Impact of Shared Decision Making on Disease-Modifying Drug Adherence in Multiple Sclerosis.

BACKGROUND: Shared decision making (SDM) and adherence to treatment are an integral part of multiple sclerosis (MS) care. A collaborative process, SDM actively involves the patient, the health care provider, and an extended network in making treatment decisions. Adherence to disease-modifying drug therapies in patients with MS presents an ongoing challenge for patients and health care providers due to the chronic nature of this disease. This narrative review aims to explore the impact of SDM on adherence based on existing literature and to identify new approaches to optimizing adherence. METHODS: A search was conducted using medical subject heading terms, including decision-making, adherence, shared decision-making, compliance, and patient-centered care. RESULTS: Shared decision making between patients and clinicians promotes adherence to the treatment plan in MS. A proactive SDM approach is based on patient preferences, education, and engagement. Providing credible and accurate sources of information is essential for improving patient engagement. Home monitoring, computerized models, and active patient engagement are a few new approaches to improve adherence in patients with MS. CONCLUSIONS: Shared decision-making interventions can have a positive effect on patient adherence to disease-modifying drug therapy in MS care. A range of new strategies is emerging that may help promote optimal disease management.

Loss of mobility and the patient burden of multiple sclerosis: expert opinion on relevance to daily clinical practice.

BACKGROUND: Walking impairment is one of the most visible and important manifestations of multiple sclerosis. MS Studies have consistently found that walking impairment occurs early during MS, and recent studies suggest that the greatest impact on socioeconomic outcomes occurs during the early stages of disability. Walking impairment is often perceived by the affected individual prior to its clinical manifestation, supporting the need for patient education and walking assessments that may be self-administered. Patient perceptions should lead to pre-emptive management strategies to maintain independence and delay the need for walking assistive devices or caregiving. Patient management should also include regular quantitative and qualitative assessments of walking by physicians or other clinicians, such as nurse practitioners, physician assistants, or physical therapists. METHODS: PubMed searches retrieved recent studies (November 2008 to August 2013) evaluating the contribution of walking impairment to the burden of MS. RESULTS: Several objective measures of walking are available, such as measures of walking speed (Timed 25-Foot Walk Test) and distance (2- or 6-Minute Walk); however, these measures may have practical considerations such as time and space. Patient-reported measures, which should have a low administration burden, include walking-specific (Multiple Sclerosis Walking Scale) and health-related quality-of-life outcome assessments. CONCLUSIONS: When used in tandem, patient-reported and objective measures can help monitor changes and facilitate patient-clinician discussions of problems, management strategies, and long-term goals related to walking impairment.

Multiple sclerosis in US minority populations: Clinical practice insights.

The heterogeneity of multiple sclerosis (MS) characteristics among various ethnic minority populations is a topic of recent interest. However, these populations are consistently underrepresented in clinical trials, leading to limited data on the effectiveness of treatments in these groups of patients and lack of an evidence-based approach to treatment. In order to achieve optimal disease management in the ethnic minority MS populations, a better understanding of the regional, socioeconomic, and cultural influences that result in underrepresentation of these groups in clinical trials is needed. Furthermore, it would be beneficial to identify the genetic factors that influence disease disparity in these minority populations. Suggestions for the identification and implementation of best practices for fostering the trust of ethnic minority patients with MS and enhancing their participation in clinical trials are offered.

Assessing relapse in multiple sclerosis questionnaire: results of a pilot study.

