Benefit-risk perception of natalizumab therapy in neurologists and a large cohort of multiple sclerosis patients

A systematic review to explore patients' MS knowledge and MS risk knowledge

Living with a chronic illness poses particular challenges, including maintaining current disease knowledge to optimise self-management and interaction with health professionals. People with Multiple Sclerosis (MS) are increasingly encouraged to participate in shared decision making. Making informed decisions is likely to rely on adequate knowledge about the condition and its associated risks. The aim of this systematic review is to explore patients' existing MS knowledge and MS risk knowledge, and how these relate to demographic and disease variables. A literature search was conducted using PsycINFO, PubMed and Cochrane Library. Eligible studies were published peer-reviewed reporting quantitative measures of MS knowledge and MS risk knowledge in adult MS patients. Eighteen studies met inclusion criteria comprising a total sample of 4,420 patients. A narrative synthesis was undertaken because studies employed various measures. Suboptimal levels of MS knowledge and MS risk knowledge were generally identified across studies. Greater self-reported adherence and a willingness to take medication were related to higher MS knowledge, while educational level was a significant predictor of both MS knowledge and MS risk knowledge. Associations with other demographic and disease-related variables were mixed for both knowledge domains. Direct comparison of results across studies were limited by methodological, sampling and contextual heterogeneity. The review's findings and implications for future research and clinical practice are considered from this perspective.

Identification and management of subclinical disease activity in early multiple sclerosis: a review

IMPORTANCE

Early treatment initiation in multiple sclerosis (MS) is crucial in preventing irreversible neurological damage and disability progression. The current assessment of disease activity relies on relapse rates and magnetic resonance imaging (MRI) lesion activity, but inclusion of other early, often "hidden," indicators of disease activity may describe a more comprehensive picture of MS.

OBSERVATIONS

Early indicators of MS disease activity other than relapses and MRI activity, such as cognitive impairment, brain atrophy, and fatigue, are not typically captured by routine disease monitoring. Furthermore, silent progression (neurological decline not clearly captured by standard methods) may occur undetected by relapse and MRI lesion activity monitoring. Consequently, patients considered to have no disease activity actually may have worsening disease, suggesting a need to revise MS management strategies with respect to timely initiation and escalation of disease-modifying therapy (DMT). Traditionally, first-line MS treatment starts with low- or moderate-efficacy therapies, before escalating to high-efficacy therapies (HETs) after evidence of breakthrough disease activity. However, multiple observational studies have shown that early initiation of HETs can prevent or reduce disability progression. Ongoing randomized clinical trials are comparing escalation and early HET approaches.

CONCLUSIONS AND RELEVANCE

There is an urgent need to reassess how MS disease activity and worsening are measured. A greater awareness of "hidden" indicators, potentially combined with biomarkers to reveal silent disease activity and neurodegeneration underlying MS, would provide a more complete picture of MS and allow for timely therapeutic intervention with HET or switching DMTs to address suboptimal treatment responses.

Longitudinal stability of JCV antibody index in Natalizumab treated people with multiple sclerosis

OBJECTIVE

The aim of this study was to evaluate the evolution of JCV index over time in Natalizumab treated people with multiple sclerosis.

MATERIALS AND METHODS

We retrospectively reviewed antibody index values from pwMS who were treated with Natalizumab for greater than six months and had at least two antibody results available between 2011 and 2019. Survival analysis was performed on those who were JCV index value negative at baseline to evaluate time to seroconversion. In pwMS who had index values available at 48 and/or 96 months post Natalizumab initiation, t-tests were performed to evaluate change in index over time.

RESULTS

1144 JCV antibody index results were available for 132 pwMS. Median time to seroconversion based on survival analysis was 103 months. Annualised seroconversion rate was 5.8%. Initial antibody index and rate of seroconversion did not differ with regards to age or gender. Antibody index increased significantly over time on treatment for the cohort as a whole, initial antibody index (0.27) to final antibody testing (0.86), t(131)=6.45, p<.0005. There was a significant increase in those with initial positive index value, between first (0.95) and final index (2.14), t(33) = 4.85, p<.0005 over a median of 77 months.

