Activity Faculty Charles H. Bombardier, PhD, ABPP Professor and Head, Division of Clinical and Neuropsychology Department of Rehabilitation Medicine University

Activity Faculty

Charles H. Bombardier, PhD, ABPPProfessor and Head, Division of Clinical and NeuropsychologyDepartment of Rehabilitation MedicineUniversity of Washington School of MedicineSeattle, WA

Aaron E. Miller, MD Professor of Neurology Medical DirectorCorinne Goldsmith Dickinson Center for Multiple Sclerosis Icahn School of Medicine at Mount SinaiNew York, NY

Learning Objectives

Upon completion, participants should be able to: Summarize recent clinical evidence for

treatment options in MS Describe how motivational interviewing

methods can be used to promote adherence to DMTs

Key Considerations in the Management of MS

The MS treatment landscape is changing rapidly

It is important to engage patients in conversations that promote self-management and shared decision making

MI has been shown to increase adherence to DMTs and may be a useful tool in your practice

Treadaway K, et al. J Neurol. 2009;256:568-76.

FDA-Approved MS Treatments:Injectables and Infusions

Agent Dose & RouteMajor or Common

Side Effects or Risks Monitoring

IFNβ-1b (2 products)250 μg SC QOD

FLS, ISR, depression, LFTs,Preg Cat C

CBC with differential, LFTs, TSH

IFNβ-1a 30 μg IM QW



IFNβ-1a 44 μg SC TIW



Glatiramer acetate 20 mg SC QD

ISR, post-injection reaction,Preg Cat B

No lab or other monitoring recommended

Glatiramer acetate40 mg TIW



Natalizumab 300 mg IV Q4W

PML, Preg Cat C FDA-approved REMS program,Monitor anti-JCV antibody status

Alemtuzumab12 mg/day IV for 5 days, then 12 mg/day for 3 days a year later

FLS, UTI, herpes infection, thyroid disorders, upper

respiratory infection, Preg Cat C

CBC with differential, TSH

Prescribing information: WKH. http://online.factsandcomparisons.com; NMSS. www.nationalmssociety.org.

FDA-Approved MS Treatments:Injectables and Infusions (cont.)



IFNβ-1b (2 products)250 μg SC QOD



IFNβ-1a 30 μg IM QW



IFNβ-1a 44 μg SC TIW



Glatiramer acetate 20 mg SC QD



Glatiramer acetate40 mg TIW



Natalizumab 300 mg IV Q4W

PML, Preg Cat C FDA-approved REMS program,Monitor anti-JCV antibody status

Alemtuzumab12 mg/day IV for 5 days, then 12 mg/day for 3 days a year later

FLS, UTI, herpes infection, thyroid disorders, upper

respiratory infection, Preg Cat C

CBC with differential, TSH


FDA-Approved MS Treatments:Oral Agents




Fingolimod 0.5 mg PO QD

First-dose bradycardia, AV block, infection risk,

macular edema, liver enzymes,

Preg Cat C

FDA-approved REMS program,ECG, HR, and

BP measurements

Teriflunomide 7 or 14 mg PO QD

liver enzymes possible, hepatotoxicity, mild alopecia,

Preg Cat X

CBC, ALT, bilirubin, pregnancy test, TB test

Dimethyl fumarate 120 or 240 mg PO BID

Flushing, abdominal pain, diarrhea, nausea,

Preg Cat C

CBC before treatment initiation and annually, monitor for

infection risk

PRACTICE PEARLInvolve your patients in making decisions about their treatment

What Is Motivational Interviewing?

MI is a collaborative, goal-oriented method of communication with particular attention to the language of change

It is designed to strengthen an individual’s motivation for and movement toward a specific goal by eliciting and exploring the person’s own arguments for change

PRACTICE PEARLRather than telling patients to change, in MI the clinician uses questions and active listening to get patients to talk about their reasons for wanting to change, evaluate their

ability to change, and commit to making a change

How Can MI Help Patients With MS?

