Outcomes in a Modern Cohort of Treated Patients with Multiple Sclerosis from Diagnosis Up to 15 Years

Impact of adherence to disease modifying therapies on long-term clinical and economic outcomes in multiple sclerosis: A claims analysis of real-world data

BACKGROUND

Multiple sclerosis (MS) is a chronic neurodegenerative inflammatory disease that requires long-term commitment to treatment for optimal outcomes. A variety of disease-modifying therapies (DMTs) are now available that reduce relapses and delay disease progression in people with MS. However, adherence remains a significant issue, with a variety of mental, physical, and emotional factors contributing to non-adherence. In a large number of studies, non-adherence has been associated with worse clinical outcomes (relapses and disease severity), a higher economic burden, and loss of work productivity. However, many of these studies were short-term (1-2 years) or cross-sectional studies; thus, more data are needed on the long-term clinical and economic impacts of DMT non-adherence. The objective of this study was to determine the longer-term impact of adherence to DMTs on disease activity and healthcare resource utilization (HCRU) in people with MS. The study hypothesis was that non-adherence to DMTs would be associated long-term with worse clinical outcomes and a higher economic burden.

METHODS

A retrospective administrative claims analysis of the US MarketScan® Commercial database (2011-2017) in individuals (18-65 years) with MS (based on International Classification of Disease coding) was conducted. Adherence was classified by proportion of days covered (PDC) ≥0.8 and non-adherence by PDC <0.8; sensitivity analyses helped further categorize as moderately (PDC ≥0.6-<0.8) or highly (PDC <0.6) non-adherent. Cohorts were matched using propensity score matching. Time to first relapse, annualized relapse rate (ARR), time to use of assistive devices (cane/walker or wheelchair), and annual HCRU (inpatient, emergency room [ER], outpatient, and MRI visits and costs) were compared between cohorts.

RESULTS

10,248 MS cases were identified; 58% met adherence criteria, and 42% met non-adherence criteria. Mean follow-up from diagnosis or first DMT claim was 5.3 years. Adherent individuals had a longer time to first relapse (hazard ratio [HR] 0.83; 95% confidence interval [CI]: 0.77-0.90; p<0.0001), a lower ARR (0.13 vs. 0.18, respectively; rate ratio [RR] 0.75 [95% CI: 0.71-0.79]; p<0.0001), and longer lag times to cane/walker use (HR 0.79 [95% CI: 0.66-0.94]; p=0.0067) and wheelchair use (HR 0.68 [95% CI: 0.55-0.83]; p=0.0002) than non-adherent individuals. Adherent individuals had fewer annual inpatient and ER visits and lower total costs than those who were non-adherent (p<0.0001). Sensitivity analyses showed that differences in disease activity and HCRU were generally more pronounced between matched adherent and highly non-adherent pairs than between matched adherent and moderately non-adherent pairs.

CONCLUSION

Significant differences in MS disease activity and HCRU were observed based on adherence to DMTs. Our study underscores the negative impact of non-adherence to DMTs on long-term clinical and economic outcomes in MS.

Update on brain MRI for the diagnosis and follow-up of MS patients

Over the past decades, MRI has become a major tool in the diagnosis and the follow-up of patients with multiple sclerosis (MS), especially for monitoring the effectiveness of therapy. The recent international recommendations issued for the standardization of neurological and radiological clinical practices converge on many points. In this setting, recommendations made by the "Observatoire français de la sclérose en plaques", the French MS registry, can be distinguished by its interdisciplinary complementarity, its longevity, its size, and its positions in direct connection with the clinic. Hence, after suspicions of gadolinium deposition in the brain, with multiple warning from the American and European health authorities, a national consultation took place and resulted in limitation to useful injections. The precautionary principle prevailing, the patient receives a limited quantity of contrast product even if no clinically harmful manifestation has been detected to date. The result of this round table bringing together neurologists and neuroradiologists from specialized centers was published in the form of a recommendation in early 2020. The interest of this project also lies in the constant improvement of the management of patients with MS and the possibility of developing advanced techniques to assist the clinician. The aim of this review is to explain to the neurologist, the interest of following this imaging protocol both in his/her clinical practice and in the possibilities that this opens up.

Real world prognosis in MS: does early versus late diagnosis matter?

BACKGROUND

Multiple sclerosis (MS) often presents soon after the onset of a recognized clinically isolated syndrome (CIS). In order to interpret data from CIS trials, it is important to know whether patients presenting as classical CIS provide group data representative of RRMS.

OBJECTIVE

We aimed to determine whether or not MS patients presenting soon after the onset of symptoms with clinically isolated syndromes have an identifiable clinical profile, including worse outcomes, versus MS patients presenting later.

METHODS

Chart review of consecutive patients with newly diagnosed relapsing MS, diagnosed in our clinic between 1989 and 2005. We divided patients into an early presentation group (EP), versus the remaining late presenting group (LP), and analyzed the impact of delay in presentation on 10- and 15-year disability outcomes. We also sought to identify reasons for later presentation.

RESULTS

The two groups were similar in terms of many demographics, clinical risk factors, and long-term disability outcomes (median EDSS 2.25 versus EDSS 2.0 at 10 years). Exceptionally, patients in the EP group had more frequent attacks in the first few years after onset and were diagnosed and treated earlier.

CONCLUSIONS

Patients in our MS clinic with EP versus LP were more likely to have multiple attacks in the first 2 years after onset and were treated earlier, but did not have a better 10- or 15-year outcome.

The impact of multiple sclerosis relapses on worsening over the long term; insights in the treatment era

Relapses of multiple sclerosis (MS) are the clinical manifestations of inflammatory events involving eloquent anatomical structures within the central nervous system. Relapses are associated with worsening disability of MS patients in both early and later disease, even after progressive features are seen. The impact of relapses on the long-term course of the disease is now being realized as a generation of treated patients is now elderly. New MRI brain lesions can be viewed as a radiologic manifestation of acute inflammation and are associated with similar prognostic value. The complex relationship between clinical relapse activity and later slow progressive worsening remains incompletely understood, however, there is increasing biological plausibility for a causative association between relapse activity and lifelong disability.