There is need for a brief but comprehensive objective assessment tool to help clinicians evaluate relapse symptoms in patients with multiple sclerosis (MS) and their impact on daily functioning, as well as response to treatment. The 2-part Assessing Relapse in Multiple Sclerosis (ARMS) questionnaire was developed to achieve these aims. Part 1 consists of 7 questions that evaluate relapse symptoms, impact on activities of daily living (ADL), overall functioning, and response to treatment for previous relapses. Part 2 consists of 7 questions that evaluate treatment response in terms of symptom relief, functioning, and tolerability. The ARMS questionnaire has been evaluated in 103 patients with MS. The most commonly reported relapse symptoms were numbness/tingling (67%), fatigue (58%), and leg/foot weakness (55%). Over half of patients reported that ADL or overall functioning were affected very much (47%) or severely (11%) by relapses. Prescribed treatments for relapses included intravenous and/or oral corticosteroids (87%) and adrenocorticotropic hormone (13%). Nearly half of patients reported that their symptoms were very much (33%) or completely resolved (16%) following treatment. The most commonly reported adverse events were sleep disturbance (45%), mood changes (33%), weight gain (29%), and increased appetite (26%). Systematic assessment of relapses and response to relapse treatment may help clinicians to optimize outcomes for MS patients.

Multiple sclerosis, relapses, and the mechanism of action of adrenocorticotropic hormone.

Relapses in multiple sclerosis (MS) are disruptive and frequently disabling for patients, and their treatment is often a challenge to clinicians. Despite progress in the understanding of the pathophysiology of MS and development of new treatments for long-term management of MS, options for treating relapses have not changed substantially over the past few decades. Corticosteroids, a component of the hypothalamic-pituitary-adrenal axis that modulate immune responses and reduce inflammation, are currently the mainstay of relapse treatment. Adrenocorticotropic hormone (ACTH) gel is another treatment option. Although it has long been assumed that the efficacy of ACTH in treating relapses depends on the peptide's ability to increase endogenous corticosteroid production, evidence from research on the melanocortin system suggests that steroidogenesis may only partly account for ACTH influences. Indeed, the melanocortin peptides [ACTH and α-, ß-, γ-melanocyte-stimulating hormones (MSH)] and their receptors (Melanocortin receptors, MCRs) exert multiple actions, including modulation of inflammatory and immune mediator production. MCRs are widely distributed within the central nervous system and in peripheral tissues including immune cells (e.g., macrophages). This suggests that the mechanism of action of ACTH includes not only steroid-mediated indirect effects, but also direct anti-inflammatory and immune-modulating actions via the melanocortin system. An increased understanding of the role of the melanocortin system, particularly ACTH, in the immune and inflammatory processes underlying relapses may help to improve relapse management.

Improving quality of life in multiple sclerosis: an unmet need.

Multiple sclerosis (MS) affects approximately 400,000 people in the United States and 2.1 million people worldwide. It is the most common chronic, non-traumatic neurological disorder afflicting young people during their peak productive ages. MS can diminish quality of life (QOL) by interfering with the ability to work, pursue leisure activities, and carry on usual life roles. Symptoms that affect QOL may include impaired mobility, fatigue, depression, pain, spasticity, cognitive impairment, sexual dysfunction, bowel and bladder dysfunction, vision and hearing problems, seizures, and sDwallowing and breathing difficulties. Direct medical costs of MS in the United States are estimated in excess of $10 billion per year. Indirect costs of MS include costs of reduced employment or unemployment, assistive equipment, disability related home modifications, and paid and unpaid personal care. Although direct medical costs predominate in the earlier stages of MS, indirect costs of productivity loss are responsible for higher costs later. Disease-modifying therapies (DMTs) lessen symptoms, reduce relapses, and delay disability progression. Unfortunately, many DMTs might produce only modest improvements in QOL. Although symptom-specific therapies do not delay disease progression, they may delay unemployment and dependency, thereby reducing indirect costs.

The evolving role of the multiple sclerosis nurse: an international perspective.

