues of research include gene and DNA studies, personalized medicine and biomarkers, and monitoring progression of disease.
Dr. Williams disclosed that she is a consultant and speaker for Biogen Idec, Teva Neuroscience, EMD Serono, Mallinckrodt Pharmaceuticals, Novartis, Genzyme, and Acorda Therapeutics.
EXPERT ANALYSIS AT THE CMSC ANNUAL MEETING
Optimizing treatment selection in MS often tricky
INDIANAPOLIS – Consider disease activity, patient comorbidities, treatment tolerability, and patient or physician preference when prescribing disease-modifying therapy for multiple sclerosis patients.
“Where I practice, patient preference can sound something like, ‘My sister-in-law’s cousin’s friend at church takes drug X, and that’s the one I’m interested in,’ ” said Dr. Myla D. Goldman, a neurologist who directs the James Q. Miller Multiple Sclerosis Clinic at the University of Virginia, Charlottesville. “It’s sometimes guided by just familiarity or word of mouth, or something that they’ve read or someone that they know. In terms of our own preferences as clinicians, those are much harder to characterize. I think they become shaped over time and our own experiences, as well as being guided by evidence-based medicine.”
In a survey, 102 neurologists were asked about how they made decisions regarding the prescription of disease-modifying therapies (DMTs) for patients with MS (Patient Prefer. Adherence 2014;8:415-22). More than 80% ranked efficacy as the most important attribute of DMT medication selection, followed by safety, tolerability, patient preference, and convenience (including dosing frequency and administration method). In a separate study presented at the 2014 meeting of the American Academy of Neurology, 1,628 MS patients in Germany were asked about the importance of different DMT features (Neurology 2014;82[10 Suppl.]:P3.137). They ranked oral administration as the most important attribute in guiding their DMT preference, while the second most relevant attribute was frequency of administration.
In a more recent study, 50 patients with relapsing-remitting MS were asked about their preferences for attributes of DMTs (Int. J. MS Care 2015;17:74-82). Survey respondents showed the highest preference for medications that would improve their symptoms, which is not a proven DMT outcome. Preventing relapses, which is a key clinical trial outcome, was not associated with significant preferences.
“This is important to know but adds another layer of challenge and complication [because] what we understand most about many of these agents is their effect on relapse rates,” Dr. Goldman said at the annual meeting of the Consortium of Multiple Sclerosis Centers. “It’s another disconnect in terms of what we’re thinking about, the tools that we have, and where our patients are coming from.”
Other factors to consider when selecting a DMT include disease activity/burden, risk/prognostic factors, treatment safety/tolerability, comorbidity, and treatment access/logistics. “As we’ve had more and more [DMT] choices available to us, we’ve become more restricted in how we make choices – which patients can have what choices in what order,” she said. “This is a reality that we all have to face but is something that varies from third-party payers and region, and can be really complicated to navigate.”
In general, Dr. Goldman continued, it’s recognized that more active disease requires more effective therapies with greater tolerance for risk. However, evidence suggesting that early disease activity predicts long-term outcome is poor, “not because it may not be true but because we don’t have as robust data as we would like,” she said. “We also have few [clinical] trials focused on this group. So when we look at high disease activity, it’s typically in a subgroup analysis. There are risks for underpowering and a lack of direct comparisons among therapies. I have found that my idea of disease activity and my individual patient’s idea of disease activity sometimes differ. Perhaps I think we need to make a change, and they feel comfortable with what they’re taking, or vice versa.”
There are various predictors of disease activity and outcomes based on early signs and symptoms, “but these outcomes are variable when we are comparing across studies,” she noted. These predictors and outcomes include:
• Early disease activity predicts relapse disease activity early, especially with posterior fossa lesions and enhancing lesions.
• Early MRI activity predicts long-term disability.
• A baseline T2 lesion burden predicts change in the Kurtzke Expanded Disability Status Scale (EDSS) and progression to secondary-progressive MS.
• A T2 lesion change at 1 year predicts EDSS change.
• Brain atrophy over 2 years predicts EDSS at 8 years.
Favorable prognostic factors include monofocal onset, onset with optic neuritis or isolated sensory symptoms, younger age at onset, being white, being female, having a low relapse rate in the first 2-5 years, and a long interval between the first and second relapse. “That’s where early treatment and impact on relapse rate has a really important role,” she said.
Unfavorable factors in relapsing-remitting MS include multifocal onset, being black, older age at onset, being male, high relapse rate in the first 2-5 years, disability at 5 years, cognitive impairment, high MRI lesion load at baseline, atrophy and T1 holes on MRI, and being a smoker.
Dr. Goldman pointed out that efficacy, safety, and tolerability of most DMTs are unknown in patients with comorbidities such as obesity or cardiovascular disease. “It’s important to remember that for many patients with comorbidity, these are exclusion criteria in the clinical trials program,” she said. “So while we know that having comorbidities in an MS population does affect quality of life and increase disability progression, what we are lacking understanding [about] is how these may affect treatment response.”
Dr. Goldman disclosed that she is a consultant and advisory board member for Questcor Pharmaceuticals.
The session was sponsored by an educational grant from Biogen.
On Twitter @dougbrunk
INDIANAPOLIS – Consider disease activity, patient comorbidities, treatment tolerability, and patient or physician preference when prescribing disease-modifying therapy for multiple sclerosis patients.
“Where I practice, patient preference can sound something like, ‘My sister-in-law’s cousin’s friend at church takes drug X, and that’s the one I’m interested in,’ ” said Dr. Myla D. Goldman, a neurologist who directs the James Q. Miller Multiple Sclerosis Clinic at the University of Virginia, Charlottesville. “It’s sometimes guided by just familiarity or word of mouth, or something that they’ve read or someone that they know. In terms of our own preferences as clinicians, those are much harder to characterize. I think they become shaped over time and our own experiences, as well as being guided by evidence-based medicine.”
In a survey, 102 neurologists were asked about how they made decisions regarding the prescription of disease-modifying therapies (DMTs) for patients with MS (Patient Prefer. Adherence 2014;8:415-22). More than 80% ranked efficacy as the most important attribute of DMT medication selection, followed by safety, tolerability, patient preference, and convenience (including dosing frequency and administration method). In a separate study presented at the 2014 meeting of the American Academy of Neurology, 1,628 MS patients in Germany were asked about the importance of different DMT features (Neurology 2014;82[10 Suppl.]:P3.137). They ranked oral administration as the most important attribute in guiding their DMT preference, while the second most relevant attribute was frequency of administration.
In a more recent study, 50 patients with relapsing-remitting MS were asked about their preferences for attributes of DMTs (Int. J. MS Care 2015;17:74-82). Survey respondents showed the highest preference for medications that would improve their symptoms, which is not a proven DMT outcome. Preventing relapses, which is a key clinical trial outcome, was not associated with significant preferences.
“This is important to know but adds another layer of challenge and complication [because] what we understand most about many of these agents is their effect on relapse rates,” Dr. Goldman said at the annual meeting of the Consortium of Multiple Sclerosis Centers. “It’s another disconnect in terms of what we’re thinking about, the tools that we have, and where our patients are coming from.”
Other factors to consider when selecting a DMT include disease activity/burden, risk/prognostic factors, treatment safety/tolerability, comorbidity, and treatment access/logistics. “As we’ve had more and more [DMT] choices available to us, we’ve become more restricted in how we make choices – which patients can have what choices in what order,” she said. “This is a reality that we all have to face but is something that varies from third-party payers and region, and can be really complicated to navigate.”
In general, Dr. Goldman continued, it’s recognized that more active disease requires more effective therapies with greater tolerance for risk. However, evidence suggesting that early disease activity predicts long-term outcome is poor, “not because it may not be true but because we don’t have as robust data as we would like,” she said. “We also have few [clinical] trials focused on this group. So when we look at high disease activity, it’s typically in a subgroup analysis. There are risks for underpowering and a lack of direct comparisons among therapies. I have found that my idea of disease activity and my individual patient’s idea of disease activity sometimes differ. Perhaps I think we need to make a change, and they feel comfortable with what they’re taking, or vice versa.”
There are various predictors of disease activity and outcomes based on early signs and symptoms, “but these outcomes are variable when we are comparing across studies,” she noted. These predictors and outcomes include:
• Early disease activity predicts relapse disease activity early, especially with posterior fossa lesions and enhancing lesions.
• Early MRI activity predicts long-term disability.
• A baseline T2 lesion burden predicts change in the Kurtzke Expanded Disability Status Scale (EDSS) and progression to secondary-progressive MS.
• A T2 lesion change at 1 year predicts EDSS change.
• Brain atrophy over 2 years predicts EDSS at 8 years.
Favorable prognostic factors include monofocal onset, onset with optic neuritis or isolated sensory symptoms, younger age at onset, being white, being female, having a low relapse rate in the first 2-5 years, and a long interval between the first and second relapse. “That’s where early treatment and impact on relapse rate has a really important role,” she said.
Unfavorable factors in relapsing-remitting MS include multifocal onset, being black, older age at onset, being male, high relapse rate in the first 2-5 years, disability at 5 years, cognitive impairment, high MRI lesion load at baseline, atrophy and T1 holes on MRI, and being a smoker.
Dr. Goldman pointed out that efficacy, safety, and tolerability of most DMTs are unknown in patients with comorbidities such as obesity or cardiovascular disease. “It’s important to remember that for many patients with comorbidity, these are exclusion criteria in the clinical trials program,” she said. “So while we know that having comorbidities in an MS population does affect quality of life and increase disability progression, what we are lacking understanding [about] is how these may affect treatment response.”
Dr. Goldman disclosed that she is a consultant and advisory board member for Questcor Pharmaceuticals.
The session was sponsored by an educational grant from Biogen.
On Twitter @dougbrunk
INDIANAPOLIS – Consider disease activity, patient comorbidities, treatment tolerability, and patient or physician preference when prescribing disease-modifying therapy for multiple sclerosis patients.
“Where I practice, patient preference can sound something like, ‘My sister-in-law’s cousin’s friend at church takes drug X, and that’s the one I’m interested in,’ ” said Dr. Myla D. Goldman, a neurologist who directs the James Q. Miller Multiple Sclerosis Clinic at the University of Virginia, Charlottesville. “It’s sometimes guided by just familiarity or word of mouth, or something that they’ve read or someone that they know. In terms of our own preferences as clinicians, those are much harder to characterize. I think they become shaped over time and our own experiences, as well as being guided by evidence-based medicine.”
In a survey, 102 neurologists were asked about how they made decisions regarding the prescription of disease-modifying therapies (DMTs) for patients with MS (Patient Prefer. Adherence 2014;8:415-22). More than 80% ranked efficacy as the most important attribute of DMT medication selection, followed by safety, tolerability, patient preference, and convenience (including dosing frequency and administration method). In a separate study presented at the 2014 meeting of the American Academy of Neurology, 1,628 MS patients in Germany were asked about the importance of different DMT features (Neurology 2014;82[10 Suppl.]:P3.137). They ranked oral administration as the most important attribute in guiding their DMT preference, while the second most relevant attribute was frequency of administration.
