Based on this evaluation, 43% of patients who were diagnosed with MS were untreated at BPVAHCS. Concern over treatment AEs, the inconvenience of injectable dosing, and patients who were not 100% service-connected and lost to follow-up because of the cost may have contributed to the poor rate of treatment.
Injected-based DMAs, such as interferon beta-1a, interferon beta-1b, and glatiramer acetate, were first introduced in the 1990s, but these proved to be inconvenient and triggered AEs, including injection site reactions. Overall, their efficacy was about 30%, with interferon beta-1a showing a 27% reduction in relapses.10 In 2010, oral DMAs, such as fingolimod, were FDA approved. These oral DMAs were a significant improvement over injectable DMAs but still had AEs. Hence, their use was restricted to neurologists by the BPVAHCS, and rightfully so.
Still, newer and more effective oral DMAs are showing promise, such as dimethyl fumarate, teriflunomide, and alemtuzumab. These new DMAs have significantly impacted the treatment of MS as they are not only easier for patients to adhere to and for neurologists to prescribe, but most significantly, have had a 50% decrease in the rate of relapse.10 Yet, the newer oral DMAs were less commonly prescribed than the older treatments at BPVAHCS.
Since this study did not demonstrate increased use of oral DMAs at the BPVAHCS, more PCP and neurologist-focused educational programs on the use of DMAs may be beneficial. Educational programs should lead to a reevaluation of patients with MS to consider oral DMAs, which offer better efficacy and fewer AEs. The newer oral DMAs have shown a higher reduction of T2 lesions, and the significantly decreased incidence of relapses in many other medical facilities is quite promising for the BPVAHCS.7-9
The data collected at BPVAHCS were part of a quality improvement (QI) study that will be used by the Neurology Department to follow up on the patients with MS in order to implement DMA therapies. A questionnaire was developed for following up with BPVAHCS patients with MS. The primary purpose of the questionnaire is to help neurologists identify the reasons patients avoid DMA therapies and to reduce the number of BPVAHCS patients not on the most efficacious MS DMA treatment.
Multiple sclerosis is a disease without a cure. Current treatment strategies focus on modifying the course of the disease and managing its symptoms. However, even as promising new treatments emerge, the current literature suggests that a significant number of patients diagnosed with MS are not receiving DMAs and may not be receiving optimal treatment.11
Findings from this study indicate that although DMAs are optimal for patients with MS, they may not be prescribed as frequently at BPVAHCS as they are at a non-VA care facility. It is unclear whether this finding is explained by an educational gap, clinical differences between non-VA and VA patients, organizational factors, or a combination of these variables. Further study is warranted to examine the use of DMAs among veterans with MS and factors that facilitate or impede optimal practice. The BPVAHCS will use data from this retrospective cohort study in a QI initiative for patients with MS. Findings from the QI initiative will be reported using the Standards for Quality Improvement Reporting Excellence.12,13
This material is the result of work supported with resources and the use of facilities at the Bay Pines VA Healthcare System.