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Wednesday, October 26, 2016

The Emerging Role of Pharmacists in the Multidisciplinary Care of Patients with Multiple Sclerosis


                                                                  
  

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Multiple sclerosis (MS) is a complex disease state requiring delivery of patient-centered care by a high-functioning multidisciplinary team. The currently accepted case management model for patients with MS, formally introduced in the 1980s, has not been updated to represent emerging complexities in MS care. Specifically, the introduction of interferon-based therapies as well as glatiramer acetate in the early 1990s completely changed the way that these patients were managed. 

During the past decade, the introductions of various oral, intravenous, and injectable medications to the market have provided additional choices for MS treatment. Additionally, the options available to treat the symptoms of MS have expanded substantially. These advancements have drastically increased the amount of time that members of the multidisciplinary team must commit to medication management. As a result, the pharmacist is becoming a much more integral member of the interdisciplinary team that cares for patients with MS.

A specialty medication is defined as any medication that is used to treat a complex, chronic, or rare condition; has an annual cost exceeding $10,000; is available only through restricted, exclusive, or limited distribution networks; requires special storage, handling, or administration; and requires ongoing monitoring for safety or efficacy.1 There are a variety of specialty medications used for patients with MS, including the disease-modifying therapies (DMTs) glatiramer acetate (Copaxone [Teva Pharmaceutical Industries Ltd, Petah Tikva, Israel] and Glatopa [Sandoz Inc, Princeton, NJ]), interferon beta-1a (Avonex [Biogen Idec Inc, Cambridge, MA] and Rebif [EMD Serono Inc, Rockland, MA]), interferon beta-1b (Betaseron [Bayer HealthCare Pharmaceuticals, Montville, NJ] and Extavia [Novartis Pharmaceuticals Corp, East Hanover, NJ]), peginterferon beta-1a (Plegridy [Biogen Idec Inc]), and fingolimod (Gilenya [Novartis Pharmaceuticals Corp, East Hanover, NJ]). 

However, it is a common misconception that only the DMTs are specialty medications that require a high level of care. Many symptomatic treatments, such as modafinil (Provigil [Teva Pharmaceutical Industries Ltd]) and dalfampridine (Ampyra [Acorda Therapeutics Inc, Ardsley, NY]) are also specialty medications and are associated with a great deal of complexity in terms of insurance issues and patient monitoring.

Simply considering the use of certain medications for patients with MS requires a great deal of knowledge and care. Providers must assess for potential drug interactions before initiating a new medication, despite the fact that most of the patient's medications may have been prescribed by outside providers. Obtaining an accurate and complete medication history can sometimes take a substantial amount of time, but it is absolutely necessary to prevent dangerous and costly drug-drug interactions. Physicians, physician assistants, and nursing professionals have historically been the ones to perform these tasks amidst all of their other patient-care duties.

Prescribers must also consider how DMTs and symptomatic treatments could affect a patient's other comorbid conditions. For example, interferon-based therapy should be avoided in patients with a history of depression,26 and fingolimod (Gilenya) should be used with great caution in patients with a history of cardiac complications.7 Many medications also require special laboratory and clinical monitoring before the provider can prescribe them. Although prescribers and nursing professionals are more than capable of performing these tasks, it is unreasonable to expect them to be the medication experts.

After a new medication is prescribed, patients often require authorizations for insurance approval (and often subsequent appeals to insurance companies) and medication administration training and counseling. Therefore, it can often be weeks before a patient can actually start taking a new medication. Once the patient is able to initiate therapy, close follow-up to assess for adverse drug reactions and adherence is required. Furthermore, regular laboratory monitoring is necessary for many medications. For example, it is recommended that patients taking dimethyl fumarate (Tecfidera [Biogen Idec]) have their lymphocyte counts measured at least every 6 months,8 and many MS centers prefer to check these values more frequently.

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