In a more recent study, 50 patients with relapsing-remitting MS were asked about their preferences for attributes of DMTs (Int. J. MS Care 2015;17:74-82). Survey respondents showed the highest preference for medications that would improve their symptoms, which is not a proven DMT outcome. Preventing relapses, which is a key clinical trial outcome, was not associated with significant preferences.
“This is important to know but adds another layer of challenge and complication [because] what we understand most about many of these agents is their effect on relapse rates,” Dr. Goldman said at the annual meeting of the Consortium of Multiple Sclerosis Centers. “It’s another disconnect in terms of what we’re thinking about, the tools that we have, and where our patients are coming from.”
Other factors to consider when selecting a DMT include disease activity/burden, risk/prognostic factors, treatment safety/tolerability, comorbidity, and treatment access/logistics. “As we’ve had more and more [DMT] choices available to us, we’ve become more restricted in how we make choices – which patients can have what choices in what order,” she said. “This is a reality that we all have to face but is something that varies from third-party payers and region, and can be really complicated to navigate.”
In general, Dr. Goldman continued, it’s recognized that more active disease requires more effective therapies with greater tolerance for risk. However, evidence suggesting that early disease activity predicts long-term outcome is poor, “not because it may not be true but because we don’t have as robust data as we would like,” she said. “We also have few [clinical] trials focused on this group. So when we look at high disease activity, it’s typically in a subgroup analysis. There are risks for underpowering and a lack of direct comparisons among therapies. I have found that my idea of disease activity and my individual patient’s idea of disease activity sometimes differ. Perhaps I think we need to make a change, and they feel comfortable with what they’re taking, or vice versa.”
There are various predictors of disease activity and outcomes based on early signs and symptoms, “but these outcomes are variable when we are comparing across studies,” she noted. These predictors and outcomes include:
• Early disease activity predicts relapse disease activity early, especially with posterior fossa lesions and enhancing lesions.
• Early MRI activity predicts long-term disability.
• A baseline T2 lesion burden predicts change in the Kurtzke Expanded Disability Status Scale (EDSS) and progression to secondary-progressive MS.
• A T2 lesion change at 1 year predicts EDSS change.
• Brain atrophy over 2 years predicts EDSS at 8 years.
Favorable prognostic factors include monofocal onset, onset with optic neuritis or isolated sensory symptoms, younger age at onset, being white, being female, having a low relapse rate in the first 2-5 years, and a long interval between the first and second relapse. “That’s where early treatment and impact on relapse rate has a really important role,” she said.
Unfavorable factors in relapsing-remitting MS include multifocal onset, being black, older age at onset, being male, high relapse rate in the first 2-5 years, disability at 5 years, cognitive impairment, high MRI lesion load at baseline, atrophy and T1 holes on MRI, and being a smoker.
Dr. Goldman pointed out that efficacy, safety, and tolerability of most DMTs are unknown in patients with comorbidities such as obesity or cardiovascular disease. “It’s important to remember that for many patients with comorbidity, these are exclusion criteria in the clinical trials program,” she said. “So while we know that having comorbidities in an MS population does affect quality of life and increase disability progression, what we are lacking understanding [about] is how these may affect treatment response.”
Dr. Goldman disclosed that she is a consultant and advisory board member for Questcor Pharmaceuticals.
The session was sponsored by an educational grant from Biogen.
On Twitter @dougbrunk
EXPERT ANALYSIS FROM THE CMSC ANNUAL MEETING
Adherence to MS treatments lower in oral vs. injectable drugs
INDIANAPOLIS – Lack of adherence was significantly higher in multiple sclerosis (MS) patients who received oral versus injectable disease-modifying therapies, a single-center study showed.
Side effect profile may have been a contributing factor to this outcome, study author Caitlin Dionne said in an interview during a poster session at the annual meeting of the Consortium of Multiple Sclerosis Centers. “There are more GI-related side effects with the oral MS drugs, compared with the injectables, so that could be part of it,” said Ms. Dionne, a registered nurse in the neurology department at the Lahey Clinic Outpatient Center, Lexington, Mass. In addition, taking an oral DMT “may not be as serious in the minds [of patients] as ‘I have to take a shot.’”
In an effort to determine if adherence and tolerability of oral disease-modifying therapies (DMTs) is better than with injectables, Ms. Dionne and her associates developed the MS Treatment Adherence Questionnaire (MS-TAQ) and collected data from October and November of 2014. The questionnaire is composed of six questions related to a patient’s current DMT: number of missed doses in 4 weeks, reason dose was missed, perceived side effects, ease of administration, and medication satisfaction. Medication types were divided into three groups: oral DMTs, subcutaneous or intramuscular (SC/IM) DMTs, and monthly IV injections.
Of the 209 patients surveyed, 75% were female and their mean age was 50. A similar number of patients were on oral and SC/IM medications (89 and 90, respectively), while the remaining 30 were on an IV infusion. Ms. Dionne reported that 55% of patients taking oral medications reported missing no doses, compared with 71% of those taking SC/IM agents and 93% of those receiving IV infusions (P = .005). Ease of medication administration was reported by 77% of patients taking oral medications, 60% of those taking SC/IM agents, and 33% of those receiving IV infusions (P < .0001).
Reasons for missing a dose differed with respect to each DMT type (P = .017), with forgetfulness being reported in 38% and 27% of patients taking oral and SC/IM agents, respectively. Side effects also differed with respect to each DMT. Nearly three-quarters (74%) of those receiving IV infusions did not experience side effects, compared with 19% of those taking oral medications and 20% of those taking SC/IM agents.
The researchers had no relevant financial conflicts to disclose.
On Twitter @dougbrunk
INDIANAPOLIS – Lack of adherence was significantly higher in multiple sclerosis (MS) patients who received oral versus injectable disease-modifying therapies, a single-center study showed.
Side effect profile may have been a contributing factor to this outcome, study author Caitlin Dionne said in an interview during a poster session at the annual meeting of the Consortium of Multiple Sclerosis Centers. “There are more GI-related side effects with the oral MS drugs, compared with the injectables, so that could be part of it,” said Ms. Dionne, a registered nurse in the neurology department at the Lahey Clinic Outpatient Center, Lexington, Mass. In addition, taking an oral DMT “may not be as serious in the minds [of patients] as ‘I have to take a shot.’”
In an effort to determine if adherence and tolerability of oral disease-modifying therapies (DMTs) is better than with injectables, Ms. Dionne and her associates developed the MS Treatment Adherence Questionnaire (MS-TAQ) and collected data from October and November of 2014. The questionnaire is composed of six questions related to a patient’s current DMT: number of missed doses in 4 weeks, reason dose was missed, perceived side effects, ease of administration, and medication satisfaction. Medication types were divided into three groups: oral DMTs, subcutaneous or intramuscular (SC/IM) DMTs, and monthly IV injections.
Of the 209 patients surveyed, 75% were female and their mean age was 50. A similar number of patients were on oral and SC/IM medications (89 and 90, respectively), while the remaining 30 were on an IV infusion. Ms. Dionne reported that 55% of patients taking oral medications reported missing no doses, compared with 71% of those taking SC/IM agents and 93% of those receiving IV infusions (P = .005). Ease of medication administration was reported by 77% of patients taking oral medications, 60% of those taking SC/IM agents, and 33% of those receiving IV infusions (P < .0001).
Reasons for missing a dose differed with respect to each DMT type (P = .017), with forgetfulness being reported in 38% and 27% of patients taking oral and SC/IM agents, respectively. Side effects also differed with respect to each DMT. Nearly three-quarters (74%) of those receiving IV infusions did not experience side effects, compared with 19% of those taking oral medications and 20% of those taking SC/IM agents.
The researchers had no relevant financial conflicts to disclose.
On Twitter @dougbrunk
INDIANAPOLIS – Lack of adherence was significantly higher in multiple sclerosis (MS) patients who received oral versus injectable disease-modifying therapies, a single-center study showed.
Side effect profile may have been a contributing factor to this outcome, study author Caitlin Dionne said in an interview during a poster session at the annual meeting of the Consortium of Multiple Sclerosis Centers. “There are more GI-related side effects with the oral MS drugs, compared with the injectables, so that could be part of it,” said Ms. Dionne, a registered nurse in the neurology department at the Lahey Clinic Outpatient Center, Lexington, Mass. In addition, taking an oral DMT “may not be as serious in the minds [of patients] as ‘I have to take a shot.’”
In an effort to determine if adherence and tolerability of oral disease-modifying therapies (DMTs) is better than with injectables, Ms. Dionne and her associates developed the MS Treatment Adherence Questionnaire (MS-TAQ) and collected data from October and November of 2014. The questionnaire is composed of six questions related to a patient’s current DMT: number of missed doses in 4 weeks, reason dose was missed, perceived side effects, ease of administration, and medication satisfaction. Medication types were divided into three groups: oral DMTs, subcutaneous or intramuscular (SC/IM) DMTs, and monthly IV injections.
Of the 209 patients surveyed, 75% were female and their mean age was 50. A similar number of patients were on oral and SC/IM medications (89 and 90, respectively), while the remaining 30 were on an IV infusion. Ms. Dionne reported that 55% of patients taking oral medications reported missing no doses, compared with 71% of those taking SC/IM agents and 93% of those receiving IV infusions (P = .005). Ease of medication administration was reported by 77% of patients taking oral medications, 60% of those taking SC/IM agents, and 33% of those receiving IV infusions (P < .0001).
Reasons for missing a dose differed with respect to each DMT type (P = .017), with forgetfulness being reported in 38% and 27% of patients taking oral and SC/IM agents, respectively. Side effects also differed with respect to each DMT. Nearly three-quarters (74%) of those receiving IV infusions did not experience side effects, compared with 19% of those taking oral medications and 20% of those taking SC/IM agents.
The researchers had no relevant financial conflicts to disclose.
On Twitter @dougbrunk
AT THE CMSC ANNUAL MEETING
Key clinical point: MS patients were less adherent to oral than to injectable disease-modifying therapies.
Major finding: Just over half of MS patients taking oral medications (55%) reported missing no doses, compared with 71% of those taking SC/IM agents and 93% of those receiving IV infusions (P = .005).
Data source: Survey responses from 209 MS patients at the Lahey Outpatient Center, Lexington, Mass.
Disclosures: The researchers had no relevant financial conflicts to disclose.
CMSC: Survey offers snapshot of MS therapy trends
INDIANAPOLIS – Although nearly all patients with multiple sclerosis have some form of insurance, 25% of them receive some form of assistance from the pharmaceutical industry in covering the cost of their disease-modifying therapies. In addition, 22% report that their health insurance coverage worsened compared with the prior year.
Those are key findings from a fall 2014 survey of the North American Research Consortium on MS (NARCOMS), a registry with self-reported information on disease-modifying therapies (DMTs), including type, duration of use, changes and reasons for changes, as well as income, insurance, and disease status.
