Cost analysis of methylprednisolone treatment of multiple sclerosis patients

Visual recovery after oral high-dose methylprednisolone in acute inflammatory optic neuropathy

PURPOSE

High doses of venous corticosteroids are currently the only validated treatment for the management of optic neuritis (ON). The objective is to assess the changes in visual function parameters after oral high-dose methylprednisolone in patients with ON.

METHODS

A retrospective analysis of patients with acute ON was performed. Patients received 1 g per day of oral methylprednisolone for 3 to 5 days. Visual function was measured using the ETDRS test for visual acuity, 30-2 automated visual field test, contrast sensitivity test, and color vision test before treatment, 4 days, 2 weeks, 1 month and 3 months, and 6 months following treatment. To assess anatomical changes, optical coherence tomography of the ganglion cells was performed at various timepoints.

RESULTS

Between September 2014 and September 2016, a total of 29 patients were included in the study. More than 80% of patients had recovered normal visual acuity after 3 and 6 months. This recovery of all parameters of visual function was observed as early as 4 days but occurred predominantly within 15 days after the initiation of treatment. We observed a thinning of the ganglion cell layer during the follow-up, which mainly occurs within one month. The P100 wave of visually evoked potentials was discernible in all patients at 6 months. During the 6 years of follow-up, 2 patients had experienced a relapse of ON. No serious adverse effects were observed.

CONCLUSION

This study demonstrated a rapid recovery of all visual function parameters after oral high-dose methylprednisolone ON with no serious adverse effects.

Trends in Plasma Exchange Use in Optic Neuritis Hospitalizations in the United States

PURPOSE

To report use trends of plasma exchange (PLEX) as well as sociodemographic and medical comorbidities associated with PLEX in the United States.

DESIGN

Retrospective cross-sectional study.

PARTICIPANTS

Adult patients (≥ 18 years) admitted for inpatient hospitalization with a primary diagnosis of optic neuritis (ON).

METHODS

Data from the National Inpatient Sample database was compiled to assess PLEX use rates between 2000 and 2020. The cohorts of patients receiving PLEX versus not receiving PLEX were analyzed between quarter 4 of 2015 through 2020 (International Classification of Diseases, Tenth Revision [ICD-10], only) for patient sociodemographic variables, medical diagnoses, insurance types, hospital characteristics, cause of disease, time to therapy, length of stay (LOS), and total charges incurred.

MAIN OUTCOME MEASURES

Incidence of ON, incidence of PLEX, demographics, diagnoses associated with PLEX therapy, total charges, and LOS.

RESULTS

From 2000 through 2020, 11 209 patients hospitalized with a primary diagnosis of ON were identified, with a significant majority managed at urban teaching hospitals. Use of PLEX increased steadily over 2 decades from 0.63% to 5.46%. Use was greatest in the western United States and least in the eastern United States. In the subset of ICD-10 cases, 3215 patients were identified. The median time to therapy of PLEX was 1 day after admission, and PLEX use was highest in patients with neuromyelitis optica spectrum disorder (NMOSD) (21.21%) and lowest in multiple sclerosis-associated ON (3.80%). Use of PLEX was associated with significantly longer LOS and higher total charges incurred. Medical comorbidities associated with PLEX included adverse reaction to glucocorticoids (adjusted odds ratio [aOR], 31.50), hemiplegia (aOR, 28.48), neuralgia (aOR, 4.81), optic atrophy (aOR, 3.74), paralytic strabismus (aOR, 2.36), and psoriasis (aOR, 1.76).

CONCLUSIONS

Over the last 2 decades in the United States, PLEX therapy for ON has increased, with the highest use in the western United States and for patients with the diagnosis NMOSD ON.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Visual Outcomes Following Plasma Exchange for Optic Neuritis: An International Multicenter Retrospective Analysis of 395 Optic Neuritis Attacks

PURPOSE

To evaluate the effectiveness of plasma exchange (PLEX) for optic neuritis (ON).

METHODS

We conducted an international multicenter retrospective study evaluating the outcomes of ON following PLEX. Outcomes were compared to raw data from the Optic Neuritis Treatment Trial (ONTT) using a matched subset.

