Best Practice Recommendations of Advanced Practice Clinicians for the Care of the Challenging MS Patient

Background:  The heterogeneity of MS and treatment response make individualized therapy a logical approach, but healthcare providers often face the challenge of balancing disease- and patient-related considerations to determine optimal disease management. The role of advanced practice clinicians (APCs) in MS patient care is becoming increasingly complex with the evolving therapeutic landscape and heightened patient expectations.

Objectives:  To examine best practices for the management of the challenging MS patient and identify knowledge gaps and educational needs of healthcare providers specializing in MS care based on recommendations from an expert panel of APCs.

Methods: The expert panel of 25 APCs, which included nurse practitioners and physician assistants from diverse clinical practice types in the US and Canada, specializing in the treatment and management of MS patients, discussed and delineated the characteristic profile of the challenging MS patient. Approaches to treatment, use of disease-modifying therapies (DMTs), and patient management, including individualized patient therapy, were considered.

Results:  Three areas were identified as potential barriers to optimizing treatment outcomes in MS: disease activity, patient characteristics, and practical considerations. Disease-related considerations included magnetic resonance imaging (MRI) activity while on DMT, presence of brainstem or spinal cord lesions, progressive disease, and abnormal laboratory results. Patient-specific characteristics were John Cunningham virus-positive status, exposure to previous immunosuppressants, and treatment-naive status. Practical considerations such as poor treatment adherence due to either administration mode or adverse events, poor socioeconomic status, and limited healthcare access could also negatively impact outcomes. Some best practices toward addressing these risk factors for poor outcomes were highlighted, including effective communication between MS specialists and primary care providers, routine MRI assessment to monitor disease progression, and early treatment initiation to enable early switching to alternative treatment if needed.

Conclusions:  A gap in the organized presentation of basic scientific information and practical aspects of MS care was identified. Efforts to address this gap will engender greater awareness of the considerations involved in the management of challenging MS patients.

Study supported by Genzyme, a Sanofi company.