At the annual meeting of the Consortium of Multiple Sclerosis Centers, Guoqiao Wang, Ph.D., and his associates reported findings based on 6,662 (88%) of 7,601 NARCOMS participants who completed the Fall 2014 NARCOMS Update survey, including questions about their health insurance status and DMT choices related to insurance. Of those 6,662 respondents, 99% reported being insured in the prior 6 months, 69% reported that their insurance coverage was unchanged compared with the prior year, and 22% said that their insurance coverage worsened compared with the prior year.
Of the 4,156 (62.4%) respondents who were taking DMTs at the time of the survey, the following financial resources were used to pay for the agents: health insurance copay only (52.1%), free or discounted drug programs (25%), full coverage by health insurance (22.2%), and full payment by the patient (0.7%). Most of those who received assistance from free or discounted drug programs were female (86%), have had their disease for a mean of 7.6 years, tended to have the relapsing-remitting form of MS (71%), and had a median Patient Determined Disease Step of 3 (Gait Disability), suggesting a lower level of disability and most likely an earlier stage of the disease course.
Of the 2,108 (31.6%) respondents who were not taking DMTs, 77.7% did so by their own choice, 14.5% did so on physician recommendation, 3.8% did so because of insurance denial, 2.7% did so because of a higher copay, and 1.3% because of having no insurance.
“Although the proportion of participants who did not take DMTs due to insurance denial was low, the absolute number of participants was 80, which is relatively high,” Dr. Wang, a research fellow at NARCOMS, said in an interview. “We don’t consider that a small number. The free or discounted drug programs helped a lot of participants obtain DMTs at the relatively early stage of their disease, even those with health insurance. On the other hand, 77.7% of those who were not to taking DMTs had a median Patient Determined Disease Steps of 4, indicating a higher level of disability (using a cane or walking aid) and more likely at a later stage of the disease course. For some of these participants, they may have entered a secondary progressive phase, where there are limited options for DMTs. The contrast between these two groups of participants showed that the free or discounted drug programs not only helped them get access to DMTs, but seemingly also helped them to get DMTs earlier, and thus maximized the benefits of DMTs.”
Of the 398 (6%) respondents who changed their DMT over the 1-year time period studied, nearly half did so for insurance-related reasons, including denial by the insurer (22.4%), higher copay resulting in a decision to skip or split DMTs (12.8%), insurance change (8.3%), and higher copay resulting in a change of DMT (4.3%).
“It’s important for neurologists to know that while their patients are likely to have insurance, a deeper discussion on how they’re going to get their medications covered is warranted,” Stacey Cofield, Ph.D., deputy director of the NARCOMS Coordinating Center, based at the University of Alabama at Birmingham, said in an interview.
In a separate abstract presented at the meeting, Dr. Cofield and her associates reported results from the same Fall 2014 Update survey of 7,601 NARCOMS participants who addressed questions about their DMT status, changes to their DMTs, and how the decision to switch or continue was made. The researchers found that 42.8% of respondents shared decision making with their physicians or spoke with their physicians prior to making a treatment decision (38.8%). They also found that patients currently on a DMT were more likely to engage in shared decision making, compared with those who were not on a DMT (47.4% vs. 33.5%; P < .0001). Patient-centered decision making increased with current worse PDDS (P < .0001).
According to Amber Salter, Ph.D., of NARCOMS, about 3% of MS patients switch DMTs within a 6-month period (Patient Prefer. Adherence 2014:8 971-9), a number that has been increasing in recent years for a variety of reasons. For example, a patient may want to switch from an injectable agent to an oral medication out of perceived convenience, not realizing that being on the oral agent may involve an increased number of office visits for blood testing during treatment, she said.
Difficulty can arise when the patient and the physician both agree on a DMT switch, but the patient’s health insurer says no. “The clinician’s best judgment is, ‘I’ve seen the MRI. There’s activity in the brain. I want to change to a different medication.’ But the insurance company says, ‘You don’t meet our criteria,’ ” said Gary R. Cutter, Ph.D., director of the NARCOMS Coordinating Center. “The patient doesn’t know what to do. The physician can fight [that decision by the insurer], can get involved in that battle. But that’s a different battle that not all physicians have the resources around to tackle. It can be a hassle for both the patient and physician.”
Dr. Cutter noted that MS patients who switch DMTs tend to do worse from a clinical standpoint. “If you look cross-sectionally at data, people who have switched end up with higher levels of disability, and it’s because the physician is reacting to something; it’s not that the drug they switched to is bad,” he said. “These drugs are not cures. They’re meant to slow the progression [of MS].”
NARCOMS is supported by the CMSC and the Foundation of the CMSC. Genentech provided additional support for the survey of treatment decision making. Dr. Cutter disclosed ties to several pharmaceutical companies. The other researchers stated that they had no financial conflicts to disclose.
On Twitter @dougbrunk
INDIANAPOLIS – Although nearly all patients with multiple sclerosis have some form of insurance, 25% of them receive some form of assistance from the pharmaceutical industry in covering the cost of their disease-modifying therapies. In addition, 22% report that their health insurance coverage worsened compared with the prior year.
Those are key findings from a fall 2014 survey of the North American Research Consortium on MS (NARCOMS), a registry with self-reported information on disease-modifying therapies (DMTs), including type, duration of use, changes and reasons for changes, as well as income, insurance, and disease status.
At the annual meeting of the Consortium of Multiple Sclerosis Centers, Guoqiao Wang, Ph.D., and his associates reported findings based on 6,662 (88%) of 7,601 NARCOMS participants who completed the Fall 2014 NARCOMS Update survey, including questions about their health insurance status and DMT choices related to insurance. Of those 6,662 respondents, 99% reported being insured in the prior 6 months, 69% reported that their insurance coverage was unchanged compared with the prior year, and 22% said that their insurance coverage worsened compared with the prior year.
Of the 4,156 (62.4%) respondents who were taking DMTs at the time of the survey, the following financial resources were used to pay for the agents: health insurance copay only (52.1%), free or discounted drug programs (25%), full coverage by health insurance (22.2%), and full payment by the patient (0.7%). Most of those who received assistance from free or discounted drug programs were female (86%), have had their disease for a mean of 7.6 years, tended to have the relapsing-remitting form of MS (71%), and had a median Patient Determined Disease Step of 3 (Gait Disability), suggesting a lower level of disability and most likely an earlier stage of the disease course.
Of the 2,108 (31.6%) respondents who were not taking DMTs, 77.7% did so by their own choice, 14.5% did so on physician recommendation, 3.8% did so because of insurance denial, 2.7% did so because of a higher copay, and 1.3% because of having no insurance.
“Although the proportion of participants who did not take DMTs due to insurance denial was low, the absolute number of participants was 80, which is relatively high,” Dr. Wang, a research fellow at NARCOMS, said in an interview. “We don’t consider that a small number. The free or discounted drug programs helped a lot of participants obtain DMTs at the relatively early stage of their disease, even those with health insurance. On the other hand, 77.7% of those who were not to taking DMTs had a median Patient Determined Disease Steps of 4, indicating a higher level of disability (using a cane or walking aid) and more likely at a later stage of the disease course. For some of these participants, they may have entered a secondary progressive phase, where there are limited options for DMTs. The contrast between these two groups of participants showed that the free or discounted drug programs not only helped them get access to DMTs, but seemingly also helped them to get DMTs earlier, and thus maximized the benefits of DMTs.”
Of the 398 (6%) respondents who changed their DMT over the 1-year time period studied, nearly half did so for insurance-related reasons, including denial by the insurer (22.4%), higher copay resulting in a decision to skip or split DMTs (12.8%), insurance change (8.3%), and higher copay resulting in a change of DMT (4.3%).
“It’s important for neurologists to know that while their patients are likely to have insurance, a deeper discussion on how they’re going to get their medications covered is warranted,” Stacey Cofield, Ph.D., deputy director of the NARCOMS Coordinating Center, based at the University of Alabama at Birmingham, said in an interview.
In a separate abstract presented at the meeting, Dr. Cofield and her associates reported results from the same Fall 2014 Update survey of 7,601 NARCOMS participants who addressed questions about their DMT status, changes to their DMTs, and how the decision to switch or continue was made. The researchers found that 42.8% of respondents shared decision making with their physicians or spoke with their physicians prior to making a treatment decision (38.8%). They also found that patients currently on a DMT were more likely to engage in shared decision making, compared with those who were not on a DMT (47.4% vs. 33.5%; P < .0001). Patient-centered decision making increased with current worse PDDS (P < .0001).
According to Amber Salter, Ph.D., of NARCOMS, about 3% of MS patients switch DMTs within a 6-month period (Patient Prefer. Adherence 2014:8 971-9), a number that has been increasing in recent years for a variety of reasons. For example, a patient may want to switch from an injectable agent to an oral medication out of perceived convenience, not realizing that being on the oral agent may involve an increased number of office visits for blood testing during treatment, she said.
Difficulty can arise when the patient and the physician both agree on a DMT switch, but the patient’s health insurer says no. “The clinician’s best judgment is, ‘I’ve seen the MRI. There’s activity in the brain. I want to change to a different medication.’ But the insurance company says, ‘You don’t meet our criteria,’ ” said Gary R. Cutter, Ph.D., director of the NARCOMS Coordinating Center. “The patient doesn’t know what to do. The physician can fight [that decision by the insurer], can get involved in that battle. But that’s a different battle that not all physicians have the resources around to tackle. It can be a hassle for both the patient and physician.”
Dr. Cutter noted that MS patients who switch DMTs tend to do worse from a clinical standpoint. “If you look cross-sectionally at data, people who have switched end up with higher levels of disability, and it’s because the physician is reacting to something; it’s not that the drug they switched to is bad,” he said. “These drugs are not cures. They’re meant to slow the progression [of MS].”
NARCOMS is supported by the CMSC and the Foundation of the CMSC. Genentech provided additional support for the survey of treatment decision making. Dr. Cutter disclosed ties to several pharmaceutical companies. The other researchers stated that they had no financial conflicts to disclose.
On Twitter @dougbrunk
INDIANAPOLIS – Although nearly all patients with multiple sclerosis have some form of insurance, 25% of them receive some form of assistance from the pharmaceutical industry in covering the cost of their disease-modifying therapies. In addition, 22% report that their health insurance coverage worsened compared with the prior year.
Those are key findings from a fall 2014 survey of the North American Research Consortium on MS (NARCOMS), a registry with self-reported information on disease-modifying therapies (DMTs), including type, duration of use, changes and reasons for changes, as well as income, insurance, and disease status.
At the annual meeting of the Consortium of Multiple Sclerosis Centers, Guoqiao Wang, Ph.D., and his associates reported findings based on 6,662 (88%) of 7,601 NARCOMS participants who completed the Fall 2014 NARCOMS Update survey, including questions about their health insurance status and DMT choices related to insurance. Of those 6,662 respondents, 99% reported being insured in the prior 6 months, 69% reported that their insurance coverage was unchanged compared with the prior year, and 22% said that their insurance coverage worsened compared with the prior year.
