Most MS Patients Miss Out on Key Drugs

WICHITA, Kan., April 5 -- A majority of multiple sclerosis patients aren't getting immunomodulatory agents, viewed as the most effective therapies for the disease, suggests a survey of patient visits and prescribing patterns.

A review of more than six million clinic visits for MS found that 92% of the patients seen by primary care physicians, were not getting prescriptions for immunomodulatory agents, reported Jagannadha R. Avasarala, M.D., of Kansas Neurological Consultants here, and colleagues.

Nor were 62% of those MS patients seen by neurologists getting prescriptions for immunomodulatory agents, Dr, Avasarala and colleagues reported in the open access online journal BMC Medicine.

"Strategies for educating both neurologists and non-neurologists about the benefits of initiating immunomodulatory agent use in MS patients and in continuing their use remain critical to improving long-term patient outcomes in treatment of MS," said Dr. Avasarala.

Immunomodulatory agents are thought to slow disease progression and reduce the frequency of relapses, the authors noted, and although the agents are comparatively expensive, their costs may be offset by their ability to reduce direct care costs and indirect costs such as lost productivity.

There are currently six immunomodulatory agents approved by the FDA for the treatment of patients with MS:

• Interferon-1b (Betaseron)
• Interferon-1a (Avonex and Rebif)
• Glatiramer acetate (Copaxone)
• Mitoxantrone (Novantrone)
• Natalizumab (Tysabri, reintroduced after being withdrawn due to concerns about risk of progressive multifocal leukoencephalopathy)

"Published data suggest that worsening expanded disability status scores (EDSS) from less than 3.5 to more than 6.5 increase the mean total cost per year of MS by a factor of 4.39," the authors wrote. "Therefore, analyses about outpatient management practices could lead to improvement in the treatment of MS patients and design of better cost-effective treatment practices."

To get an idea of just what those practices are, the authors reviewed data from the National Ambulatory Medical Care Survey on MS patients visits conducted from 1998 through 2004. The data were weighted to provide an estimate of the nationwide frequency of outpatient clinic visits.

The investigators looked at the proportion of MS patient visits to neurologists and primary care practitioners, demographic patterns, and the proportion of patients with prescriptions for immunomodulatory agents.

During the study period, there were an estimated 6.7 million MS patient visits, with neurologists accounting for just over half of all visits (50.7%). A majority of the visits (57.9%) were by patients in their 40s or 50s, and there were four visits by women to every one by a man.

When data on all six FDA-approved immunomodulatory agents were combined, the authors found that there were not statistically significant trends in prescription patterns, either up or down.

As might be expected, neurologists prescribed immunomodulatory agents more than did primary care physicians (21% vs. 8%, respectively).

"The increased use of immunomodulatory agents by neurologists probably reflects greater awareness of the drugs' availability and their use by specialists who more often treat patients with MS," the authors speculated. "Additionally, an association between co-payments and immunomodulatory agent use in patients with private-sector health plans may have a role.. It would be important to test whether reducing co-payments for MS treatment would reduce the use of other health care services through better MS treatment that modifies the course of illness."

They also found that women were twice as likely as men to be get an immunomodulatory agent prescription during a visit (odds ratio 1.98, 95% confidence interval, 1.09- 3.58), and that patients on Medicaid were less likely to do so (odd ratio 0.34, 95% CI,. 0.11 - 0.99). In contrast, patients on Medicare had an odds ratio for getting an immunomodulatory agent prescription during a visit of 0.86, 95% CI, 0.43 - 1.72).

Study limitations included a lack of data on MS symptom severity or longitudinal follow-up of patients, and possible under-representation of visits to tertiary care centers, the authors noted.

"To improve immunomodulatory agent prescription practices, a possible solution would be to pinpoint variations in service delivery and to initiate longitudinal follow-up studies," they wrote. "Above all, strategies for educating both neurologists and non-neurologists about the benefits of initiating immunomodulatory agent use in MS patients and in continuing their use remain critical to improving long-term patient outcomes in the treatment of MS."