A greater understanding of the pathogenesis of multiple sclerosis (MS) and the need for treatments with increased efficacy, safety, and tolerability have led to the ongoing development of new treatments. The evolution of treatments for MS is expected to have a dramatic impact on the entire health-care team, especially MS nurses, who build strong collaborative partnerships with their patients. MS nurses help patients better understand their disease and treatment options, facilitate the initiation and management of treatment, and encourage adherence. With new oral therapies entering the market, the potential for increased efficacy, tolerability, adherence, and convenience for patients is evident. However, the resulting change in the treatment paradigm means that the skill set required of an MS nurse will inevitably expand. There will be a growing need for professional training and development to ensure that nurses are familiar with the wider range of treatments and their specific modes of action, dosing schedules, and benefit/risk profiles. In addition, the MS nurse's role will expand to include management of the complex monitoring needs specific to each therapy. This article explores how the role of the MS nurse is evolving with the development of new MS therapies, including novel oral therapies.

Injectable disease-modifying therapy for relapsing-remitting multiple sclerosis: a review of adherence data.

Long-term adherence to disease-modifying therapy in relapsing-remitting multiple sclerosis (RRMS) is associated with improved patient outcomes, including a reduced risk of relapse and a better preserved quality of life. However, the unpredictable nature of the disease--even when it is being treated--may make it difficult to convince patients of the importance of treatment adherence. A number of studies have attempted to pinpoint factors that affect adherence. Nursing interventions that address some of these factors may improve adherence and, thus, the disease course for a variety of RRMS patients. This article summarizes literature that approximates the prevalence and impact of nonadherence and reviews factors identified in clinical trials that affect adherence. Nursing interventions that can improve adherence, including telephone counseling and motivational interview techniques, are also addressed.

Factors that influence adherence and strategies to maintain adherence to injected therapies for patients with multiple sclerosis.

A key aspect of the management of care for patients with multiple sclerosis (MS) is identifying which patients are struggling with adherence. Disease-modifying therapies for the treatment of MS are primarily preventative, with modest efficacy, and they can possibly cause significant side effects. These factors can lead patients to stop taking their medication because they continue to experience symptoms or relapses of the disease, and/or they have painful injection-site reactions on most parts of their bodies. However, striving for 100% adherence to the prescribed treatment regimen remains the goal and is the surest way to reap all the benefits associated with immunomodulatory therapy. Building trust, promoting injection self-efficacy, and educating patients about proper injection techniques to prevent injection-site reactions have the greatest impact on patient adherence. Factors including family involvement, financial stability and support, hope, and faith can also have a positive impact on adherence. Identifying patients who may be struggling with depression, which is easily treatable but often not well addressed, and providing access to mental health services are important. Although many strides have been made with regard to MS patient care, outlining strategies that can maintain or encourage adherence can provide practitioners with tools to facilitate their patients' health and well-being.

Enhancing adherence through education.

The treatment of multiple sclerosis (MS) has advanced greatly since the introduction of disease-modifying therapies (DMTs) in the early 1990s. Although the DMTs have exhibited significant efficacy in relapsing-remitting MS and other forms of the disease, the degree of benefit depends heavily on patient adherence to recommended regimens. This article addresses some of the most pressing areas of unmet need in educating advanced-practice nurses, neurologists, patients, and support care partners regarding strategies that can overcome obstacles to adherence. The observations presented here are based on clinical experience with real-life cognitive, psychosocial, and cultural impediments to adherence. The article also explores the ways in which adherence may be affected by emerging therapies for MS (such as oral agents) as well as the educational needs that will arise with the further evolution of MS care.

Immunomodulatory effects of 3-hydroxy-3-methylglutaryl coenzyme-A reductase inhibitors, potential therapy for relapsing remitting multiple sclerosis.

This study characterized immunomodulatory targets of statins in humans and their potential for treatment of relapsing remitting multiple sclerosis (RR MS). Statins inhibited the proliferative response of mononuclear cells. Simvastatin, the statin with the strongest antiproliferative effect, inhibited IFN-gamma-induced expression of MHC class II DR on monocytes and decreased their antigen presenting capacity. As for T lymphocytes, it inhibited their activation and expression of the Th1 lineage differentiation markers. Simvastatin inhibited IFN-gamma, TNF-alpha, and IL-2 secretion, as well as the expression of T-bet, a transcription factor that regulates Th1 cell differentiation.