Of the 4,156 (62.4%) respondents who were taking DMTs at the time of the survey, the following financial resources were used to pay for the agents: health insurance copay only (52.1%), free or discounted drug programs (25%), full coverage by health insurance (22.2%), and full payment by the patient (0.7%). Most of those who received assistance from free or discounted drug programs were female (86%), have had their disease for a mean of 7.6 years, tended to have the relapsing-remitting form of MS (71%), and had a median Patient Determined Disease Step of 3 (Gait Disability), suggesting a lower level of disability and most likely an earlier stage of the disease course.
Of the 2,108 (31.6%) respondents who were not taking DMTs, 77.7% did so by their own choice, 14.5% did so on physician recommendation, 3.8% did so because of insurance denial, 2.7% did so because of a higher copay, and 1.3% because of having no insurance.
“Although the proportion of participants who did not take DMTs due to insurance denial was low, the absolute number of participants was 80, which is relatively high,” Dr. Wang, a research fellow at NARCOMS, said in an interview. “We don’t consider that a small number. The free or discounted drug programs helped a lot of participants obtain DMTs at the relatively early stage of their disease, even those with health insurance. On the other hand, 77.7% of those who were not to taking DMTs had a median Patient Determined Disease Steps of 4, indicating a higher level of disability (using a cane or walking aid) and more likely at a later stage of the disease course. For some of these participants, they may have entered a secondary progressive phase, where there are limited options for DMTs. The contrast between these two groups of participants showed that the free or discounted drug programs not only helped them get access to DMTs, but seemingly also helped them to get DMTs earlier, and thus maximized the benefits of DMTs.”
Of the 398 (6%) respondents who changed their DMT over the 1-year time period studied, nearly half did so for insurance-related reasons, including denial by the insurer (22.4%), higher copay resulting in a decision to skip or split DMTs (12.8%), insurance change (8.3%), and higher copay resulting in a change of DMT (4.3%).
“It’s important for neurologists to know that while their patients are likely to have insurance, a deeper discussion on how they’re going to get their medications covered is warranted,” Stacey Cofield, Ph.D., deputy director of the NARCOMS Coordinating Center, based at the University of Alabama at Birmingham, said in an interview.
In a separate abstract presented at the meeting, Dr. Cofield and her associates reported results from the same Fall 2014 Update survey of 7,601 NARCOMS participants who addressed questions about their DMT status, changes to their DMTs, and how the decision to switch or continue was made. The researchers found that 42.8% of respondents shared decision making with their physicians or spoke with their physicians prior to making a treatment decision (38.8%). They also found that patients currently on a DMT were more likely to engage in shared decision making, compared with those who were not on a DMT (47.4% vs. 33.5%; P < .0001). Patient-centered decision making increased with current worse PDDS (P < .0001).
According to Amber Salter, Ph.D., of NARCOMS, about 3% of MS patients switch DMTs within a 6-month period (Patient Prefer. Adherence 2014:8 971-9), a number that has been increasing in recent years for a variety of reasons. For example, a patient may want to switch from an injectable agent to an oral medication out of perceived convenience, not realizing that being on the oral agent may involve an increased number of office visits for blood testing during treatment, she said.
Difficulty can arise when the patient and the physician both agree on a DMT switch, but the patient’s health insurer says no. “The clinician’s best judgment is, ‘I’ve seen the MRI. There’s activity in the brain. I want to change to a different medication.’ But the insurance company says, ‘You don’t meet our criteria,’ ” said Gary R. Cutter, Ph.D., director of the NARCOMS Coordinating Center. “The patient doesn’t know what to do. The physician can fight [that decision by the insurer], can get involved in that battle. But that’s a different battle that not all physicians have the resources around to tackle. It can be a hassle for both the patient and physician.”
Dr. Cutter noted that MS patients who switch DMTs tend to do worse from a clinical standpoint. “If you look cross-sectionally at data, people who have switched end up with higher levels of disability, and it’s because the physician is reacting to something; it’s not that the drug they switched to is bad,” he said. “These drugs are not cures. They’re meant to slow the progression [of MS].”
NARCOMS is supported by the CMSC and the Foundation of the CMSC. Genentech provided additional support for the survey of treatment decision making. Dr. Cutter disclosed ties to several pharmaceutical companies. The other researchers stated that they had no financial conflicts to disclose.
On Twitter @dougbrunk
AT THE CMSC ANNUAL MEETING
Key clinical point: Free or discounted drug programs helped 25% of MS patients obtain DMTs.
Major finding: Among MS patients who were taking DMTs at the time of a survey, the following financial resources were used to pay for the agents: health insurance copay only (52.1%), free or discounted drug programs (25%), full health insurance coverage (22.2%), or full payment by the patient (0.7%).
Data source: Responses from 6,662 of 7,601 North American Research Consortium on MS (NARCOMS) participants who completed the Fall 2014 NARCOMS Update survey.
Disclosures: NARCOMS is supported by the Consortium of Multiple Sclerosis Centers (CMSC) and the Foundation of the CMSC. Genentech provided additional support for the survey of treatment decision making. Dr. Cutter disclosed ties to several pharmaceutical companies. The other researchers stated that they had no financial conflicts to disclose.
CMSC: Many menopausal and MS symptoms overlap
INDIANAPOLIS – About 50% of women with multiple sclerosis are postmenopausal, but objective data about the impact of menopause on the course of multiple sclerosis are lacking.
“We don’t know anything about the impact of menopause on the MS course; there is wide variability in patient-reported outcomes, but nothing written about comorbidities or symptom management,” Dr. Riley Bove, a neurologist at Brigham and Women’s Hospital, Boston, said at the annual meeting of the Consortium of Multiple Sclerosis Centers. “We’ve been working on this. A lot of it is unknown.”
She described menopause is “an opportunity for providers to tackle symptoms and improve well-being and discuss meaningful quality of life and priorities with patients. It can be a good time to talk about these things.”
In a study that Dr. Bove conducted with the online patient-powered research platform PatientsLikeMe, female MS patients were asked to describe the impact of menopause on their disease. Among the themes that emerged were an occasional perimenopausal onset of MS (“menopause and MS symptoms were pretty much simultaneous,” one 58-year-old respondent said); the effect of hot flashes on MS symptoms (“I confused the two, especially hot flashes,” said a 53-year-old woman); and worsening of MS-related disability after menopause, particularly surgical (“Before I stopped taking birth control pills I was working and able to walk and house clean , etc.,” a 53-year-old respondent said. “I had the surgery, and I started to progress toward being completely wheelchair bound.”)
When it comes to solid recommendations for how to manage MS symptoms that overlap with menopause, “we’re in an evidence-free zone,” Dr. Bove said. “Symptoms in MS are kind of like dominoes: You have difficulty sleeping and then your day is off, fatigue is up and your mood is off, and everything can spiral. In the clinic, perimenopausal women often say things like, ‘I feel like I’m falling apart’ or ‘something has to give’ or ‘I need a change.’ ”
Common overlapping symptoms include vasomotor manifestations such as hot flashes, cold flashes, vascular instability, and rapid heartbeat. “The leading mechanistic explanation for the vasomotor symptoms is that abrupt hormone deprivation will result in the loss of negative feedback over hypothalamic NA [noradrenaline] synthesis,” Dr. Bove explained. “The proximity of the hypothalamic thermoregulatory center to luteinizing hormone–releasing hormone-producing areas may also be involved.”
Sleep disturbances and insomnia in menopausal MS patients can impact fatigue and mood. Also, hot flashes can directly exacerbate the MS symptoms, fluctuating over the day or the week.
According to recommendations from the North American Menopause Society, estradiol is the most effective therapy for treating vasomotor symptoms. Other options include selective serotonin reuptake inhibitors (SSRIs) and selective noradrenergic reuptake inhibitors (SNRIs). “Probably the best studied SNRI is venlafaxine,” Dr. Bove said. “It seems to have modest effects on sleep quality and insomnia perimenopausally, as well as on hot flashes.”
Other alternatives include clonidine and gabapentin.
“If a patient wants to use [hormone therapy] for menopausal symptoms, it has to be an individualized approach,” Dr. Bove said. “You have to communicate with the primary care physician to understand what else is going on in this woman’s medical history. The current recommendations are to treat the symptoms with as low a dose as possible for as short a duration as possible. Our MS patients are also at risk for neurodegeneration, for brain volume loss, for cognitive decline, and for worsening function over time.”
With respect to cognition, observational studies have demonstrated that during a certain window of opportunity – defined as within 5 years of the last menstrual period – hormone therapy (HT) may have protective effects against Alzheimer’s disease and against cognitive decline in general. “Beyond this window of time, perhaps due to estrogen receptor down regulation, HT can be harmful, with an increased risk of stroke and dementia reported later on,” she said.
Against this, the Women’s Health Initiative Memory Study (WHIMS) looked at unopposed estrogen, and estrogen and progestin combination, compared with placebo. It found that in women who initiated HT at the age of 65 or older faced an increased risk of dementia from any cause, and of cognitive decline. “This study really put the kibosh on HT as a form of neuroprotection,” Dr. Bove said. “But perhaps it’s unfair to the many patients who are at risk for cognitive decline and neurodegeneration, because the WHIMS did not find an increased risk of adverse cognitive events in women in whom HT was started perimenopausally. Longitudinal, placebo-controlled trials of the effects of HT within the window of opportunity are required to either prove or refute the observational studies that already exist that suggest HT may be neuroprotective. This is an important point to discuss with patients.”
The impact of perimenopausal sleep disturbance on MS symptoms also is unknown. A practical approach to managing sleep disturbance in perimenopausal MS patients is to identify and assess the triggers. “If the bladder symptoms are the major trigger versus mood disturbances such as depression and anxiety, the intervention will be different,” she said. “Consider counseling and/or consultation with a sleep specialist.” Some patients may benefit from pharmacologic treatment to “get them over the hump and get them sleeping better for a little while, versus longer term management if they have a life history of insomnia,” she said. “If the problem is sleep management, you’ll need a drug with a longer half-life. Consider other comorbidities such as anxiety and restless leg syndrome.” Classes of medications to consider include benzodiazepines, nonbenzodiazepines, tricyclic antidepressants, SSRIs and SNRIs.
Mood symptoms commonly overlap in menopausal patients with MS, especially those related to depression and anxiety. “They may be underdiagnosed and undertreated,” Dr. Bove said. “It’s been shown that depression influences the perceived severity of other MS symptoms. Depression is a strong predictor of cognitive and sexual dysfunction, so our perimenopausal MS women have a vulnerability to more severe mood symptoms.” Managing mood symptoms “needs to be multifaceted” and may include psychotherapy to optimize coping abilities, antidepressants, support groups, fatigue and sleep optimization, and social work “to see how employment or financial stressors may be playing a role in a person’s mood.”
In addition, menopausal women may report changes in attention, executive function, multitasking, word finding difficulties, and memory problems, especially in the first year after the final menstrual period. “It’s known that about half of MS patients experience some degree of cognitive impairment,” she said. “Neurocognitive testing may help to identify particular areas of dysfunction that would be amenable to some kind of cognitive rehabilitation.”