RESULTS

A total of 395 ON attack treated with PLEX from 317 patients were evaluated. The median age was 37 years (range 9-75), and 71% were female. Causes of ON included multiple sclerosis (108), myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) (92), aquaporin-4-IgG-positive neuromyelitis optica spectrum disorder (AQP4+NMOSD) (75), seronegative-NMOSD (34), idiopathic (83), and other (3). Median time from onset of vision loss to PLEX was 2.6 weeks (interquartile range [IQR], 1.4-4.0). Median visual acuity (VA) at the time of PLEX was count fingers (IQR, 20/200-hand motion), and median final VA was 20/25 (IQR, 20/20-20/60) with no differences among etiologies except MOGAD-ON, which had better outcomes. In 81 (20.5%) ON attacks, the final VA was 20/200 or worse. Patients with poor outcomes were older (P = .002), had worse VA at the time of PLEX (P < .001), and longer delay to PLEX (P < .001). In comparison with the ONTT subset with severe corticosteroid-unresponsive ON, a final VA of worse than 20/40 occurred in 6 of 50 (12%) PLEX-treated ON vs 7 of 19 (37%) from the ONTT treated with intravenous methylprednisolone without PLEX (P = .04).

CONCLUSION

Most ON attacks improved with PLEX, and outcomes were better than attacks with similar severity in the ONTT. The presence of severe vision loss at nadir, older age, and longer delay to PLEX predicted a worse outcome whereas MOGAD-ON had a more favorable prognosis. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.

Effect of Treating Acute Optic Neuritis With Bioequivalent Oral vs Intravenous Corticosteroids: A Randomized Clinical Trial

Importance

Intravenous (IV) administration of corticosteroids is the standard of care in the treatment of acute optic neuritis. However, it is uncertain whether a bioequivalent dose of corticosteroid administered orally, which may be more cost-efficient and convenient for patients, is as effective as IV administration in the treatment of acute optic neuritis.

Objective

To determine whether recovery of vision following treatment of acute optic neuritis with a high-dose IV corticosteroid is superior to that with a bioequivalent dose of an oral corticosteroid.

Design, Setting, and Participants

This single-blind (participants unblinded) randomized clinical trial with 6-month follow-up was conducted at a single tertiary care center in London, Ontario, Canada. Participants were enrolled from March 2012 to May 2015, with the last participant's final visit occurring November 2015. Patients 18 to 64 years of age presenting within 14 days of acute optic neuritis onset, without any recovery at time of randomization and without history of optic neuritis in the same eye, were screened. Inclusion criteria included best-corrected visual acuity (BCVA) of 20/40 or worse and corticosteroids deemed required by treating physician. In total, 89 participants were screened; 64 were eligible, but 9 declined to participate. Thus, 55 participants were enrolled and randomized. Primary analysis was unadjusted and according to the intention-to-treat principle.

Interventions

Participants were randomized 1:1 to the IV methylprednisolone sodium succinate (1000-mg) or oral prednisone (1250-mg) group.

Main Outcomes and Measures

Primary outcome was recovery of the latency of the P100 component of the visual evoked potential at 6 months. Secondary outcomes were the P100 latency at 1 month and BCVA as assessed with Early Treatment Diabetic Retinopathy Study letter scores on the alphabet chart and scores on low-contrast letters at 1 and 6 months.

Results

Of 55 randomized participants, the final analyzed cohort comprised 23 participants in the IV and 22 in the oral treatment groups. The mean (SD) age of the cohort was 34.6 (9.5) years, and there were 28 women (62.2%). At 6 months' recovery, P100 latency in the IV group improved by 62.9 milliseconds (from a mean [SD] of 181.9 [53.6] to 119.0 [16.5] milliseconds), and the oral group improved by 66.7 milliseconds (from a mean [SD] of 200.5 [67.2] to 133.8 [31.5] milliseconds), with no significant difference between groups (P = .07). Similarly, no significant group difference was found in the mean P100 latency recovery at 1 month. For BCVA, recovery between the groups did not reach statistical significance at 1 month or 6 months. In addition, improvements in low-contrast (1.25% and 2.5%) BCVA were not significantly different between treatment groups at 1 or 6 months' recovery.

