Many healthcare providers face the challenge of navigating an increasingly complex landscape of multiple sclerosis (MS) treatments. With over 20 different treatment options now available, compared to just four two decades ago, the task of selecting the most suitable treatment for each unique patient can be overwhelming. This is where the role of experienced, trusted providers is crucial in setting the most effective and appropriate treatment course tailored to each patient’s specific stage and experience with MS.
At Boston Medical Center’s (BMC) Multiple Sclerosis Center, nurse practitioner Kerin Flanagan and neurologist Konstantin Balashov, MD, PhD, FAAN, work daily with patients who are grappling with these complex medication choices. They adopt a patient-centered approach to treatment planning, ensuring that each plan is tailored to the individual’s comprehensive needs.
BMC’s Multiple Sclerosis Center, one of only three hospitals in Boston recognized by the National Multiple Sclerosis Society as a “Center for Comprehensive MS Care,” exemplifies this approach. These centers are recognized for their exceptional care, knowledge, and expertise in treating patients with MS. BMC further supports its providers with an onsite specialty pharmacy, offering easy access to both common and innovative MS treatments and therapies. This includes injectable and oral medications, with BMC’s on-site infusion center enabling prompt access to disease-modifying therapies.
To learn more about BMC’s personalized approach to the new world of MS medication options, we spoke with Flanagan and Balashov about treating the person rather than the disease.
HC: How do you begin a discussion about treatment with a newly diagnosed patient?
Kerin Flanagan, NP: Over the course of my 10 years working with MS patients at BMC, I’ve learned that it’s so important to meet each patient where they’re at. Some people are very eager to start treatment right away, and others need time for the diagnosis to become real to them before they can think about treatment.
I also think it’s important to give patients time to review their options on their own, outside of the clinic. So, I generally see my patients one to two weeks after their diagnosis to discuss their treatment plan, rather than overwhelming them in one visit. If a patient isn’t ready to start treatment, I schedule follow-ups to check in and review their diagnosis and the implications of delaying treatment. This helps improve compliance and gain the patient’s trust.
I always explain that early treatment for MS is the key to controlling symptoms and preventing long term disability, and though they may feel fine now, they will want to still feel their best when they’re 60. This is hard to conceptualize if you’re a previously healthy 20- to 30-year-old, but I want them to have the knowledge to make this decision.
HC: What types of MS treatments are available now?
Konstantin Balashov, MD, PhD: There are essentially two lines of treatment: symptomatic medication and disease-modifying therapies (DMT). Symptomatic medications help alleviate the symptoms of MS, for example, decreasing muscle spasms or leg pain. DMT is more preventative; we use it to decrease the chance of relapses and improve long-term prognosis.
Our teams at BMC tailors care based on each individual patient’s needs. There is no one treatment for everybody. At the same time, no one medication will control all MS-related symptoms and effects.
HC: What kinds of choices do you have to make with your patients when finding the right MS treatment path?
KB: Essentially, we make treatment decisions with patients based on a medication’s indication, efficacy, side effects, and safety.
For example, most injectable medications are relatively safe — they were introduced more than 25 years ago. I have patients who have been treated with them for 20 years and longer and are doing fine. These medications usually do not cause malignancy or life-threatening infection, but the efficacy is much lower compared to the newest IV infusion medications.
When my patient has active disease, I’m inclined to the newer medications — but since patients need an IV infusion, there are more risks involved, like increased risk for infection. In that case, we need to be more vigilant. Oral medications sit between the injectable medications and IV infusions in that they have moderate efficacy and moderate safety.
HC: How do you help your patients understand and choose an MS treatment that’s right for them?
KF: Knowledge is power, so my approach is to give patients all the information they need to empower them to make the choice that’s right for them. It takes more time to go over all the options, but it’s important to me that they have that knowledge to decide for themselves. I am there to support them and help guide them.
KB: Yes, we respect patients’ autonomy, their right to make decision.
KP: At the Multiple Sclerosis Center we also talk about things like their family, their culture, their support network, what they do for a living, and how they will get to the clinic. For example, my Muslim patients can’t take pills during the day during Ramadan [because they need to be taken with food]. Some patients don’t like needles. Some might have a hard time getting to the clinic because of work or childcare, so coming in once a month for an infusion might not be possible.
Also, because recent studies have shown that MS tends to progress faster and lead to more disability in the Black population, that’s something I also need to consider especially as a white provider, which is why building trust, providing all the necessary information, and allowing the patient to guide the visit is incredibly important.
KB: In parallel to this, in our Center, we provide help to a very diverse group of patients. This is actually very important when we’re talking about research and potential future treatment for MS. Now, pharmaceutical companies are very interested in having more inclusive, diverse clinical studies. That means we’re collaborating and studying, for example, to assess the effects of different medications on people of different races ethnicities, as well as looking at access to medical care for people with MS based on their background.
HC: How does treatment change as a patient’s multiple sclerosis progresses?
KF: MS is interesting because you never know how it’s going to progress in a given patient. And there’s a wide range of thought on how to treat people and what stages need treatment, so it’s always evolving and changing, and we stay on top of that. I always let my patients know whenever any new treatments come out or if there are changes in any of the treatments, so they can reevaluate their plan to see if it still makes sense.
As their disease progresses, our MS providers take on the higher level of care that’s needed. We have a great team of compassionate, caring and intelligent providers who go above and beyond to make sure patients get the care they need, regardless of their life circumstances.
This interview has been edited and condensed for clarity and length.
This article was originally published in July 2023. It’s been updated with input from Konstantin Balshov, MD, PhD, FAAN.