Bladder symptoms also can impact postmenopausal patients, especially increasing bladder irritability and incontinence (stress and urge). In MS, “the baseline bladder dysfunction may be magnified,” Dr. Bove said. “If you’re trying to tease out whether the postmenopausal bladder symptoms are from menopause or MS, the MS relapses tend to have more urgency, frequency, and urge incontinence, and the presentation will be more acute. Urodynamic testing can be used to tease this out. The big lifestyle piece that urologists like to hone in on is that people in America drink too much fluid. A practical guideline is that after 3 p.m. just drink for thirst; don’t worry that everything will fall apart if you don’t get your eight glasses of water per day in. If you’re not thirsty, you probably don’t need it.”
While postmenopausal women face an increased risk for osteoporosis, that risk is magnified for MS patients because of the cumulative effect of steroid use – particularly for those who were diagnosed in the pre–disease-modifying-therapy era – being sedentary, and being deconditioned. “Other MS issues such as balance, vision problems, strength or cognitive impairments may all impact gait and compound the risk of falls,” Dr. Bove said. “Osteoporosis prevention and screening should be encouraged in these patients.”
Dr. Bove concluded her presentation by noting that in general, women with disabilities are less likely to be up to date on Pap tests, mammograms, and other important preventive screening tests. “The magnitude of disparities is greater for women with complex limitations,” she said. “Women with MS may have a lower cancer risk, but a larger tumor size at diagnosis.” For example, “is this because the patient is uncomfortable getting on an exam table to get a Pap smear, or is the physician not thinking about other aspects of the person’s life because the focus is on the MS?”
Dr. Bove disclosed that she has received funding from the National Multiple Sclerosis Society, the National Institutes of Health, and from the Harvard Clinical Investigator Training Program.
On Twitter @dougbrunk
INDIANAPOLIS – About 50% of women with multiple sclerosis are postmenopausal, but objective data about the impact of menopause on the course of multiple sclerosis are lacking.
“We don’t know anything about the impact of menopause on the MS course; there is wide variability in patient-reported outcomes, but nothing written about comorbidities or symptom management,” Dr. Riley Bove, a neurologist at Brigham and Women’s Hospital, Boston, said at the annual meeting of the Consortium of Multiple Sclerosis Centers. “We’ve been working on this. A lot of it is unknown.”
She described menopause is “an opportunity for providers to tackle symptoms and improve well-being and discuss meaningful quality of life and priorities with patients. It can be a good time to talk about these things.”
In a study that Dr. Bove conducted with the online patient-powered research platform PatientsLikeMe, female MS patients were asked to describe the impact of menopause on their disease. Among the themes that emerged were an occasional perimenopausal onset of MS (“menopause and MS symptoms were pretty much simultaneous,” one 58-year-old respondent said); the effect of hot flashes on MS symptoms (“I confused the two, especially hot flashes,” said a 53-year-old woman); and worsening of MS-related disability after menopause, particularly surgical (“Before I stopped taking birth control pills I was working and able to walk and house clean , etc.,” a 53-year-old respondent said. “I had the surgery, and I started to progress toward being completely wheelchair bound.”)
When it comes to solid recommendations for how to manage MS symptoms that overlap with menopause, “we’re in an evidence-free zone,” Dr. Bove said. “Symptoms in MS are kind of like dominoes: You have difficulty sleeping and then your day is off, fatigue is up and your mood is off, and everything can spiral. In the clinic, perimenopausal women often say things like, ‘I feel like I’m falling apart’ or ‘something has to give’ or ‘I need a change.’ ”
Common overlapping symptoms include vasomotor manifestations such as hot flashes, cold flashes, vascular instability, and rapid heartbeat. “The leading mechanistic explanation for the vasomotor symptoms is that abrupt hormone deprivation will result in the loss of negative feedback over hypothalamic NA [noradrenaline] synthesis,” Dr. Bove explained. “The proximity of the hypothalamic thermoregulatory center to luteinizing hormone–releasing hormone-producing areas may also be involved.”
Sleep disturbances and insomnia in menopausal MS patients can impact fatigue and mood. Also, hot flashes can directly exacerbate the MS symptoms, fluctuating over the day or the week.
According to recommendations from the North American Menopause Society, estradiol is the most effective therapy for treating vasomotor symptoms. Other options include selective serotonin reuptake inhibitors (SSRIs) and selective noradrenergic reuptake inhibitors (SNRIs). “Probably the best studied SNRI is venlafaxine,” Dr. Bove said. “It seems to have modest effects on sleep quality and insomnia perimenopausally, as well as on hot flashes.”
Other alternatives include clonidine and gabapentin.
“If a patient wants to use [hormone therapy] for menopausal symptoms, it has to be an individualized approach,” Dr. Bove said. “You have to communicate with the primary care physician to understand what else is going on in this woman’s medical history. The current recommendations are to treat the symptoms with as low a dose as possible for as short a duration as possible. Our MS patients are also at risk for neurodegeneration, for brain volume loss, for cognitive decline, and for worsening function over time.”
With respect to cognition, observational studies have demonstrated that during a certain window of opportunity – defined as within 5 years of the last menstrual period – hormone therapy (HT) may have protective effects against Alzheimer’s disease and against cognitive decline in general. “Beyond this window of time, perhaps due to estrogen receptor down regulation, HT can be harmful, with an increased risk of stroke and dementia reported later on,” she said.
Against this, the Women’s Health Initiative Memory Study (WHIMS) looked at unopposed estrogen, and estrogen and progestin combination, compared with placebo. It found that in women who initiated HT at the age of 65 or older faced an increased risk of dementia from any cause, and of cognitive decline. “This study really put the kibosh on HT as a form of neuroprotection,” Dr. Bove said. “But perhaps it’s unfair to the many patients who are at risk for cognitive decline and neurodegeneration, because the WHIMS did not find an increased risk of adverse cognitive events in women in whom HT was started perimenopausally. Longitudinal, placebo-controlled trials of the effects of HT within the window of opportunity are required to either prove or refute the observational studies that already exist that suggest HT may be neuroprotective. This is an important point to discuss with patients.”
The impact of perimenopausal sleep disturbance on MS symptoms also is unknown. A practical approach to managing sleep disturbance in perimenopausal MS patients is to identify and assess the triggers. “If the bladder symptoms are the major trigger versus mood disturbances such as depression and anxiety, the intervention will be different,” she said. “Consider counseling and/or consultation with a sleep specialist.” Some patients may benefit from pharmacologic treatment to “get them over the hump and get them sleeping better for a little while, versus longer term management if they have a life history of insomnia,” she said. “If the problem is sleep management, you’ll need a drug with a longer half-life. Consider other comorbidities such as anxiety and restless leg syndrome.” Classes of medications to consider include benzodiazepines, nonbenzodiazepines, tricyclic antidepressants, SSRIs and SNRIs.
Mood symptoms commonly overlap in menopausal patients with MS, especially those related to depression and anxiety. “They may be underdiagnosed and undertreated,” Dr. Bove said. “It’s been shown that depression influences the perceived severity of other MS symptoms. Depression is a strong predictor of cognitive and sexual dysfunction, so our perimenopausal MS women have a vulnerability to more severe mood symptoms.” Managing mood symptoms “needs to be multifaceted” and may include psychotherapy to optimize coping abilities, antidepressants, support groups, fatigue and sleep optimization, and social work “to see how employment or financial stressors may be playing a role in a person’s mood.”
In addition, menopausal women may report changes in attention, executive function, multitasking, word finding difficulties, and memory problems, especially in the first year after the final menstrual period. “It’s known that about half of MS patients experience some degree of cognitive impairment,” she said. “Neurocognitive testing may help to identify particular areas of dysfunction that would be amenable to some kind of cognitive rehabilitation.”
Bladder symptoms also can impact postmenopausal patients, especially increasing bladder irritability and incontinence (stress and urge). In MS, “the baseline bladder dysfunction may be magnified,” Dr. Bove said. “If you’re trying to tease out whether the postmenopausal bladder symptoms are from menopause or MS, the MS relapses tend to have more urgency, frequency, and urge incontinence, and the presentation will be more acute. Urodynamic testing can be used to tease this out. The big lifestyle piece that urologists like to hone in on is that people in America drink too much fluid. A practical guideline is that after 3 p.m. just drink for thirst; don’t worry that everything will fall apart if you don’t get your eight glasses of water per day in. If you’re not thirsty, you probably don’t need it.”
While postmenopausal women face an increased risk for osteoporosis, that risk is magnified for MS patients because of the cumulative effect of steroid use – particularly for those who were diagnosed in the pre–disease-modifying-therapy era – being sedentary, and being deconditioned. “Other MS issues such as balance, vision problems, strength or cognitive impairments may all impact gait and compound the risk of falls,” Dr. Bove said. “Osteoporosis prevention and screening should be encouraged in these patients.”
Dr. Bove concluded her presentation by noting that in general, women with disabilities are less likely to be up to date on Pap tests, mammograms, and other important preventive screening tests. “The magnitude of disparities is greater for women with complex limitations,” she said. “Women with MS may have a lower cancer risk, but a larger tumor size at diagnosis.” For example, “is this because the patient is uncomfortable getting on an exam table to get a Pap smear, or is the physician not thinking about other aspects of the person’s life because the focus is on the MS?”
Dr. Bove disclosed that she has received funding from the National Multiple Sclerosis Society, the National Institutes of Health, and from the Harvard Clinical Investigator Training Program.
On Twitter @dougbrunk
INDIANAPOLIS – About 50% of women with multiple sclerosis are postmenopausal, but objective data about the impact of menopause on the course of multiple sclerosis are lacking.
“We don’t know anything about the impact of menopause on the MS course; there is wide variability in patient-reported outcomes, but nothing written about comorbidities or symptom management,” Dr. Riley Bove, a neurologist at Brigham and Women’s Hospital, Boston, said at the annual meeting of the Consortium of Multiple Sclerosis Centers. “We’ve been working on this. A lot of it is unknown.”
She described menopause is “an opportunity for providers to tackle symptoms and improve well-being and discuss meaningful quality of life and priorities with patients. It can be a good time to talk about these things.”
In a study that Dr. Bove conducted with the online patient-powered research platform PatientsLikeMe, female MS patients were asked to describe the impact of menopause on their disease. Among the themes that emerged were an occasional perimenopausal onset of MS (“menopause and MS symptoms were pretty much simultaneous,” one 58-year-old respondent said); the effect of hot flashes on MS symptoms (“I confused the two, especially hot flashes,” said a 53-year-old woman); and worsening of MS-related disability after menopause, particularly surgical (“Before I stopped taking birth control pills I was working and able to walk and house clean , etc.,” a 53-year-old respondent said. “I had the surgery, and I started to progress toward being completely wheelchair bound.”)