CONCLUSIONS

In those who were seronegative at baseline there is a long median duration of treatment with Natalizumab prior to seroconversion. In individuals with positive JCV antibody index at treatment initiation, antibody index increases over time.

Editorial: risky business. What do sufferers' perceptions of risk from interventions for irritable bowel syndrome really mean?

This article is linked to Goodoory et al papers. To view these articles, visit https://doi.org/10.1111/apt.16816 and https://doi.org/10.1111/apt.16917

Patient-based benefit-risk assessment of medicines: development, refinement, and validation of a content search strategy to retrieve relevant studies

Introduction:

Poor indexing and inconsistent use of terms and keywords may prevent efficient retrieval of studies on the patient-based benefit-risk assessment (BRA) of medicines. We aimed to develop and validate an objectively derived content search strategy containing generic search terms that can be adapted for any search for evidence on patient-based BRA of medicines for any therapeutic area.

Methods:

We used a robust multistep process to develop and validate the content search strategy: (1) we developed a bank of search terms derived from screening studies on patient-based BRA of medicines in various therapeutic areas, (2) we refined the proposed content search strategy through an iterative process of testing sensitivity and precision of search terms, and (3) we validated the final search strategy in PubMed by firstly using multiple sclerosis as a case condition and secondly computing its relative performance versus a published systematic review on patient-based BRA of medicines in rheumatoid arthritis.

Results:

We conceptualized a final search strategy to retrieve studies on patient-based BRA containing generic search terms grouped into two domains, namely the patient and the BRA of medicines (sensitivity 84%, specificity 99.4%, precision 20.7%). The relative performance of the content search strategy was 85.7% compared with a search from a published systematic review of patient preferences in the treatment of rheumatoid arthritis. We also developed a more extended filter, with a relative performance of 93.3% when compared with a search from a published systematic review of patient preferences in lung cancer.

Training physicians in providing complex information to patients with multiple sclerosis: a randomised controlled trial

OBJECTIVE

To evaluate the effect of a specific communication training for neurologists on how to provide complex information about treatment options to patients with multiple sclerosis (MS).

DESIGN

Single-centre, single-blind, randomised controlled trial.

SETTING

One university hospital in Norway.

PARTICIPANTS

Thirty-four patients with early-stage MS.

INTERVENTION

A 3-hour training for neurologists on how to provide complex information about MS escalation therapy.

MAIN OUTCOME MEASURES

Patient recall rate, measured with a reliable counting system of provided and recalled information about drugs.

SECONDARY OUTCOME MEASURES

Number of information units provided by the physicians. Effects on patient involvement through questionnaires.

METHODS

Patients with MS were instructed to imagine a disease development and were randomised and blinded to meet a physician to receive information on escalation therapy, before or after the physician had participated in a 3-hour training on how to provide complex information. Consultations and immediate patient recall interviews were video-recorded and transcribed verbatim.

RESULTS

Patient recall rate was 0.37 (SD=0.10) pre-intervention and 0.39 (SD=0.10) post-intervention. The effect of the intervention on recall rate predicted with a general linear model covariate was not significant (coefficient parameter 0.07 (SE 0.04, 95% CI (-0.01 to 0.15)), p=0.099).The physicians tended to provide significantly fewer information units after the training, with an average of 91.0 (SD=30.3) pre-intervention and 76.5 (SD=17.4) post-intervention; coefficient parameter -0.09 (SE 0.02, 95% CI (-0.13 to -0.05)), p<0.001. There was a significant negative association between the amount of provided information and the recall rate (coefficient parameter -0.29 (SE 0.05, 95% CI (-0.39 to -0.18)), p<0.001). We found no significant effects on patient involvement using the Control Preference Scale, Collaborate or Four Habits Patient Questionnaire.

CONCLUSION

A brief course for physicians on providing complex information reduced the amount of information provided, but did not improve patient recall rate.

TRIAL REGISTRATION NUMBER

ISRCTN42739508.

