Despite the availability of over a dozen different disease-modifying therapies (DMTs) for the long-term management of multiple sclerosis (MS), evidence shows that clinicians have difficulty personalizing the selection of these therapies. To help address this issue it is important to assess the clinical decision-making process of clinicians who manage MS. .
A study utilizing a proprietary online medical simulation platform assessed the specific reasons why neurologists chose or avoided DMTs in patients with highly active MS.
A cohort of US-based neurologists who participated in a simulation-based CME intervention were evaluated. The simulation consisted of two cases presented in a platform that allowed physician learners to choose from lab tests and assessment scales as well as the free form identification of a specific diagnosis and appropriate therapeutic treatment. Both of the cases involved a patient with highly active MS and who is a candidate for higher efficacy DMTs. Clinical decisions made by the participants regarding assessment, diagnosis, and treatment are captured. After a physician learner identifies a specific DMT, he or she is then prompted to select an appropriate rationale for why a DMT was chosen. A rationale was also asked if a DMT was chosen which was not an immune reconstitution therapy. The data being reported focus only on the rationale portion of the simulation. Data were collected between June 6, 2019 and September 25, 2019.
112 neurologists completed the first case simulation and 80 neurologists completed the second case simulation. The first case was a patient diagnosed with MS 8 months ago and initially prescribed dimethyl fumarate, but is experiencing a debilitating relapse with new lesions on MRI. Among the monoclonal antibodies chosen by the learners, perceived efficacy was the most frequently chosen rationale. Fingolimod and siponimod were chosen due to the oral route of administration. In learners who did not choose alemtuzumab or cladribine, insurance coverage and adverse events were the reasons given for avoiding these therapies. In the second case, the patient was diagnosed with MS 22 months ago, was on several prior DMTs, and most recently experienced a relapse with new MRI lesions while receiving fingolimod. Learners who chose to treat this patient with cladribine and natalizumab did so because of its perceived efficacy. The most frequent reason for choosing alemtuzumab was because it results in immune reconstitution and those who chose ocrelizumab did so because of positive clinical trial data. In learners who did not choose alemtuzumab or cladribine, insurance coverage and adverse events were the most common reasons.
This study demonstrated that neurologists choose DMTs for different reasons depending on the case. Additional programming should continue to identify rationales for the selection of DMTs in clinically representative cases of MS.