When it comes to solid recommendations for how to manage MS symptoms that overlap with menopause, “we’re in an evidence-free zone,” Dr. Bove said. “Symptoms in MS are kind of like dominoes: You have difficulty sleeping and then your day is off, fatigue is up and your mood is off, and everything can spiral. In the clinic, perimenopausal women often say things like, ‘I feel like I’m falling apart’ or ‘something has to give’ or ‘I need a change.’ ”
Common overlapping symptoms include vasomotor manifestations such as hot flashes, cold flashes, vascular instability, and rapid heartbeat. “The leading mechanistic explanation for the vasomotor symptoms is that abrupt hormone deprivation will result in the loss of negative feedback over hypothalamic NA [noradrenaline] synthesis,” Dr. Bove explained. “The proximity of the hypothalamic thermoregulatory center to luteinizing hormone–releasing hormone-producing areas may also be involved.”
Sleep disturbances and insomnia in menopausal MS patients can impact fatigue and mood. Also, hot flashes can directly exacerbate the MS symptoms, fluctuating over the day or the week.
According to recommendations from the North American Menopause Society, estradiol is the most effective therapy for treating vasomotor symptoms. Other options include selective serotonin reuptake inhibitors (SSRIs) and selective noradrenergic reuptake inhibitors (SNRIs). “Probably the best studied SNRI is venlafaxine,” Dr. Bove said. “It seems to have modest effects on sleep quality and insomnia perimenopausally, as well as on hot flashes.”
Other alternatives include clonidine and gabapentin.
“If a patient wants to use [hormone therapy] for menopausal symptoms, it has to be an individualized approach,” Dr. Bove said. “You have to communicate with the primary care physician to understand what else is going on in this woman’s medical history. The current recommendations are to treat the symptoms with as low a dose as possible for as short a duration as possible. Our MS patients are also at risk for neurodegeneration, for brain volume loss, for cognitive decline, and for worsening function over time.”
With respect to cognition, observational studies have demonstrated that during a certain window of opportunity – defined as within 5 years of the last menstrual period – hormone therapy (HT) may have protective effects against Alzheimer’s disease and against cognitive decline in general. “Beyond this window of time, perhaps due to estrogen receptor down regulation, HT can be harmful, with an increased risk of stroke and dementia reported later on,” she said.
Against this, the Women’s Health Initiative Memory Study (WHIMS) looked at unopposed estrogen, and estrogen and progestin combination, compared with placebo. It found that in women who initiated HT at the age of 65 or older faced an increased risk of dementia from any cause, and of cognitive decline. “This study really put the kibosh on HT as a form of neuroprotection,” Dr. Bove said. “But perhaps it’s unfair to the many patients who are at risk for cognitive decline and neurodegeneration, because the WHIMS did not find an increased risk of adverse cognitive events in women in whom HT was started perimenopausally. Longitudinal, placebo-controlled trials of the effects of HT within the window of opportunity are required to either prove or refute the observational studies that already exist that suggest HT may be neuroprotective. This is an important point to discuss with patients.”
The impact of perimenopausal sleep disturbance on MS symptoms also is unknown. A practical approach to managing sleep disturbance in perimenopausal MS patients is to identify and assess the triggers. “If the bladder symptoms are the major trigger versus mood disturbances such as depression and anxiety, the intervention will be different,” she said. “Consider counseling and/or consultation with a sleep specialist.” Some patients may benefit from pharmacologic treatment to “get them over the hump and get them sleeping better for a little while, versus longer term management if they have a life history of insomnia,” she said. “If the problem is sleep management, you’ll need a drug with a longer half-life. Consider other comorbidities such as anxiety and restless leg syndrome.” Classes of medications to consider include benzodiazepines, nonbenzodiazepines, tricyclic antidepressants, SSRIs and SNRIs.
Mood symptoms commonly overlap in menopausal patients with MS, especially those related to depression and anxiety. “They may be underdiagnosed and undertreated,” Dr. Bove said. “It’s been shown that depression influences the perceived severity of other MS symptoms. Depression is a strong predictor of cognitive and sexual dysfunction, so our perimenopausal MS women have a vulnerability to more severe mood symptoms.” Managing mood symptoms “needs to be multifaceted” and may include psychotherapy to optimize coping abilities, antidepressants, support groups, fatigue and sleep optimization, and social work “to see how employment or financial stressors may be playing a role in a person’s mood.”
In addition, menopausal women may report changes in attention, executive function, multitasking, word finding difficulties, and memory problems, especially in the first year after the final menstrual period. “It’s known that about half of MS patients experience some degree of cognitive impairment,” she said. “Neurocognitive testing may help to identify particular areas of dysfunction that would be amenable to some kind of cognitive rehabilitation.”
Bladder symptoms also can impact postmenopausal patients, especially increasing bladder irritability and incontinence (stress and urge). In MS, “the baseline bladder dysfunction may be magnified,” Dr. Bove said. “If you’re trying to tease out whether the postmenopausal bladder symptoms are from menopause or MS, the MS relapses tend to have more urgency, frequency, and urge incontinence, and the presentation will be more acute. Urodynamic testing can be used to tease this out. The big lifestyle piece that urologists like to hone in on is that people in America drink too much fluid. A practical guideline is that after 3 p.m. just drink for thirst; don’t worry that everything will fall apart if you don’t get your eight glasses of water per day in. If you’re not thirsty, you probably don’t need it.”
While postmenopausal women face an increased risk for osteoporosis, that risk is magnified for MS patients because of the cumulative effect of steroid use – particularly for those who were diagnosed in the pre–disease-modifying-therapy era – being sedentary, and being deconditioned. “Other MS issues such as balance, vision problems, strength or cognitive impairments may all impact gait and compound the risk of falls,” Dr. Bove said. “Osteoporosis prevention and screening should be encouraged in these patients.”
Dr. Bove concluded her presentation by noting that in general, women with disabilities are less likely to be up to date on Pap tests, mammograms, and other important preventive screening tests. “The magnitude of disparities is greater for women with complex limitations,” she said. “Women with MS may have a lower cancer risk, but a larger tumor size at diagnosis.” For example, “is this because the patient is uncomfortable getting on an exam table to get a Pap smear, or is the physician not thinking about other aspects of the person’s life because the focus is on the MS?”
Dr. Bove disclosed that she has received funding from the National Multiple Sclerosis Society, the National Institutes of Health, and from the Harvard Clinical Investigator Training Program.
On Twitter @dougbrunk
EXPERT ANALYSIS AT THE CMSC ANNUAL MEETING
Expert: Don’t discourage pregnancy in MS patients; manage it
INDIANAPOLIS – If you feel overwhelmed by the notion of managing multiple sclerosis patients who seek your guidance in navigating their pregnancy, you’re not alone.
Comprehensive management programs for pregnant MS patients currently do not exist, even within most dedicated MS centers and clinics, Dr. Maria K. Houtchens said at the annual meeting of the Consortium of Multiple Sclerosis Centers.
“Individual providers have an interest in this area, but there are no guidelines for most physicians or nurse practitioners to follow yet,” she said. “The level of care these patients receive varies dramatically, from one part of the country to another and from one provider to the next.”
An estimated 50% of all pregnancies in the United States and about 40% of all pregnancies worldwide are unplanned.
“I believe that women with MS should receive support and counseling from their MS specialist on issues about possible pregnancy,” said Dr. Houtchens, a neurologist who directs the Women’s Health Program at the Partners MS Center at Brigham and Women’s Hospital, Boston. “I believe that we should all feel comfortable discussing with our patients the effects of pregnancy on their MS course and the reciprocal effect on pregnancy outcomes of their disease, the genetic risk of disease in their offspring, and optimal conception timing. We need to be able to talk to them freely about disease control before, during, and after pregnancy.”
Dr. Houtchens, one of the authors of a recent multinational systematic review on the topic noted that increasing numbers of MS patients with stable disease are choosing not to become pregnant (Obstet. Gynecol. 2014;124:1157-68). Others “want to get pregnant and feel cheated out of their life goal,” she said.
A large survey of female patients with MS from Canada found that more than three-quarters had not become pregnant since being diagnosed with the disease. The most common contributing factor across both MS-related and non–MS-related categories was completion of families prior to an MS diagnosis (53%). The top MS-related reasons that contributed to not having children were symptoms interfering with parenting, burdening the partner, and finances (Mult. Scler. 2013;19:351-8).
“It’s only in the last 2-3 decades that this issue has come to the forefront in caring for MS patients,” she said. “Previous to that, a lot of colleagues would discourage patients from becoming pregnant. Some of those attitudes persist to this day. There’s a perception of disapproval from health care providers on the part of the patient, and from their family and peers, and historic misconceptions. Our goal as physicians is to help women live lives to their fullest potential with a disease that can’t be cured. We should not discourage our patients from becoming pregnant.”
To optimize chances of conception, she recommended that oral contraceptives be stopped 2-3 months prior to conception attempts, and patients should be advised to transition to mechanical birth control. The optimal “fertility window” is a 6-day period, ending with the ovulation day. This window can be estimated based on duration of menstrual cycle, cervical mucus, and basal body temperature, as well as commercially available ovulation kits. Intercourse is most likely going to result in a pregnancy if attempted within a 3-day period, ending with the ovulation day. Moderate alcohol consumption, smoking, drug use, and vaginal lubricant use decrease the chance of contraception, she said.
Assisted reproductive technologies, if associated with failed pregnancy attempts, can lead to an increased relapse rate.
“If somebody really wants to have a child and are not able to conceive on their own, they may certainly consider ART; it’s all about education,” Dr. Houtchens said. “You just need to tell them what to expect and that they might have a higher risk of relapses if their attempt is unsuccessful.”
According to the medical literature, an MS patient’s prepregnancy annualized relapse rate predicts her risk for relapse during the postpartum period. “From that perspective, if you have the luxury of time, you ideally try to make sure that her disease is stabilized for the year before she becomes pregnant,” she said. “That means if she has an active MRI or has had a couple of attacks on whatever drug she’s taking, you talk to her about that, and you change the medication and repeat the MRI after the medication is changed to try to make sure that her disease is stable before she becomes pregnant. Hopefully that will help prevent postpartum attacks.”
Dr. Houtchens recommends standard preconception care including prenatal vitamins with 0.4 mg-1 mg of daily folate, smoking and alcohol cessation, improved sleep hygiene, and vitamin D3 supplementation. Low levels of vitamin D3 are associated with adverse pregnancy outcomes, and a poorer clinical and radiologic MS course. Low levels may also be associated with increased MS risk in offspring.
“A pregnancy test should be administered prior to every treatment with a chemotherapeutic or cytotoxic agent in a woman of child-bearing age, even if she thinks her periods have ceased as a result of chemotherapy treatment,” she said. “They may have ceased due to pregnancy, and we don’t want to treat our pregnant patients with chemotherapy.”
The approximate risk of MS is 1 in 500 in the general population, 1 in 100 in people with an affected second-degree relative, 1 in 50 with an affected first-degree relative, and 1 in 4 in monozygotic twins born to an affected mother, according to Dr. Houtchens.
Babies born to MS moms face a risk of being slightly smaller for gestational age by weight (odds ratio, 1.45) but their Apgar scores are the same as their healthy mom counterpart babies. MS moms face a slight risk for operative deliveries but no increased risk for birth defects or other adverse fetal outcomes specifically related to MS. The method of labor and delivery does not impact the postpartum course of the disease, she said.
