Activity Faculty Charles H. Bombardier, PhD, ABPP Professor and Head, Division of Clinical and Neuropsychology Department of Rehabilitation Medicine University.
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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
FLS, ISR, depression, LFTs,Preg Cat C
CBC with differential, LFTs, TSH
IFNβ-1a 44 μg SC TIW
FLS, ISR, depression, LFTs,Preg Cat C
CBC with differential, LFTs, TSH
Glatiramer acetate 20 mg SC QD
ISR, post-injection reaction,Preg Cat B
No lab or other monitoring recommended
Glatiramer acetate40 mg TIW
ISR, post-injection reaction,Preg Cat B
No lab or other monitoring recommended
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.)
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
FLS, ISR, depression, LFTs,Preg Cat C
CBC with differential, LFTs, TSH
IFNβ-1a 44 μg SC TIW
FLS, ISR, depression, LFTs,Preg Cat C
CBC with differential, LFTs, TSH
Glatiramer acetate 20 mg SC QD
ISR, post-injection reaction,Preg Cat B
No lab or other monitoring recommended
Glatiramer acetate40 mg TIW
ISR, post-injection reaction,Preg Cat B
No lab or other monitoring recommended
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:Oral Agents
Prescribing information: WKH. http://online.factsandcomparisons.com; NMSS. www.nationalmssociety.org.
Agent Dose & RouteMajor or Common
Side Effects or Risks Monitoring
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
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