Conclusions and Relevance

This study finds that bioequivalent doses of oral corticosteroids may be used as an alternative to IV corticosteroids to treat acute optic neuritis.

Trial Registration

clinicaltrials.gov Identifier: NCT01524250.

Impact of a national medical fee schedule revision on the cessation of physician home visits among older patients in Tokyo: A retrospective study

As Japan's population continues to age rapidly, the national government has implemented several measures to improve the efficiency of healthcare services and to control rising medical expenses for older patients. One such measure was the revision of the medical fee schedule for physician home visits in April 2014, in which eligibility for these visits was restricted to patients who are unable to visit outpatient clinics without assistance. Through an investigation of patients who were receiving physician home visits in Tokyo, this study examines whether this fee schedule revision resulted in an increase in patients who transitioned from home visits to outpatient care. In a retrospective analysis of health insurance claims data, we examined 80,914 Tokyo residents aged 75 years or older who had received at least one physician home visit between January and May 2014. The study period was divided into four periods (January-February, February-March, March-April, and April-May), and we examined the number of patients receiving home visits in the index month of each period who subsequently transitioned to outpatient care in the following month. Potential factors associated with this transition to outpatient care were examined using a generalised estimating equation. The March-April period that included the fee schedule revision was significantly associated with a higher number of patients who transitioned from home visits in the index month to outpatient care in the following month (odds ratio: 4.46, p < 0.001) than the other periods. In addition, patients receiving home visits at residential facilities were more likely to transition to outpatient care (odds ratio: 10.40, p < 0.001). These findings indicate that the fee schedule revision resulted in an increase in patients who ceased physician home visits and began visiting outpatient clinics for treatment.

Oral versus intravenous steroids for treatment of relapses in multiple sclerosis

BACKGROUND

This is an updated Cochrane review of the previous version published (Cochrane Database of Systematic Reviews 2009, Issue 3. Art. No.: CD006921. DOI: 10.1002/14651858.CD006921.pub2).Multiple sclerosis (MS), a chronic inflammatory and neurodegenerative disease of the central nervous system (CNS), is characterized by recurrent relapses of CNS inflammation ranging from mild to severely disabling.  Relapses have long been treated with steroids to reduce inflammation and hasten recovery.  However, the commonly used intravenous methylprednisolone (IVMP) requires repeated infusions with the added costs of homecare or hospitalization, and may interfere with daily responsibilities. Oral steroids have been used in place of intravenous steroids, with lower direct and indirect costs.

OBJECTIVES

The primary objective was to compare efficacy of oral versus intravenous steroids in promoting disability recovery in MS relapses <= six weeks.  Secondary objectives included subsequent relapse rate, disability, ambulation, hospitalization, immunological markers, radiological markers, and quality of life.

SEARCH METHODS

A literature search was performed using Cochrane Multiple Sclerosis and Rare Diseases of the Central Nervous System Group's Trials Register (January 2012), abstracts from meetings of the American Academy of Neurology (2008-2012), the European Federation of Neurological Sciences (2008-2012), the European Committee for Treatment and Research in Multiple Sclerosis and American Committee for Treatment and Research in Multiple Sclerosis (2008-2012) handsearching. No language restrictions were applied.

SELECTION CRITERIA

Randomized or quasi-randomized trials comparing oral versus intravenous steroids for acute relapses (<= six weeks) in patients with clinically definite MSover age 16 were eligible.

DATA COLLECTION AND ANALYSIS

Three review authors (JB, PO and MH) participated in the independent assessment of all published articles as potentially relevant to the review. Any disagreement was resolved by discussion among review authors.We contacted study authors for additional information.Methodological quality was assessed by the same three review authors. Relevant data were extracted, and effect size was reported as mean difference (MD), mean difference (MD), odds ratio (OR) and absolute risk difference (ARD).