"I'm walking into the unknown": Qualitative insights into how emotions and lived experience related to multiple sclerosis diagnosis impact on decisions to pursue disease modifying treatment

INTRODUCTION

People with Relapsing Remitting Multiple Sclerosis (RRMS) are increasingly included as active participants in shared decision making around their treatment options. Choosing a first disease modifying treatment (DMT) is a complex process that often takes place soon after a diagnosis has been given. Patients therefore are often required to make difficult decisions at a time when they are still coming to terms with their illness. This study investigated the views and experiences of recently diagnosed patients with RRMS when they were making their initial DMT choice.

METHOD

This was a qualitative study involving in-depth semi-structured interviews with patients with RRMS in a National Health Service (NHS) setting in the United Kingdom. Data were collected from 6 patients and analysis was guided by an Interpretive Phenomenological Analysis (IPA) approach.

RESULTS

Initial reactions to diagnosis were characterized by strong emotions and a feeling of despair and hopelessness. Subsequently the DMT decision was shaped by multiple considerations around maintaining normality, and restoring hope and control over one's life whilst reconciling uncertainty around efficacy. Considering the future with a DMT elicited reflections around employment and family planning.

CONCLUSION

Emotions and lived experience related to recent MS diagnosis can impact on the initial DMT decision in number of ways. Health care professionals need to understand the lived experience of patients making DMT decisions soon after diagnosis when engaging in shared decision making.

Progressive Multifocal Leukoencephalopathy Risk Perception in Patients Considering Natalizumab for Multiple Sclerosis

Background:

Progressive multifocal leukoencephalopathy (PML) remains a concern when considering natalizumab for multiple sclerosis (MS) treatment. Extensive research has identified factors that increase PML risk, and it is important that providers and patients accurately understand risk to make appropriate benefit-risk decisions.

Methods:

One hundred adult US patient-candidates for natalizumab therapy were questioned about their PML risk perception, the maximum PML risk they deemed acceptable, and sources of information used to understand risk. Differences in group distributions were compared.

Results:

Patients estimated their potential PML risk from 0.1% to 87% (mean, 31.5%). Maximum PML risk deemed acceptable ranged from 0.1% to 45% (mean, 14.5%). Actual risk (mean, 0.01%), based on published risk estimates, was calculated as a function of time receiving therapy, anti–John Cunningham virus antibody index, and previous use of immunosuppressants. The sexes perceived their risks similarly and had similar risk acceptance. Patient perception of PML risk increased with age, whereas willingness to accept risk remained similar among all ages. Higher levels of education correlated with more accurate risk perception and lower risk tolerance. Neither risk perception nor tolerance was correlated with disability level. Sixty-three percent of patients indicated that their primary/referring physician’s concern level regarding potential risk of PML during the benefit-risk discussion was their main source of information about risk.

Conclusions:

Patients with MS substantially overestimated their PML risk, often by three orders of magnitude. Patients with MS could benefit from accurate risk education, and providers could play an essential role in presenting PML risk information in a manner understandable to each individual patient.

"I Will Respect the Autonomy of My Patient": A Scoping Review of Shared Decision Making in Multiple Sclerosis

Background

Patient autonomy is a bioethical principle that was strengthened in the revised Declaration of Geneva. Shared decision making (SDM) is particularly relevant in the management of multiple sclerosis (MS) because many preference-sensitive decisions have to be made during the disease course. We aimed to summarize the available evidence on SDM in the MS field and to inform future research and practice.

Methods

We performed a scoping review by searching MEDLINE (past 5 years). Studies were included if they reported primary/secondary research and focused on SDM related to people with MS. Data were grouped into topics, with results presented in narrative form.

Results

From 865 references, we included 55 studies conducted mostly in Europe. Half of the studies were observational, followed by qualitative (20%), mixed-methods (17%), randomized controlled trials (RCTs, 5%), quasi-experimental (5%), and reviews (4%). Most studies addressed people with relapsing-remitting MS (85%); the remaining addressed health care professionals, patients' significant others, or a combination. We identified five main topics: decisions on disease-modifying drugs, decisions on chronic cerebrospinal venous insufficiency treatment, information provision and patient education, health literacy, and risk knowledge.

