There Are More Multiple Sclerosis Treatment Options Than Ever—Which Creates a New Obstacle

Multiple sclerosis (MS) is a complex chronic disease that requires a comprehensive approach to care. While researchers are still learning more about the nuances of MS, including who is most at risk, patients can now choose from a wide range of treatment options. In the past, treatment options for MS have been limited — there were about four options 20 years ago — but there has been a real expansion of the drug market, which now offers 23 different modalities. These therapies include disease-modifying medications that can slow the course of the condition and help reduce the frequency and severity of relapses of in many patients.

While having a wide range of medications to choose from is great news for people living with MS, the sheer number of options can be overwhelming.

In her role as a nurse practitioner (NP) in the Multiple Sclerosis Center at Boston Medical Center (BMC), Kerin Flanagan sees her patients grappling with these treatment choices every day. That's why she's made it her goal to help her patients find a treatment that will work best for them, wherever they are in their life.

To learn more about her personalized approach to MS treatment, HealthCity spoke with Flanagan 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. Starting medication is a life-altering decision, and they should have a few days to sit with it if they are clinically stable. 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.

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 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, and what are the kinds of choices patients need to make?

KF: Injectable medications have been around the longest — more than 20 years. Patients inject themselves anywhere from once a day to once every two weeks, depending on the medication. Then there are IV infusions. Those are given in the hospital at different frequency intervals, depending on the type. The newest treatment option are oral pills and infrequent infusions, which just became available in the last 10 to 15 years.

The side effects of all these types of medication really range from injection site reactions or nausea to more significant side effects, like liver or kidney damage and heart rhythm issues. For example, there are a handful of infusion medications that can cause a life-threatening brain infection. But each medication has its own risk assessment and sometimes these medications are more effective at preventing disease progression and relapse. This is the type of information that's really important for my patients to understand when making decisions about treatment.

For many patients, the choice often comes down to disease treatment versus side effects. One medication may have an 80% chance of preventing a relapse but has potentially severe side effects, while another may have less evidence on relapse prevention but has no side effects. Some people are more comfortable taking a risk with side effects to have a better chance of preventing relapse. It's a very personal decision.

HC: How do you help your patients understand and choose an MS treatment?

KF: While many MS providers may tell their patients what medication to begin when they get diagnosed, I don't feel like it's my place to tell patients what to do. Some of our patients are struggling with other issues in their lives, on top of having this chronic illness, so one approach is not for everyone.

While many MS providers may tell their patients what medication to begin when they get diagnosed, I don't feel like it's my place to tell patients what to do. Some of our patients are struggling with other issues in their lives, on top of having this chronic illness, so one approach is not for everyone.

I feel like 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.

I also talk with them about their lifestyle, because this can play a huge role in choosing a treatment that works for them. So, we 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]. And some patients don't like needles. Some might have a hard time getting to the clinic because of work or child care, so coming in once a month for an infusion might not be possible.

And 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.

Finally, everyone is at a different disease stage, so depending on whether their disease is mild or moderate, they may benefit from a more aggressive treatment.

HC: How does treatment change as patients' multiple sclerosis progresses?

KF: MS is interesting because you never know how it's going to progress in a 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 up or if there are changes in any of the treatments, so they can reevaluate their plan if it makes sense.

Generally, most patients' MS does progress over time, and we may need to re-evaluate their treatment. We don't have many options for progressive MS right now, but we are hoping that some of these newer medications may be able to delay secondary progression. It's too soon to tell, but that's what I hope for my patients.

As their disease progresses, our MS doctors take on the higher level of care that's needed. We have a great team of compassionate, caring and intelligent doctors, and they go above and beyond to make sure patients get the care they need.

This interview has been edited and condensed for clarity and length