Counseling Points Multiple Sclerosis - Winter 2015 - 9

The Role of Patient Adherence
in Switching

that most or all MS symptoms (e.g., numbness,
tingling, fatigue, or weakness) would be resolved
with treatment. The perception that DMT should
"cure" MS or eliminate any signs or possible progression persists and may even be conveyed by
a healthcare provider by or misleading medical
or web-based media. One of the most difficult
aspects involved in educating the person with MS
is conveying that absence of change (e.g., no worsening of disease) is the primary goal. It may be
helpful to explain that the goal is to "freeze the
person in time" with respect to MS worsening or
progression.
In contrast, there are patients who believe that
their therapy is working well for them, even
when there are signs of worsening disease. These
people may become accustomed to a DMT and
the effects of MS and fail to notice subtle signs of
disease worsening that may warrant further exploration. In these cases, giving the patient an opportunity to view new enhancing lesions on an MRI
or other evidence of advancing disease may help
the person to accept the need to explore a switch
to a different DMT.
The issue of discontinuing DMT is controversial, especially in light of a recent Agency for
Healthcare Research and Quality (AHRQ) report
that claimed little evidence of efficacy for longterm treatment.23 The AHRQ report has drawn
much criticism from MS organizations such as
the National Multiple Sclerosis Society, the Multiple Sclerosis Coalition, and others, which argued
that healthcare providers and patients may misinterpret the document as justification to go off
of treatment when they should not.24 While this
issue continues to be debated, it is important that
patients not discontinue DMT unless advised by
their healthcare professional.

Is the best MS therapy simply one that the individual will use correctly and consistently? Efficacy
and safety matters must be given precedence, but
considerations of adherence are tied closely to
both of these issues. Obviously, if the drug is not
being taken at therapeutic levels, its efficacy is a
moot point. Similarly, problems with tolerability
or worries about adverse effects are among the
chief reason for patients to skip doses or discontinue therapy. In controlled clinical trials of MS
therapies, efficacy rates appear to be reasonably
high, but the available "real life" data tell another
story, as shown in Table 4.5,6,9,25-28
Most of the adherence analyses done in MS to
date were performed in patient groups receiving injectable therapies. Limited data are available adherence to oral therapies, but one study
suggested that medication possession ratio was
higher in patients receiving fingolimod (versus
injectable therapies) and rates of discontinuation were lower.29 While taking a pill is easier for
most people than administering an injection, it is
common for patients on oral MS therapies (and
oral therapies in general) to miss doses or discontinue.21 For example, if an oral drug has a twicedaily dosage schedule, patients admit they often
skip the second dose because of forgetfulness or to
avoid adverse effects such as gastrointestinal upset.
True adherence to therapy is difficult to measure because it relies on a person's honest recounting of medication doses taken. Most patients overreport their adherence,30 while physicians and
other healthcare providers tend to over-estimate
the degree to which their patients are taking the
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Winter 2015
Counseling Points Multiple Sclerosis - Winter 2015

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