Conclusions

The high proportion of included studies on SDM in MS in Europe suggests an earlier adoption of these concepts in this area. Decisions on disease-modifying drugs was the prevalent topic. Only 5% of studies were RCTs, indicating that more research is needed to study the effectiveness of SDM interventions. Studies addressing people with primary and secondary progressive MS are also needed.

High-Efficacy Disease-Modifying Therapies in People with Relapsing-Remitting Multiple Sclerosis: The Role of Risk Attitude in Treatment Decisions

BACKGROUND

Risk attitude is defined as the willingness to tolerate risk to achieve a greater expected return. Limited information is available on how relapsing-remitting multiple sclerosis people's perceptions about disease trajectory and risk attitude may influence treatment choices.

METHODS

A non-interventional study applying principles of behavioral economics was conducted to assess willingness to receive unwarranted high-efficacy disease-modifying therapy (DMT) according to best-practice guidelines. People with relapsing-remitting multiple sclerosis (PwRRMS) according to 2010 McDonald criteria completed a survey on symptom severity, risk preferences, and management of simulated case scenarios mimicking the current treatment landscape. PwRRMS's choice for high-efficacy agents was established as the participant's selection of monoclonal antibodies for case scenarios with at least 2 years of clinical and radiological stability.

RESULTS

A total of 211 PwRRMS were studied (mean age 39.1 ± 9.5 years, 70.1% female, mean Expanded Disability Status Scale score 1.8 ± 1.1). Almost 50% (n = 96) opted for a high-efficacy DMT despite the lack of evidence of disease activity. Younger age and risk-seeking behavior were associated with an increased likelihood of selecting unwarranted high-efficacy DMT [odds ratio (OR) 2.00, 95% confidence interval (CI) 1.02-3.93, p = 0.043, and OR 2.17, 95% CI 1.09-4.30, p = 0.027, respectively]. Clinical characteristics or subjective perception of symptom severity had no influence on participants' treatment choices.

CONCLUSION

Identifying PwRRMS with risk-seeking behavior would be crucial to implementing specific educational strategies to manage information on disease prognosis, treatment expectations, and safety risk knowledge.

Pharmaceutical Benefit-Risk Perception and Age Differences in the USA and Germany

INTRODUCTION

Understanding how patients of all ages perceive the benefits and risks of medical treatments is vitally important. Yet, the role of older age on pharmaceutical benefit-risk perceptions has hardly been empirically investigated as a central focus of study.

OBJECTIVE

This study tested the generalizability of recent pilot findings to explore benefit-risk perception age differences between adults aged 65 years old and over (older group) and those aged 18-64 years old (younger group).

METHODS

An online survey representative for age, sex, and education was conducted in Ohio, USA (N = 1520) and Germany (N = 1536). A combination of benefit, risk, and affect questions measured respondents' perceptions of 18 medicines, tests, vaccines, and procedures. Further questions investigated general perceptions of side effects and effectiveness, as well as respondents' reliance on different sources of medicines information.

RESULTS

Clear age differences were found that strongly support recent pilot findings. Older adults perceived prescription medicines significantly more positively than their younger counterparts. They had significantly higher benefit and lower risk perceptions for most, but not all, medical treatments investigated. Older adults' benefit-risk perceptions were more strongly correlated with positive/negative affect, that is, their positive/negative experiences and feelings of "goodness" or "badness" they associated with each medical treatment investigated. They also perceived doctors and pharmacists as more competent and trustworthy. Contrary to popular belief, both age groups ranked their reliance on 15 different medical (e.g. doctors), societal (e.g. social media), industry (e.g. pharmaceutical company websites), and governmental (e.g. regulatory agencies) sources of medicines information remarkably similarly.

CONCLUSION

Age has an important role in patients' pharmaceutical benefit-risk perceptions. Findings show that, when designing messages, benefit-risk communicators should incorporate age differences. This includes older patients' positive perceptions of pharmaceuticals, greater reliance on affect, and information seeking versus scanning behaviour. Field experiments are now needed to test the effectiveness of such changes for improving benefit-risk communication practice.