“Epidural anesthesia is perfectly safe and does not impact the postpartum course of MS,” Dr. Houtchens said. “There’s still an ongoing misconception [about this], especially among obstetric providers and anesthesiologists. Multiple studies have been published stating that there is no increased risk of relapse in these patients after they get an epidural. If they don’t want an epidural, that’s okay, but they shouldn’t be denied it because they have MS.”
Secondary MS symptoms may be affected by pregnancy, including fatigue, bladder symptoms, and mobility difficulty due to increased weight. IV corticosteroids are used widely to treat MS relapses during pregnancy, as well as in obstetrics to speed fetal lung maturity.
Steroids “cross the placental barrier and may increase the risk of cleft palate when used in the first trimester or may cause lower birth weight in the baby and earlier than expected delivery. They could also in theory delay healing for the mother after giving birth,” she said.
However, prednisone, prednisolone, and methylprednisolone can be administered with low levels of fetal exposure. “These agents are metabolized to inactive forms by 11 beta-hydroxysteroid dehydrogenase in the placenta, allowing less than 10% of the maternal dose to reach the fetus,” she said. Betamethasone and dexamethasone cross the placenta with minimal metabolism, leading to direct full-dose effects on the fetus.
Dr. Houtchens cautioned that none of the available MS drugs should be used in pregnant patients.
“It appears that pregnancy itself is protective enough that we don’t need to use a drug to keep them healthier,” she said.
For a nonlactating patient, it’s safe to resume MS therapy within 1 week after birth. For a lactating patient with previously active disease, it may be safe to administer monthly steroids or monthly IVIG, instructing them to discontinue breastfeeding for 24 hours after treatment. In breast milk, beta-interferon agents are found at 0.006% of the maternal dose. Oral small molecules such as fingolimod and dimethyl fumarate “are freely passed in breast milk at a lower level than in sera but are more likely to directly affect the infant’s immune/neurological systems,” Dr. Houtchens said. “Hepatic clearance is slower in infants. We don’t have anyone at our MS center taking any MS medications and breastfeeding. Is this the right thing to do? I don’t know. But if you have someone who really wants to breastfeed, you could theoretically put them on an injectable medication.”
MRI should be repeated within 6 months postpartum to assess radiographic disease activity, she recommended.
Dr. Houtchers pointed out that postpartum depression is common in mothers with MS, “and it’s probably under-studied in general.” In fact, the lifetime prevalence of major depressive disorder in people with MS is estimated to be approximately 50%, while the rate of suicides among people with MS is 7.5 times greater than that of the general population.
Helping MS patients navigate conception, pregnancy, and the postpartum period is just the beginning.
“You’re still going to be her doctor,” Dr. Houtchens said. “She’s still going to have that child for the rest of her life. How is she going to deal with raising the child with all of the symptoms of her disease over time? How is she going to relate to her child? You’re going to walk this road with your patients, as one of their most important health care providers.”
Dr. Houtchens disclosed that she has received research grants from Genzyme Sanofi, Biogen Idec, and Novartis. She has also served as a consultant for Teva Pharmaceuticals, Genzyme Sanofi, Questcor, Biogen Idec, and Novartis.
On Twitter @dougbrunk
INDIANAPOLIS – If you feel overwhelmed by the notion of managing multiple sclerosis patients who seek your guidance in navigating their pregnancy, you’re not alone.
Comprehensive management programs for pregnant MS patients currently do not exist, even within most dedicated MS centers and clinics, Dr. Maria K. Houtchens said at the annual meeting of the Consortium of Multiple Sclerosis Centers.
“Individual providers have an interest in this area, but there are no guidelines for most physicians or nurse practitioners to follow yet,” she said. “The level of care these patients receive varies dramatically, from one part of the country to another and from one provider to the next.”
An estimated 50% of all pregnancies in the United States and about 40% of all pregnancies worldwide are unplanned.
“I believe that women with MS should receive support and counseling from their MS specialist on issues about possible pregnancy,” said Dr. Houtchens, a neurologist who directs the Women’s Health Program at the Partners MS Center at Brigham and Women’s Hospital, Boston. “I believe that we should all feel comfortable discussing with our patients the effects of pregnancy on their MS course and the reciprocal effect on pregnancy outcomes of their disease, the genetic risk of disease in their offspring, and optimal conception timing. We need to be able to talk to them freely about disease control before, during, and after pregnancy.”
Dr. Houtchens, one of the authors of a recent multinational systematic review on the topic noted that increasing numbers of MS patients with stable disease are choosing not to become pregnant (Obstet. Gynecol. 2014;124:1157-68). Others “want to get pregnant and feel cheated out of their life goal,” she said.
A large survey of female patients with MS from Canada found that more than three-quarters had not become pregnant since being diagnosed with the disease. The most common contributing factor across both MS-related and non–MS-related categories was completion of families prior to an MS diagnosis (53%). The top MS-related reasons that contributed to not having children were symptoms interfering with parenting, burdening the partner, and finances (Mult. Scler. 2013;19:351-8).
“It’s only in the last 2-3 decades that this issue has come to the forefront in caring for MS patients,” she said. “Previous to that, a lot of colleagues would discourage patients from becoming pregnant. Some of those attitudes persist to this day. There’s a perception of disapproval from health care providers on the part of the patient, and from their family and peers, and historic misconceptions. Our goal as physicians is to help women live lives to their fullest potential with a disease that can’t be cured. We should not discourage our patients from becoming pregnant.”
To optimize chances of conception, she recommended that oral contraceptives be stopped 2-3 months prior to conception attempts, and patients should be advised to transition to mechanical birth control. The optimal “fertility window” is a 6-day period, ending with the ovulation day. This window can be estimated based on duration of menstrual cycle, cervical mucus, and basal body temperature, as well as commercially available ovulation kits. Intercourse is most likely going to result in a pregnancy if attempted within a 3-day period, ending with the ovulation day. Moderate alcohol consumption, smoking, drug use, and vaginal lubricant use decrease the chance of contraception, she said.
Assisted reproductive technologies, if associated with failed pregnancy attempts, can lead to an increased relapse rate.
“If somebody really wants to have a child and are not able to conceive on their own, they may certainly consider ART; it’s all about education,” Dr. Houtchens said. “You just need to tell them what to expect and that they might have a higher risk of relapses if their attempt is unsuccessful.”
According to the medical literature, an MS patient’s prepregnancy annualized relapse rate predicts her risk for relapse during the postpartum period. “From that perspective, if you have the luxury of time, you ideally try to make sure that her disease is stabilized for the year before she becomes pregnant,” she said. “That means if she has an active MRI or has had a couple of attacks on whatever drug she’s taking, you talk to her about that, and you change the medication and repeat the MRI after the medication is changed to try to make sure that her disease is stable before she becomes pregnant. Hopefully that will help prevent postpartum attacks.”
Dr. Houtchens recommends standard preconception care including prenatal vitamins with 0.4 mg-1 mg of daily folate, smoking and alcohol cessation, improved sleep hygiene, and vitamin D3 supplementation. Low levels of vitamin D3 are associated with adverse pregnancy outcomes, and a poorer clinical and radiologic MS course. Low levels may also be associated with increased MS risk in offspring.
“A pregnancy test should be administered prior to every treatment with a chemotherapeutic or cytotoxic agent in a woman of child-bearing age, even if she thinks her periods have ceased as a result of chemotherapy treatment,” she said. “They may have ceased due to pregnancy, and we don’t want to treat our pregnant patients with chemotherapy.”
The approximate risk of MS is 1 in 500 in the general population, 1 in 100 in people with an affected second-degree relative, 1 in 50 with an affected first-degree relative, and 1 in 4 in monozygotic twins born to an affected mother, according to Dr. Houtchens.
Babies born to MS moms face a risk of being slightly smaller for gestational age by weight (odds ratio, 1.45) but their Apgar scores are the same as their healthy mom counterpart babies. MS moms face a slight risk for operative deliveries but no increased risk for birth defects or other adverse fetal outcomes specifically related to MS. The method of labor and delivery does not impact the postpartum course of the disease, she said.
“Epidural anesthesia is perfectly safe and does not impact the postpartum course of MS,” Dr. Houtchens said. “There’s still an ongoing misconception [about this], especially among obstetric providers and anesthesiologists. Multiple studies have been published stating that there is no increased risk of relapse in these patients after they get an epidural. If they don’t want an epidural, that’s okay, but they shouldn’t be denied it because they have MS.”
Secondary MS symptoms may be affected by pregnancy, including fatigue, bladder symptoms, and mobility difficulty due to increased weight. IV corticosteroids are used widely to treat MS relapses during pregnancy, as well as in obstetrics to speed fetal lung maturity.
Steroids “cross the placental barrier and may increase the risk of cleft palate when used in the first trimester or may cause lower birth weight in the baby and earlier than expected delivery. They could also in theory delay healing for the mother after giving birth,” she said.
However, prednisone, prednisolone, and methylprednisolone can be administered with low levels of fetal exposure. “These agents are metabolized to inactive forms by 11 beta-hydroxysteroid dehydrogenase in the placenta, allowing less than 10% of the maternal dose to reach the fetus,” she said. Betamethasone and dexamethasone cross the placenta with minimal metabolism, leading to direct full-dose effects on the fetus.
Dr. Houtchens cautioned that none of the available MS drugs should be used in pregnant patients.
“It appears that pregnancy itself is protective enough that we don’t need to use a drug to keep them healthier,” she said.
For a nonlactating patient, it’s safe to resume MS therapy within 1 week after birth. For a lactating patient with previously active disease, it may be safe to administer monthly steroids or monthly IVIG, instructing them to discontinue breastfeeding for 24 hours after treatment. In breast milk, beta-interferon agents are found at 0.006% of the maternal dose. Oral small molecules such as fingolimod and dimethyl fumarate “are freely passed in breast milk at a lower level than in sera but are more likely to directly affect the infant’s immune/neurological systems,” Dr. Houtchens said. “Hepatic clearance is slower in infants. We don’t have anyone at our MS center taking any MS medications and breastfeeding. Is this the right thing to do? I don’t know. But if you have someone who really wants to breastfeed, you could theoretically put them on an injectable medication.”
MRI should be repeated within 6 months postpartum to assess radiographic disease activity, she recommended.
Dr. Houtchers pointed out that postpartum depression is common in mothers with MS, “and it’s probably under-studied in general.” In fact, the lifetime prevalence of major depressive disorder in people with MS is estimated to be approximately 50%, while the rate of suicides among people with MS is 7.5 times greater than that of the general population.
Helping MS patients navigate conception, pregnancy, and the postpartum period is just the beginning.
“You’re still going to be her doctor,” Dr. Houtchens said. “She’s still going to have that child for the rest of her life. How is she going to deal with raising the child with all of the symptoms of her disease over time? How is she going to relate to her child? You’re going to walk this road with your patients, as one of their most important health care providers.”