MAIN RESULTS

With this current update, a total of five eligible studies (215 patients) were identified. Only one outcome, the proportion of patients with Expanded Disability Status Scale (EDSS) improvement at four weeks, was common to three trials, while two trials examined magnetic resonance imaging (MRI) outcomes. The results of this review shows there is no significant difference in relapse recovery at week four (MD -0.22, 95% confidence interval (95% CI), 0.71 to 0.26, P = 0.20) nor differences in magnetic resonance imaging (MRI) gadolinium enhancement activity based on oral versus intravenous steroid treatment. However, only two of the five studies employed more current and rigorous methodological techniques, so these results must be taken with some caution. The Oral Megadose Corticosteroid Therapy of Acute Exacerbations of Multiple Sclerosis (OMEGA) trial and the "Efficacy and Safety of Methylprednisolone Per os Versus IV for the Treatment of Multiple Sclerosis (MS) Relapses" (COPOUSEP) trial, designed to address such limitations, are currently underway.

AUTHORS' CONCLUSIONS

The analysis of the five included trials comparing intravenous versus oral steroid therapy for MS relapses do not demonstrate any significant differences in clinical (benefits and adverse events), radiological or pharmacological outcomes. Based on the evidence, oral steroid therapy may be a practical and effective alternative to intravenous steroid therapy in the treatment of MS relapses.

The socioeconomic consequences of multiple sclerosis: a controlled national study

Multiple sclerosis (MS) has serious negative effects on health-, social-, and work-related issues for the patients and their families, thus causing significant socioeconomic burden. The objective of the study was to determine healthcare costs and indirect illness costs in MS patient in a national sample. We used all national records from the Danish National Patient Registry (1998-2006), and identified 10,849 MS patients which were compared with 43,396 randomly age-, sex- and social matched citizens. Healthcare sector costs included frequencies and costs of hospitalizations and weighted outpatient use, frequencies of visits and hospitalizations and costs from primary sectors, and the use and costs of drugs. Productivity costs (the value of lost productivity from time off from work due to illness) and all social transfer payments were also calculated. Patients with MS had significantly higher rates of health-related contact and medication use and very low employment rate which incurred a higher socioeconomic cost. The income level of employed MS patients was significantly lower than that of control subjects. The annual total health sector costs and productivity costs were €14,575 for MS patients vs. €1163 for control subjects (p<0.001), corresponding to an annual mean excess health-related cost of €13,413 for each patient with MS. In addition, the MS patients received an annual mean excess social transfer income of €6843. MS present social and economical consequences more than eight years before diagnosis. We conclude that MS causes major socioeconomic consequences for the individual patient and for society. Productivity costs are a far more important economic factor, especially due to reduced employment, which are enhanced by the early age of diagnose onset.

Treatment modalities for Graves' ophthalmopathy: systematic review and metaanalysis

BACKGROUND

Graves' ophthalmopathy (GO) is a common cause of morbidity in patients with Graves' disease. Optimal treatment of GO remains unclear, and an evidence-based approach may improve patients' outcome.

METHODS

A systematic review and metaanalysis of randomized, controlled trials comparing treatment modalities for GO vs. placebo, no intervention, or other treatments. Primary outcome was the clinical activity score (CAS).

RESULTS

Thirty-three trials evaluating 1367 patients fulfilled inclusion criteria. In patients with moderate to severe GO, iv pulse corticosteroids were significantly better than oral corticosteroids in reducing CAS [standardized mean difference -0.64, 95% confidence interval (CI) -1.11 to -0.17, chi(2) 7.91, I(2) 62%, random effect], with lower rate of adverse events. Somatostatin analogs showed a minor but statistically significant advantage over placebo (mean difference -0.63, 95% CI -0.98 to -0.28). There was no advantage of orbital radiotherapy over sham radiation in CAS, but radiotherapy was superior for response rates of diplopia (odds ratio 4.88, 95% CI 1.93-12.34, two trials). Treatment with combination of orbital radiotherapy and corticosteroids was significantly better than with either treatment alone (standardized mean difference -1.05, 95% CI -1.62 to -0.48).