More than one-third of MS patients interviewed missed > 1 DMT injection during past 4 weeks

Most common reasons for nonadherence: forgot (58%), did not feel like taking (22%), tired of injections (16%)

Patients who underwent MI saw greater improvements in physical activity, stress management, and mental health than controls

MI can improve adherence to DMTs and rates of exercise in patients with MS

Treadaway K, et al. J Neurol. 2009;256:568-76.

Four Foundational Processes of MI

EngagingIntroductions. Ask open question(s).

Chief concerns. Listen and reflect. Activate the patient.

FocusingAsk for permission to discuss a topic.

Give a menu of options.

ElicitingElicit importance of change and

confidence to change.Give advice with permission.

PlanningAsk key questions. Elicit commitment.

Implementation intentions. “SMART” goals.

1

2

3

4

Four Foundational Processes of MI (cont.)

EngagingIntroductions. Ask open question(s).

Chief concerns. Listen and reflect. Activate the patient.

FocusingAsk for permission to discuss a topic.

Give a menu of options.

ElicitingElicit importance of change and

confidence to change.Give advice with permission.

PlanningAsk key questions. Elicit commitment.

Implementation intentions. “SMART” goals.

1

2

3

4

“On a scale from 0 to 10, how ready are you to change?”

Plant Seeds Plan for Action

Low readiness High readiness

Tip The BalanceToward Change

Build Relationships

Moderate readiness

Low Readiness

Build a relationship bridge: Reflect resistance and

demonstrate acceptance– “It sounds like you are not

ready to change [behavior].”– “It’s a big step.”

Affirm– “You are a thoughtful person.

You want to consider all your options.”

Explore reasons– “What would it take for you to

move from X to X+1?”

Plant seeds: Provide information or advice

with permission– “What do you already know

about changing [behavior]?” – “May I give you some additional

information about [behavior]? May I tell you what some other people in your situation have done?”

– “What do you make of that?” (or) “Where does that leave you?”

Moderate Readiness

Elicit motivation and explore ambivalence to tip the balance toward change “Why are you at X and not at a LOWER number?”

– “Tell me more.” Reflect, reflect, summarize. “What would need to happen for you to get from

X to X+1?”– “Tell me more.” Reflect, reflect, summarize.

“If you decided to change, how confident are you that you would succeed?”

“On a scale from 0 to 10, what number would you give yourself?” “What would it take to get to X+1?”

Moderate Readiness (cont.)

Ask strategic open-ended questions—tip the balance toward change: “What are the good things (or

advantages) about not starting DMT right now?”

“What are the not so good things (or disadvantages) about not starting DMT right now?”

Reflect, reflect, summarize Summarize both sides, focusing on

change talk

Ask a key question:– “Where does this leave you now?”– “What is the next step?”– “What, if anything, are you willing

to do at this point?” If the patient cannot think of

anything, you may ask permission to give advice

Give menu of options (include status quo)

Have the patient choose; “no change” should be an option

PRACTICE PEARLWhat your patient says is much more predictive of behavior change than

what you say. Get her to talk about changes she is willing to make, benefits of those changes, and how she will implement the changes.

High Readiness:Action Planning—SMART

Specific: What am I going to do? When? How do I do it?

Measurable: How often? How much? Attainable: How confident am I that

I can do this? What could help? Realistic: What barriers might make

this tough? What can I do? Time-related: What day and time am

I going to do this?

Key Considerations in the Management of MS

The MS treatment landscape is changing rapidly

It is important to engage patients in conversations that promote patient self-management and shared decision making

MI has been shown to increase adherence to DMTs and may be a useful tool in your practice

Thank You!

Documents

Activity Faculty Charles H. Bombardier, PhD, ABPP Professor and Head, Division of Clinical and Neuropsychology Department of Rehabilitation Medicine University