Low rate of MS medication use in B.C.
Revised April 25, 2016
Only 1 in 3 people living with multiple sclerosis in the Canadian province of British Columbia has filled a prescription for an immune-modulating medication for their MS. That was the surprising finding of a recent analysis of the province’s MS and health administration databases (McKay and colleagues. Eur J Neurol 2016; epublished March 15, 2016).
Between 1996 and 2004, a total of 2,841 people with MS were newly registered in the provincial databases. The purpose of the study was to compare people treated in an MS clinic with those being managed by a doctor outside of the network of specialty clinics. Overall, 58% of people with MS were seen at an MS clinic. The average age when a first claim was made by someone treated at a clinic was 41 years. This was about five years earlier compared to people seen outside the network of clinics, suggesting that people being managed by a community neurologist or family doctor had less severe symptoms, were not diagnosed as quickly, or delayed starting treatment.
People treated in the community were more likely to be hospitalized, and to be suffering from multiple health problems, such as high blood pressure, lung disease, diabetes or depression, even adjusting for the fact that they were older than the clinic cases. However, people treated in an MS clinic were more likely to be hospitalized for their MS, suggesting that they may have more active or severe disease.
The researchers concluded that people with MS treated in the community may differ in important ways from those receiving care at an MS clinic. So clinical studies, which are run by MS clinics, may underestimate the number of other illnesses people have, or may not fully address the issues of people with MS living in the community.
Another issue that emerged from the study was that 51% of people treated in an MS clinic received a prescription for an MS medication at some point over the observation period. Those outside the MS clinic system generally did not receive an MS medication; only 13 of 1,193 people (1%) in this latter group were treated. Overall, only 30% of people with MS living in B.C. ever filled at least one prescription for an MS therapy between 1996 and 2004 – and a considerably smaller proportion would be taking treatment on an ongoing basis since many people quit therapy.
There are several reasons why the rate of medication use may be so low. Some people are not eligible for treatment (e.g. the 10-15% of people diagnosed with primary-progressive MS from the onset). People in B.C. may choose not to start therapy, or their doctors may not be strong advocates of MS medications. For example, a controversial paper by B.C. researchers questioned whether long-term use of a beta-interferon provided any benefit with respect to slowing disability (Shirani and colleagues. JAMA 2012;308:247-256). (See Do interferons work? MSology, July 26, 2012, and the accompanying Interview with researcher Helen Tremlett, MSology, July 26, 2012.)
A further reason may be limited access to treatment for the 42% of people in the study who did not go to an MS clinic. In B.C., Manitoba and Nova Scotia, doctors working outside of an MS clinic generally do not prescribe MS medications because of provincial drug plan restrictions. In B.C., a Collaborative Prescribing Agreement limits drug reimbursement to MS medications prescribed by neurologists specialized in MS who practice at an MS clinic. MS medications prescribed by non-MS clinic physicians are generally not reimbursed – which explains why the study found that almost everyone seen by a community neurologist remained untreated. This restriction means that people who want treatment must travel to one of the province’s five MS clinics – in Victoria, Vancouver, Burnaby, Kelowna and Prince George. For someone living in Kamloops, this would involve a two-hour drive to the Kelowna clinic, or a three-hour drive to the Vancouver or Burnaby clinics.
Medication use may have increased since 2004, notably with the introduction of oral therapies (Gilenya, Aubagio, Tecfidera) starting in 2010. However, a recent study suggested that treatment rates were still low in B.C., Manitoba and Nova Scotia as recently as 2010-2012, with only 29.6% of people in the three provinces starting an injectable medication (an interferon or Copaxone; orals were not yet available) during the observation period (Zhang and colleagues. Neurology 2016;86:1287-1295).
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