CONCLUSIONS

Current evidence demonstrates the efficacy of iv corticosteroids in decreasing CAS in patients with moderate to severe GO. Intravenous pulse corticosteroids therapy has a small but statistically significant advantage oral therapy and causes significantly fewer adverse events. Somatostatin analogs have marginal clinical efficacy. The efficacy of orbital radiotherapy as single therapy remains unclear, whereas the combination of radiotherapy with corticosteroids has better efficacy than either radiotherapy or oral corticosteroids alone.

Oral versus intravenous steroids for treatment of relapses in multiple sclerosis

BACKGROUND

Multiple Sclerosis (MS), a chronic inflammatory and neurodegenerative disease of the central nervous system (CNS), is characterized by recurrent relapses of CNS inflammation ranging from mild to severely disabling. Relapses have long been treated with steroids to reduce inflammation and hasten recovery. However, the commonly used intravenous methylprednisolone requires repeated infusions with the added costs of homecare or hospitalization, and may interfere with daily responsibilities. Oral steroids have been used in place of intravenous steroids, with lower direct and indirect costs.

OBJECTIVES

The primary objective was to compare efficacy of oral versus intravenous steroids for MS relapses <= 6 weeks. Secondary comparisons included subsequent relapse rate, disability, ambulation, hospitalization, immunological markers, radiological markers, and quality of life.

SEARCH STRATEGY

A literature search was performed using Cochrane MS Group Trials Register (July 2008), Cochrane Central Register of Controlled Trials (CENTRAL) "The Cochrane Library 2008, issue 3, MEDLINE (PubMed) (1966-July 2008), EMBASE (1980-July 2008), abstracts from meetings of the American Academy of Neurology (2002-2008), the European Federation of Neurological Sciences (2002-2008), the European Committee for Treatment and Research in Multiple Sclerosis and American Committee for Treatment and Research in Multiple Sclerosis (2002-2008) handsearching. No language restrictions were applied.

SELECTION CRITERIA

Randomized or quasi-randomized trials comparing oral and intravenous steroids for acute relapses (<=30 days) in clinically definite MS patients over age 16 were eligible.

DATA COLLECTION AND ANALYSIS

Methodological was assessed using trial publications and personal communication. Elevant data was extracted, and effect size was reported as mean difference (MD),weighted mean difference (WMD), odds ratio (OR) and absolute risk difference (ARD).

MAIN RESULTS

Eligible studies (167 patients) were identified. Only one outcome, the proportion of patients with EDSS improvement at 4 weeks, was common to three trials. Otherwise outcomes were too heterogeneous to pool. Only one trial employed an equivalence design, but all reported no statistically significant difference in outcomes between groups. Namely, there was no significant difference in the degree of recovery 4 weeks following treatment. No difference was found in subsequent relapse rate, disability, hospitalization, ambulation, bioavailability, or in magnetic resonance imaging (MRI). Due to methodological limitations, heterogeneous treatment regimens and limited data, formal conclusions about equivalence of oral and intravenous steroidscannot be made. Oral Megadose Corticosteroid Therapy of Acute Exacerbations of Multiple Sclerosis (OMEGA) trial, designed to address such limitations, is currently underway.

AUTHORS' CONCLUSIONS

The trials reviewed support the hypothesis that no significant differences in clinical, radiological or pharmacological outcomes oral and intravenous steroids for MS relapses exist. However, with the small number of patients and methodological limitations, conclusions of equivalence are premature.

Home administration of intravenous methylprednisolone for multiple sclerosis relapses: the experience of French multiple sclerosis networks

BACKGROUND

One single center study has provided support for a home-based approach to the therapeutic management of multiple sclerosis (MS) relapse.

OBJECTIVE

To report a multicenter series of patients with MS who were treated at home for a relapse with a 3-day course of intravenous methylprednisolone.

METHODS

The home administration of intravenous methylprednisolone was coordinated by four MS networks in France; patients with MS with a relapse were referred by their neurologists, and treatment was administered by a local nurse. We analyzed the safety and efficiency of this approach and estimated the related cost savings. Patients completed a patient satisfaction questionnaire.