Dr. Houtchens disclosed that she has received research grants from Genzyme Sanofi, Biogen Idec, and Novartis. She has also served as a consultant for Teva Pharmaceuticals, Genzyme Sanofi, Questcor, Biogen Idec, and Novartis.
On Twitter @dougbrunk
INDIANAPOLIS – If you feel overwhelmed by the notion of managing multiple sclerosis patients who seek your guidance in navigating their pregnancy, you’re not alone.
Comprehensive management programs for pregnant MS patients currently do not exist, even within most dedicated MS centers and clinics, Dr. Maria K. Houtchens said at the annual meeting of the Consortium of Multiple Sclerosis Centers.
“Individual providers have an interest in this area, but there are no guidelines for most physicians or nurse practitioners to follow yet,” she said. “The level of care these patients receive varies dramatically, from one part of the country to another and from one provider to the next.”
An estimated 50% of all pregnancies in the United States and about 40% of all pregnancies worldwide are unplanned.
“I believe that women with MS should receive support and counseling from their MS specialist on issues about possible pregnancy,” said Dr. Houtchens, a neurologist who directs the Women’s Health Program at the Partners MS Center at Brigham and Women’s Hospital, Boston. “I believe that we should all feel comfortable discussing with our patients the effects of pregnancy on their MS course and the reciprocal effect on pregnancy outcomes of their disease, the genetic risk of disease in their offspring, and optimal conception timing. We need to be able to talk to them freely about disease control before, during, and after pregnancy.”
Dr. Houtchens, one of the authors of a recent multinational systematic review on the topic noted that increasing numbers of MS patients with stable disease are choosing not to become pregnant (Obstet. Gynecol. 2014;124:1157-68). Others “want to get pregnant and feel cheated out of their life goal,” she said.
A large survey of female patients with MS from Canada found that more than three-quarters had not become pregnant since being diagnosed with the disease. The most common contributing factor across both MS-related and non–MS-related categories was completion of families prior to an MS diagnosis (53%). The top MS-related reasons that contributed to not having children were symptoms interfering with parenting, burdening the partner, and finances (Mult. Scler. 2013;19:351-8).
“It’s only in the last 2-3 decades that this issue has come to the forefront in caring for MS patients,” she said. “Previous to that, a lot of colleagues would discourage patients from becoming pregnant. Some of those attitudes persist to this day. There’s a perception of disapproval from health care providers on the part of the patient, and from their family and peers, and historic misconceptions. Our goal as physicians is to help women live lives to their fullest potential with a disease that can’t be cured. We should not discourage our patients from becoming pregnant.”
To optimize chances of conception, she recommended that oral contraceptives be stopped 2-3 months prior to conception attempts, and patients should be advised to transition to mechanical birth control. The optimal “fertility window” is a 6-day period, ending with the ovulation day. This window can be estimated based on duration of menstrual cycle, cervical mucus, and basal body temperature, as well as commercially available ovulation kits. Intercourse is most likely going to result in a pregnancy if attempted within a 3-day period, ending with the ovulation day. Moderate alcohol consumption, smoking, drug use, and vaginal lubricant use decrease the chance of contraception, she said.
Assisted reproductive technologies, if associated with failed pregnancy attempts, can lead to an increased relapse rate.
“If somebody really wants to have a child and are not able to conceive on their own, they may certainly consider ART; it’s all about education,” Dr. Houtchens said. “You just need to tell them what to expect and that they might have a higher risk of relapses if their attempt is unsuccessful.”
According to the medical literature, an MS patient’s prepregnancy annualized relapse rate predicts her risk for relapse during the postpartum period. “From that perspective, if you have the luxury of time, you ideally try to make sure that her disease is stabilized for the year before she becomes pregnant,” she said. “That means if she has an active MRI or has had a couple of attacks on whatever drug she’s taking, you talk to her about that, and you change the medication and repeat the MRI after the medication is changed to try to make sure that her disease is stable before she becomes pregnant. Hopefully that will help prevent postpartum attacks.”
Dr. Houtchens recommends standard preconception care including prenatal vitamins with 0.4 mg-1 mg of daily folate, smoking and alcohol cessation, improved sleep hygiene, and vitamin D3 supplementation. Low levels of vitamin D3 are associated with adverse pregnancy outcomes, and a poorer clinical and radiologic MS course. Low levels may also be associated with increased MS risk in offspring.
“A pregnancy test should be administered prior to every treatment with a chemotherapeutic or cytotoxic agent in a woman of child-bearing age, even if she thinks her periods have ceased as a result of chemotherapy treatment,” she said. “They may have ceased due to pregnancy, and we don’t want to treat our pregnant patients with chemotherapy.”
The approximate risk of MS is 1 in 500 in the general population, 1 in 100 in people with an affected second-degree relative, 1 in 50 with an affected first-degree relative, and 1 in 4 in monozygotic twins born to an affected mother, according to Dr. Houtchens.
Babies born to MS moms face a risk of being slightly smaller for gestational age by weight (odds ratio, 1.45) but their Apgar scores are the same as their healthy mom counterpart babies. MS moms face a slight risk for operative deliveries but no increased risk for birth defects or other adverse fetal outcomes specifically related to MS. The method of labor and delivery does not impact the postpartum course of the disease, she said.
“Epidural anesthesia is perfectly safe and does not impact the postpartum course of MS,” Dr. Houtchens said. “There’s still an ongoing misconception [about this], especially among obstetric providers and anesthesiologists. Multiple studies have been published stating that there is no increased risk of relapse in these patients after they get an epidural. If they don’t want an epidural, that’s okay, but they shouldn’t be denied it because they have MS.”
Secondary MS symptoms may be affected by pregnancy, including fatigue, bladder symptoms, and mobility difficulty due to increased weight. IV corticosteroids are used widely to treat MS relapses during pregnancy, as well as in obstetrics to speed fetal lung maturity.
Steroids “cross the placental barrier and may increase the risk of cleft palate when used in the first trimester or may cause lower birth weight in the baby and earlier than expected delivery. They could also in theory delay healing for the mother after giving birth,” she said.
However, prednisone, prednisolone, and methylprednisolone can be administered with low levels of fetal exposure. “These agents are metabolized to inactive forms by 11 beta-hydroxysteroid dehydrogenase in the placenta, allowing less than 10% of the maternal dose to reach the fetus,” she said. Betamethasone and dexamethasone cross the placenta with minimal metabolism, leading to direct full-dose effects on the fetus.
Dr. Houtchens cautioned that none of the available MS drugs should be used in pregnant patients.
“It appears that pregnancy itself is protective enough that we don’t need to use a drug to keep them healthier,” she said.
For a nonlactating patient, it’s safe to resume MS therapy within 1 week after birth. For a lactating patient with previously active disease, it may be safe to administer monthly steroids or monthly IVIG, instructing them to discontinue breastfeeding for 24 hours after treatment. In breast milk, beta-interferon agents are found at 0.006% of the maternal dose. Oral small molecules such as fingolimod and dimethyl fumarate “are freely passed in breast milk at a lower level than in sera but are more likely to directly affect the infant’s immune/neurological systems,” Dr. Houtchens said. “Hepatic clearance is slower in infants. We don’t have anyone at our MS center taking any MS medications and breastfeeding. Is this the right thing to do? I don’t know. But if you have someone who really wants to breastfeed, you could theoretically put them on an injectable medication.”
MRI should be repeated within 6 months postpartum to assess radiographic disease activity, she recommended.
Dr. Houtchers pointed out that postpartum depression is common in mothers with MS, “and it’s probably under-studied in general.” In fact, the lifetime prevalence of major depressive disorder in people with MS is estimated to be approximately 50%, while the rate of suicides among people with MS is 7.5 times greater than that of the general population.
Helping MS patients navigate conception, pregnancy, and the postpartum period is just the beginning.
“You’re still going to be her doctor,” Dr. Houtchens said. “She’s still going to have that child for the rest of her life. How is she going to deal with raising the child with all of the symptoms of her disease over time? How is she going to relate to her child? You’re going to walk this road with your patients, as one of their most important health care providers.”
Dr. Houtchens disclosed that she has received research grants from Genzyme Sanofi, Biogen Idec, and Novartis. She has also served as a consultant for Teva Pharmaceuticals, Genzyme Sanofi, Questcor, Biogen Idec, and Novartis.
On Twitter @dougbrunk
EXPERT ANALYSIS AT THE CMSC ANNUAL MEETING
VIDEO: Cannabis further compromises cognitive function in some MS patients
INDIANAPOLIS – Although an estimated 10%-20% of multiple sclerosis patients currently smoke cannabis for pain control or to alleviate symptoms, new research from Canada suggests that smoking the drug can worsen cognitive function in some patients with the disease.
“We already know that 40%-70% of people with MS already have cognitive problems,” Dr. Anthony Feinstein, professor of psychiatrist at the University of Toronto, said in a video interview at the annual meeting of the Consortium of Multiple Sclerosis Centers. “Some of the research that I’ve done shows that, in the presence of cannabis, these rates go up.”
Even so, he emphasized that patients should weigh such side effects against the benefits of use.
“I think it’s going to be an individual decision,” he said. “If it’s helping with pain, that’s good. Our data needs to be replicated by other groups.”
Dr. Feinstein disclosed that his work on MS and cannabis is funded by the Multiple Sclerosis Society of Canada.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @dougbrunk
INDIANAPOLIS – Although an estimated 10%-20% of multiple sclerosis patients currently smoke cannabis for pain control or to alleviate symptoms, new research from Canada suggests that smoking the drug can worsen cognitive function in some patients with the disease.
“We already know that 40%-70% of people with MS already have cognitive problems,” Dr. Anthony Feinstein, professor of psychiatrist at the University of Toronto, said in a video interview at the annual meeting of the Consortium of Multiple Sclerosis Centers. “Some of the research that I’ve done shows that, in the presence of cannabis, these rates go up.”
Even so, he emphasized that patients should weigh such side effects against the benefits of use.
“I think it’s going to be an individual decision,” he said. “If it’s helping with pain, that’s good. Our data needs to be replicated by other groups.”
Dr. Feinstein disclosed that his work on MS and cannabis is funded by the Multiple Sclerosis Society of Canada.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @dougbrunk
INDIANAPOLIS – Although an estimated 10%-20% of multiple sclerosis patients currently smoke cannabis for pain control or to alleviate symptoms, new research from Canada suggests that smoking the drug can worsen cognitive function in some patients with the disease.
“We already know that 40%-70% of people with MS already have cognitive problems,” Dr. Anthony Feinstein, professor of psychiatrist at the University of Toronto, said in a video interview at the annual meeting of the Consortium of Multiple Sclerosis Centers. “Some of the research that I’ve done shows that, in the presence of cannabis, these rates go up.”
Even so, he emphasized that patients should weigh such side effects against the benefits of use.
“I think it’s going to be an individual decision,” he said. “If it’s helping with pain, that’s good. Our data needs to be replicated by other groups.”
Dr. Feinstein disclosed that his work on MS and cannabis is funded by the Multiple Sclerosis Society of Canada.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @dougbrunk
AT THE CMSC ANNUAL MEETING
