Counseling Points Multiple Sclerosis - Winter 2015 - 8

evaluated and addressed.4,16,17 Assessing a patient's

Table 3. Reasons for Switching DMTs
in MS18

reasons for a change in therapy is an important step in the shared decision-making process
between the MS nurse, the prescribing physician,

Efficacy

and the patient. A variety of possible reasons for

* No response or suboptimal therapeutic
response

switching were outlined recently in the Interna-

* Initial response followed by breakthrough
disease

tional Journal of MS Care (Table 3).18

* Neutralizing antibodies leading to

Clinical attacks may occur relatively infre-

suboptimal response

quently in patients receiving DMT, making it dif-

* Introduction of new therapy that may offer
better management of disease

ficult to establish the efficacy of a new agent in a
time period of less than 6 months.19 In addition,

Safety

some agents may require a number of months

* Significant adverse events such as liver
toxicity or decreased blood counts
* Comorbid condition or new safety

after start-up to reach full therapeutic efficacy.

consideration (e.g., pregnancy,

Sometimes, a need to change therapy may arise

development of renal disease)

because the current therapy is no longer reim-

* Change in patient's risk profile for adverse

bursed by the insurer or third-party payer. In

events (e.g., JC virus antibody conversion)
* Development of tolerability problems over

these cases it may be up to the MS nurse to help

time (e.g., skin damage)

determine whether such a change is appropriate

* Introduction of new therapy that may offer

for the patient therapeutically. For prior authori-

better safety

zation to change a patient's therapy, insurers may
Patient-related * Difficulties with adherence to therapy

require documentation of new MS symptoms,

Reasons

MRI changes, or ancillary evaluations such as lab

* Desire to try different administration
method

results or eye examination findings.

* Perceived lack of efficacy of current therapy
* Introduction of new therapy that may offer

Acute relapses while a patient is on therapy may

better tolerability

indicate a suboptimal response.20 Does a single
acute attack represent a treatment failure, regard-

Prescriber- or

less of the patient's prior relapse rate? Expecta-

Payer-related

tions that DMT should completely eliminate MS

Reasons

* Patient has new prescriber who switches
therapy related Reasons
* Changes in practice of existing prescriber
* Change in payer or payer formulary choices

relapses have been raised with the availability of

forces switch due to lack of coverage

newer therapies showing high relapse-reduction
rates in controlled clinical trials. However, DMTs

prompt an increased level of monitoring, if not a

should not be regarded as conferring complete

treatment switch.18
Perceived lack of efficacy is a primary reason
for patients to request a switch in therapy.21,22
This may be because the patient had anticipated

protection from relapses, and no existing DMT is
thought to cure MS. At the same time, any relapse
that a patient experiences while on therapy should
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