Dutch Guideline Adherence First-Line Injection Therapy Multiple Sclerosis

Background: Adherence to first-line therapy among patients with MS is poor and could be associated with increased healthcare costs and need for high-risk escalation therapies. Patients behaviour may be influenced by different factors like experiencing disease symptoms, side effects associated with first-line injection therapy, or the way information on interferon bèta or glatiramer acetate injection therapy is provided in clinical practice.                           

Objectives: This guideline supports caregivers in achieving an uniform approach on adherence among patients with Multiple Sclerosis treated with first-line injection therapy.

Methods: Influence factors impacting adherence to first- line injection therapy were selected: Flu-like symptoms, Injection site reactions, Fatigue, Depression, (Injection-) Anxiety and Cognitive dysfunction. First, Digital Delphi rounds with MS- nurses were used to achieve consensus on how to deal with these influence factors. The consensus was included in the guideline, which was developed with the Evidence Based Richtlijn Ontwikkeling (EBRO) method, structurally applying evidence levels to scientific literature.

Results: Fifty Delphi round theses were accompanied by evidence from scientific literature. Conclusions and recommendations for each influence factor of adherence in clinical practice were made based on the scientific evidence present and other important aspects like patient preferences, availability of special techniques or expertise, organizational aspects, social consequences and costs. To optimize adherence, you may use the screening instruments like Morisky Medication Adherence Scale (MMAS), Modified Fatigue Impact Scale (MFIS), Hospital Anxiety Depression Scale (HADS) and the Cognitive Failure Questionnaire (CFQ). A guideline was written, documenting the outcomes and implemented in clinical practice in the Netherlands.

Conclusions:  First step to improve adherence of patients with MS: On regular monitoring visits, identify which of the influence factors: Flu-like symptoms, Injection- site reactions, Fatigue, Depression, (Injection-) Anxiety and Cognitive dysfunction have an effect on patient adherence. To verify adherence 'ask open questions without reproachful undertone’. Verify adherence using instruments, e.g. MMAS to obtain a good impression of the risk for treatment failure for each MS patient. Implementation of additional instruments, HADS for depression and anxiety, MFIS for fatigue, and the CFQ for cognitive dysfunction will give beneficial results on long-term adherence.