The Dilemma of When to Stop Disease-Modifying Therapy in Multiple Sclerosis: A Narrative Review and Canadian Regional Reimbursement Policies

BACKGROUND

Disease-modifying therapy (DMT) has changed the landscape of multiple sclerosis (MS) care. However, there is lack of consensus on the duration of treatment and the selection of individuals most likely to benefit from continued treatment. Current evidence, practice guidelines, health policy, and ethical considerations presented together may further inform challenging clinical decision making and future directions. The objectives of this study were to conduct a narrative review of original research and practice guideline recommendations on discontinuation of DMTs in MS; to collect information regarding Canadian regional reimbursement policies for DMT coverage in MS; and to present ethical considerations applicable to such decision making.

METHODS

A literature review was conducted of the MEDLINE/PubMed, OneFile (GALE), Scopus (Elsevier), and ProQuest Biological Science Collection databases. Data regarding Canadian regional reimbursement policies for DMT coverage in MS were collected from the ministry/government websites. Ethical considerations were reviewed in the context of the identified evidence, guidelines, and policies.

RESULTS

The literature lacks evidence from prospective randomized controlled trials that directly addresses the issue of discontinuation of DMTs in MS. Current practice guidelines advocate the vital role of patient choice in decision making. There are regional variations in Expanded Disability Status Scale criteria scores for continuing MS DMT coverage among Canadian provinces/territories.

CONCLUSIONS

In the absence of strong evidence on discontinuation of DMTs, shared decision making and consideration of the ethical complexities could help in the decision-making process.

Progressive multifocal leukoencephalopathy in Finland: a cross-sectional registry study

Objective

To investigate if progressive multifocal leucoencephalopathy (PML) incidence has increased in Finland like in the neighbouring Sweden.

Methods

National administrative registries were searched for all PML admissions aged 16 years or more in 2004–2014 on all neurological and internal medicine wards in Finland. The mortality data of the patients was extracted from the national causes of death registry. National level data on annual predisposing drug use was obtained from the national pharmaceutical authority.

Results

We identified 35 PML cases (57% male) with a peak in 2010–2011 that amounted to 49% of all cases. The annual incidence for the entire study period was 0.072/100,000 person-years (95% CI 0.050–0.10) with no temporal trend (p = 0.18). Mean age was 57 years (22–88 years) with no sex difference (p = 0.42). Neoplasms (60%), HIV infection (17%) and systemic connective tissue disorders (CTD, 14%) were the most common predisposing conditions. MS was recorded in three cases (9%). The national level use of drugs that predispose to PML increased during the study period, with the exceptions of alemtuzumab and fludarabine. Overall survival was 85% at 90 days, 79% at 1 year, and 66% at 5 years. Survival was worst in patients with malignancy and best in patients with CTD.

Conclusions

PML most often occurs in patients with malignancies and patients with HIV or CTD cover a third. PML incidence in Finland is lower than in Sweden and shows no temporal trend despite increasing use of predisposing drugs. Mortality after PML varies according to the predisposing condition.

Electronic supplementary material

The online version of this article (10.1007/s00415-018-09167-y) contains supplementary material, which is available to authorized users.

Factors influencing multiple sclerosis disease-modifying treatment prescribing decisions in the United Kingdom: A qualitative interview study

BACKGROUND

The proportion of people with relapsing-remitting multiple sclerosis prescribed disease modifying treatments (DMTs) in the United Kingdom (UK) is considered low compared with other countries. There are differences in DMT prescription rates between UK nations (England, Wales, Scotland, Northern Ireland). Despite this, there has been little research into decision-making processes and prescribing practices.

OBJECTIVE

To investigate views and experiences of neurologists prescribing DMTs and MS specialist nurses to identify factors influencing prescribing.

METHODS

Semi-structured interviews with 18 consultant neurologists and 16 specialist nurses from diverse settings across the four UK nations. Data were analysed using thematic framework analysis.

RESULTS

Prescribing practices are influenced by organisational prescribing "cultures", informal "benchmarking" within peer networks, and prior experience with different DMTs. Health professionals differ in their perceptions of benefits and risks of DMTs and personal "thresholds" for discerning relapses and determining eligibility for DMTs. Prescribers in England felt most constrained by guidelines.

