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VBCN - November 2016 Volume 3, No 3 - Multiple Sclerosis
Laura Morgan

The past 2 decades have seen significant improvements in disease-modifying therapies (DMTs) for multiple sclerosis (MS), and with them a surge in prices in the cost of therapy with sales more than doubling just in the past few years. As a result, there has been a significant rise in the cost of care for patients with MS.

Insurance companies have found ways to help reduce the companies’ costs, by placing some of the financial burden directly on patients through high deductibles, copayments, and coinsurance—all of which can compromise the quality of patient care and patient access to care, according to a recent article by 2 neurology experts (Kister I, Corboy JR. Neurology. 2016;87:1617-1622).

“Clinicians are uniquely positioned to introduce innovative management strategies that are both medically sound and cost-efficient,” observed Ilya Kister, MD, NYU Langone Multiple Sclerosis Comprehensive Care Center, New York City, and John R. Corboy, MD, FAAN, Co-Director, Rocky Mountain Multiple Sclerosis Center, University of Colorado, Aurora, in their article.

5 Strategies to Reduce Cost While Improving Care

Drs Kister and Corboy outlined 5 strategies that neurologists can use to improve patient outcomes and reduce the cost of MS care:

  1. Avoid use of DMTs in patients with “improbable MS”
  2. Customize the treatment of disease relapses
  3. Develop alternative dosing strategies for DMTs approved by the FDA for MS
  4. Use off-label drugs as DMTs in patients with MS
  5. Consider whether DMTs should be continued indefinitely

Avoiding Inappropriate Use of DMTs

The first of these strategies involves avoiding the use of DMTs in patients who likely do not have MS. The misdiagnosis of MS is quite common and may be attributed to a lack of specific serum or cerebrospinal fluid biomarkers of MS, or of radiographic criteria for differentiating demyelinating lesions from lesions of other causes.

The authors note that the use of expensive DMTs in patients misdiagnosed with MS is associated with considerable economic cost, not to mention adverse effects. Although the early detection and treatment of MS is important, there should be a high degree of diagnosis certainty before starting treatment with DMTs, emphasized Drs Kister and Corboy.

Customize the Disease Relapse Treatment

Customizing the treatment of MS relapses is another approach that may help to reduce cost while improving care—MS relapses vary in severity, and selecting an appropriate treatment based on the severity of the attack may save time and money. For example, the use of high-dose oral methylprednisolone instead of high-dose intravenous (IV) methylprednisolone for acute attacks is a treatment strategy that neurologists should consider, given that IV methylprednisolone is expensive. It costs approximately $800 for an hour of outpatient infusion at the University of Colorado Hospital. IV infusion is also inconvenient for patients, whereas oral methylprednisolone costs less, is patient-friendly, and is just as effective as the IV formulation.

A lack of prepackaged oral high-dose steroid preparations can be resolved by using compounding pharmacies, explained Drs Kister and Corboy. In addition, the use of Acthar gel, with an average wholesale price that exceeds $40,000, should also be avoided for the treatment of MS relapses, the authors advise.

Alternative Treatments

Another cost-saving strategy is to develop alternative dosing regimens for FDA-approved DMTs for MS. The dose and schedule of approved DMTs are not always evidence-based, the authors note. In fact, clinical trials and anecdotal experience indicate that less frequent dosing of DMTs for patients with MS—including glatiramer acetate (Copaxone), fingolimod (Gilenya), and nata­lizumab (Tysabri)—have demonstrated similar efficacy compared with more frequent dosing. In the case of natalizumab, less frequent dosing has been shown to be more cost-effective and safer than more frequent dosing schedules.

Off-Label Drug Use

The off-label use of drugs for MS is also an attractive option. For example, rituximab (Rituxan), which is indicated for non-Hodgkin lymphoma, rheumatoid arthritis, and other conditions, has shown robust efficacy in patients with relapsing-remitting MS, and costs considerably less than the standard DMTs. “While costs vary by location and may change over time, the current costs for 1,500 mg spread over 2 doses, including the infusions themselves, is approximately $20,000 at a Walgreen’s infusion center in Colorado near our institution, well below the average wholesale prices, or wholesale acquisition costs of the standard DMTs,” according to the authors.

Length of Treatment

Finally, although the benefits of continuously using DMTs in younger patients with recent inflammatory activity is well-established, whether the same is true in older patients with lower risk for relapses is unclear and warrants further study. A multicenter clinical trial, which will include 300 patients aged ≥55 years, is underway to help answer this question. The study results will have important economic implications, and will “help patients and clinicians make an informed decision as to whether and when it may be safe to stop DMT,” advise Drs Kister and Corboy.

Neurologists Should Adopt Cost-Saving Strategies

In an accompanying editorial Dennis Bourdette, MD, FAAN, Director, and Ruth Whitham, MD, Co-Director, Multiple Sclerosis and Neuroimmunology Center at Oregon Health and Science University, Portland, advise neurologists to adopt cost-saving strategies (Bourdette D, Whitham R. Neurology. 2016;87:1532-1533).

They contend, however, that the successful implementation of some of the proposed strategies is largely dependent on the geographic region. For example, whereas Drs Kister and Corboy were able to obtain approval from insurance companies for the off-label use of rituximab for use in patients with MS in Colorado, the same is often not true in Oregon, where Drs Bourdette and Whitham practice.

Drs Bourdette and Whitham also maintain that other strategies, such as modifying dosing schedules and using drugs off-label, will require clinical trials, for which neurologists will have to seek funding outside of pharmaceutical companies, given that the study results will potentially lower their profits in the future. Nevertheless, “Kister and Corboy present useful strategies that could lower the cost of MS care without sacrificing efficacy, but they do more. They call for neurologists to light the way toward better and more cost-effective treatment of MS,” they concluded.

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