Mastering Multiple Sclerosis: Challenges and Opportunities For Managed Care Pharmacists
Including proceedings from a roundtable held in San Diego, California
Activity Date: October 2007  — Activity Info: Volume 4, (11)
Goals & Objectives | Faculty | Introduction | Full Activity Content | CME Test & Evaluation (CME Expired)

Mastering Multiple Sclerosis: Challenges and Opportunities For Managed Care Pharmacists
Jacquelyn L. Bainbridge, PharmD, FCCP*

Multiple sclerosis (MS) is a chronic, usually progressing, neurologic condition that is among the leading causes of long-term disability in the United States. The effects of MS are often devastating, and it remains the most common disabling neurologic condition among young adults.1 Recent research has highlighted the importance of early diagnosis and treatment of MS. Brain imaging studies using newer techniques, such as diffusion tensor magnetic resonance imaging (MRI), have demonstrated that the signs of neurologic injury are present long before symptoms first appear. These studies have also demonstrated that MS also produces early, subtle signs of disturbance in the brain's gray matter, and in regions of white matter that appear normal using conventional MRI scanning.2 In addition, clinical research suggests that early initiation of therapy slows the long-term progression of MS.3-5

As in other chronic, progressive disorders, the principal goals of treatment are to improve symptoms and to modify the long-term progression of the disease.6 Although there is no cure for MS, a number of treatments that reduce the frequency of attacks or slow disease progression have been introduced during the past 10 to 15 years. These new therapies help to reduce the disability associated with MS, but they also create new challenges within the managed care environment. All of these newer medications are costly, and it can be difficult to evaluate the long-term economic impact of new therapies because any effect on disease progression may not be apparent until several years have passed.6 Some patients do not respond to treatment with conventional medications (interferon beta or glatiramer acetate), and many experience significant difficulties with treatment adherence due to adverse effects. Other patients respond initially but experience a gradual loss of treatment efficacy over time due to the formation of neutralizing antibodies against MS medications.7 In addition, treatments may affect the symptoms or progression of MS in complex ways. Some agents primarily affect the severity or duration of an ongoing relapse, whereas others may prevent future relapses. Few randomized controlled clinical trials have directly compared the efficacy, safety, and costs of the available and emerging treatment options. Due to the cost, potential for treatment nonresponse, and risk of adverse effects, there is considerable interest in identifying patients who are most likely to benefit from therapy. Experts in MS care have proposed various treatment algorithms or other systematic approaches to MS treatment to try to optimize treatment efficacy and minimize the risk of adverse events.8 These approaches will require further evaluation and refinement as new treatments become available and are characterized in clinical trials.

This issue of University of Tennessee Advanced Studies in Pharmacy provides an update and overview of recent research regarding the diagnosis and treatment of MS for managed care pharmacists. Managed care pharmacists play a key role in the management of patients with MS by educating patients and fellow clinicians, monitoring therapeutic efficacy, and screening for potential adverse effects. In addition, the managed care pharmacist must make difficult and complex decisions regarding the effects of MS and its treatment on health systems, managed care plans, and large patient groups. This monograph will provide managed care pharmacists with a thorough and timely update, including practical strategies for translating the latest medical and scientific developments into the best possible patient outcomes and unique perspectives in the managed care setting.

In the first article, Ellen Whipple Guthrie, PharmD, provides a general overview of the epidemiology, pathogenesis, and diagnosis of MS. This presentation highlights several of the important fundamental challenges in the management of MS, including the variable initial presentation and clinical course of MS, our limited understanding of the precise causes of the disorder, and difficulty with adherence to treatment that many patients experience. In the second article, Melody Ryan, PharmD, MPH, BCPS, CGP, reviews current treatment options for relapsing-remitting MS (RRMS), the most common clinical presentation. Although a number of agents are available to prevent new relapses, surprisingly few studies have directly compared the efficacy, safety, and tolerability of the available agents with one another. Despite therapy for RRMS, most patients will eventually progress to a more persistent form of progressive MS. Treatment options for progressing MS or for patients who are not responding adequately to their initial therapy are described by Jeffrey L. Bennett, MD, PhD. I provide a brief overview of the economic impact of MS. The monograph concludes with a final discussion of the role of managed care pharmacy in MS treatment moderated by Richard L. Cook, PharmD.


1.    Murray TJ. Diagnosis and treatment of multiple sclerosis. BMJ. 2006;332:525-527.
2.    Kutzelnigg A, Lucchinetti CF, Stadelmann C, et al. Cortical demyelination and diffuse white matter injury in multiple sclerosis. Brain. 2005;128:2705-2712.
3.    Comi G, Filippi M, Barkhof F, et al. Effect of early interferon treatment on conversion to definite multiple sclerosis: a randomised study. Lancet. 2001;357:1576-1582.
4.    Jacobs LD, Beck RW, Simon JH, et al. Intramuscular interferon beta-1a therapy initiated during a first demyelinating event in multiple sclerosis. N Engl J Med. 2000;343:898-904.
5.    Kinkel RP, Kollman C, O'Connor P, et al. IM interferon beta-1a delays definite multiple sclerosis 5 years after a first demyelinating event. Neurology. 2006;66:678-684.
6.    Kobelt G, Jonsson L, Fredrikson S. Cost-utility of interferon beta-1b in the treatment of patients with active relapsing-remitting or secondary progressive multiple sclerosis. Eur J Health Econ. 2003;4:50-59.
7.    The IFNB Multiple Sclerosis Study Group, University of British Columbia MS/MRI Analysis Group. Neutralizing antibodies during treatment of multiple sclerosis with interferon beta-1b: experience during the first three years. Neurology. 1996;47:889-894.
8.    Rich SR, Coleman IC, Cook R, et al. Stepped-care approach to treating MS: a managed care treatment algorithm. J Manag Care Pharm. 2004;10(suppl B):S26-S32.

The content in this monograph was developed with the assistance of a staff medical writer. Each author had final approval of his/her article and all its contents.

*Associate Professor, Department of Clinical Pharmacy, University of Colorado at Denver and Health Sciences Center, Denver, Colorado.
Address correspondence to: Jacquelyn L. Bainbridge, PharmD, Associate Professor, Department of Clinical Pharmacy, University of Colorado at Denver and Health Sciences Center, Academic Office 1, 12631EÐ17th Avenue, Room L15-1419, School of Pharmacy C238-L15, PO Box 6511, Aurora, CO 80045. E-mail:
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