CONCLUSION

To achieve equity in access to DMTs for people with MS eligible for treatment, there is a need for public discussion acknowledging differences in health professionals' interpretations of "relapses" and guidelines and perceptions of DMTs, variation in organisational prescribing "cultures", and whether the prevailing culture sufficiently meets patients' needs.

Understanding treatment decisions from the perspective of people with relapsing remitting multiple Sclerosis: A critical interpretive synthesis

BACKGROUND

Multiple Sclerosis (MS) is a chronic inflammatory demyelinating disorder of the central nervous system that mainly affects young adults. While there is no cure for MS, disease modifying treatments (DMTs) reduce the relapse rate and partial accrual of disability. More effective DMTs may have higher risks including life-threatening infections or secondary autoimmunity. The complexity and novelty of available treatments cause challenges for clinicians when prescribing treatments and for people with MS (PwMS) when deciding what trade-offs they are willing and ready to make.

OBJECTIVE

To explore the experience of people with relapsing remitting MS (PwRRMS) and their perspectives in choosing treatments.

METHODS

Critical interpretive synthesis was employed to review and synthesis the published literature. Eighty-three publications were selected in a multi-step systematic process.

RESULTS

Findings are presented in four interrelated areas: the influence of the clinical evidence-base in decision making; the meaning of DMT efficacy for PwRRMS; the influence of models of decision-making and information acquisition practices in PwRRMS; and the importance of psychosocial dimensions in DMT decision making. Synthesis of the findings revealed that alongside medical and individual reasoning, contextual circumstances play an important role in making treatment decisions.

CONCLUSION

This review identifies and explains the importance of diverse contextual circumstances (clinical, social, psychological) that are important for PwRRMS when making treatment decisions. The findings demonstrate the importance of eliciting, understanding and addressing such contextual factors.

Numeracy of multiple sclerosis patients: A comparison of patients from the PERCEPT study to a German probabilistic sample

OBJECTIVE

A shared decision-making approach is suggested for multiple sclerosis (MS) patients. To properly evaluate benefits and risks of different treatment options accordingly, MS patients require sufficient numeracy - the ability to understand quantitative information. It is unknown whether MS affects numeracy. Therefore, we investigated whether patients' numeracy was impaired compared to a probabilistic national sample.

METHODS

As part of the larger prospective, observational, multicenter study PERCEPT, we assessed numeracy for a clinical study sample of German MS patients (N=725) with a standard test and compared them to a German probabilistic sample (N=1001), controlling for age, sex, and education. Within patients, we assessed whether disease variables (disease duration, disability, annual relapse rate, cognitive impairment) predicted numeracy beyond these demographics.

RESULTS

MS patients showed a comparable level of numeracy as the probabilistic national sample (68.9% vs. 68.5% correct answers, P=0.831). In both samples, numeracy was higher for men and the highly educated. Disease variables did not predict numeracy beyond demographics within patients, and predictability was generally low.

CONCLUSION

This sample of MS patients understood quantitative information on the same level as the general population.

PRACTICE IMPLICATIONS

There is no reason to withhold quantitative information from MS patients.

Treatment and disease management of multiple sclerosis patients: A review for nurse practitioners

BACKGROUND AND PURPOSE

This review discusses the role of the nurse practitioner (NP) in evaluating the clinical effects, potential side effects, and monitoring requirements for treatment options in multiple sclerosis (MS) and provides guidance on how to help patients understand these issues.

METHODS

A literature search was conducted on PubMed to identify publications on monitoring and disease management of MS patients. Additional resources included drug information web sites and package inserts.

CONCLUSIONS

NPs play an active role in the management of MS patients via effective monitoring and communication throughout the patient's treatment regimen and disease course. In the shared decision-making model of MS treatment, NPs ensure that patients understand the implications of their disease-modifying therapies (DMTs). As patients move through treatments during the course of their disease, the importance of this role increases, and it is critical that NPs follow the guidelines in each medication's product label and take into account any potential lingering effects of prior medications.

IMPLICATIONS FOR PRACTICE

It is critical for NPs to promote patient adherence, to ensure that patients understand treatment side effects and monitoring requirements, and to take sequencing and reversibility implications of DMTs into account when making clinical decisions.