RESULTS

Eight hundred and seven patients received intravenous methylprednisolone at home. The mean disease duration was 10.3 +/- 7.9 years. Treatment was often prescribed by community-based neurologists. The delay between prescription and treatment was 2.8 +/- 0.5 days if treatment was initiated at home and 1.9 +/- 3.0 days if treatment was initiated in hospital (the subsequent two injections were always administered at home). Home treatment was well tolerated; three serious side effects requiring hospital transfer were observed (anxiety, thoracic oppression, and arrhythmia), which were fully reversible. Overall, 93.8% of patients were satisfied with the treatment approach, and 98% wished to receive future treatment courses at home. The overall cost savings of home-based treatment versus hospital-based treatment were evaluated at EUR1,091,482.

CONCLUSION

Safety data, patient satisfaction, and economic considerations support home-based treatment of MS relapses with intravenous methylprednisolone, provided strict patient selection criteria are observed and the process is coordinated and closely monitored by an MS network.

Multiple sclerosis: diagnosis and the management of acute relapses

Multiple sclerosis is an inflammatory demyelinating disease of the central nervous system that may result in a wide range of neurological symptoms and accumulating disability. Its course is unpredictable resulting in a changing pattern of clinical need. Diagnostic criteria for multiple sclerosis require objective evidence for dissemination in space and time. The diagnostic and management process should follow good practice guidelines with the person at the centre of the process. Appropriate support and information should be available from the time of diagnosis. Continuing education is key in enabling the person to actively participate in their management. In the event of an acute relapse the person should have direct access to the most appropriate local service. Provided medical causes have been excluded, corticosteroid treatment to hasten the recovery from the relapse should be considered. Management of an acute relapse should be comprehensive addressing any medical, functional, or psychosocial sequelae.

Incremental cost analysis of ambulatory clinic and home-based intravenous therapy for patients with multiple myeloma

BACKGROUND

Patients with multiple myeloma and other forms of cancer receiving pamidronate via intravenous (IV) infusion at the Hamilton Regional Cancer Centre in Hamilton, Ontario, Canada face 2 treatment options: they can have their entire treatment completed at the clinic using traditional IV therapy (e.g. IV bag and pole) or they can have the treatment initiated at the clinic and then return home to complete the treatment utilising a portable and disposable IV therapy device.

OBJECTIVE

To perform a cost analysis of these 2 treatment options.

PERSPECTIVE

Societal.

METHODS AND PATIENTS

Data on all patients with multiple myeloma who attended the Hamilton Regional Cancer Centre for pamidronate therapy from November 1, 1997 to October 31, 1998 were collected from clinic records. As almost all of these patients with multiple myeloma completed their IV therapy at home, comparison to clinic-based therapy was based on derived cost estimates. Cost data, where possible, were acquired from the Hamilton Regional Cancer Centre's records. A sensitivity analysis was also conducted.

RESULTS

In the base-case scenario for the study period, the incremental cost of the infusion device and training in Canadian dollars ($Can; 1998 values) for the 48 patients (299 cycles) who had their infusion initiated at the clinic but completed at home was $Can 5.50/cycle ($Can 4,636 for the 299 cycles). If these 48 patients had had their entire infusion at the clinic, the incremental costs of overtime treatment, parking, clinic overheads and lost work or leisure time would have been $Can 68.49/cycle ($Can 20,477 for the 299 cycles). Therefore, shifting treatment from the clinic to the home resulted in net cost savings to society of $Can 52.98/cycle ($Can 15,841 for the 299 cycles). Sensitivity analysis of best- and worst-cost scenarios did not alter the substantive findings although the relative difference between treatment options varied. In the best-case scenario, home treatment was $Can 95.97/cycle ($Can 28,696 for the 299 cycles) less costly than clinic treatment, while in the worst-case scenario, home treatment was $Can 17.19/cycle ($Can 5,141 for the 299 cycles) less costly than clinic treatment. The results also demonstrated that clinic overheads, the cost of a portable and disposable infusion device and the cost of lost work and leisure time had the greatest impact on incremental costs for each treatment option.

CONCLUSION

Subject to study limitations, a significant cost advantage was demonstrated through the home-based treatment option for patients with multiple myeloma. Key issues that must be addressed in future evaluations include the precise determination of clinic overheads, the valuation of lost work and/or leisure time and the direct cost of portable and disposable infusion devices.