Ryan Haumschild, PharmD, MS, MBA: Before we move on, I do want to get Dr Hickman’s experience, because I know with this there’s a lot of switching of agents that comes into play. When we talk about total cost of care, if a patient’s switching from one agent to another, there might be a higher cost through the induction period, or even [fewer] proportionate days covered as patients are moving through therapies so rapidly. From your experience, when should patients and providers consider switching agents due to a nonresponse or a less-than-optimal response?

Amanda Hickman, PharmD, MPH, MSCS: Absolutely, because now we have treatment options and such a variety of mechanisms we can go after. Then is the question, the moment they have a relapse we’re always changing therapy, or if they’ve been stable so far and are adherent to the medication, do we keep that going for a bit? The guidelines still allow a bit of practitioner and patient conversation in that they predominantly say first, make sure the patient is adherent to the medication. Make sure it’s not a breakthrough because they’re not taking the medication. Because then it’s not necessarily medication failure, it’s more not a good match for the patient. But once that’s established and they’ve been on the therapy long enough to say it has kicked in, it should be effective, then absolutely. If there are MRI changes, especially if there are 2 or more lesions that pop up, that could be a good indicator of maybe let’s try something different. Or if the patient’s having clinical decline. It’s a bit of dealer’s choice once you’ve set the checkmarks of, they are adherent, this is a true breakthrough.

Ryan Haumschild, PharmD, MS, MBA: Excellent. Dr Williams, I don’t know if, from a practitioner’s standpoint, Dr Hickman gave us a lot of the overview of when switching would occur. I didn’t know if there’s anything you want to add when you have a patient come up where you start to say we may need to try a new therapy here.

Mitzi Joi Williams, MD FAAN: She was spot on. Reasons we switch are if my patients are having relapses on the therapy. For most therapies, we ballpark and say after 6 months we should be seeing some type of effect. Some have an earlier onset than that. But usually by 6 months, I’m repeating an MRI. And if we see any changes from our new baseline MRI after we’ve been on therapy for a period of time, that would definitely be an indication to switch, or if they’re having clinical relapses and they’re compliant with therapy. Then finally, adverse effects. Again, some of our therapies may increase liver enzymes or indirectly cause lymphopenia, so if that is an adverse effect that a patient is having, or if they, for instance, begin having recurrent infections, those would be reasons also to switch therapy.

Ryan Haumschild, PharmD, MS, MBA: Excellent.

Mitzi Joi Williams, MD FAAN: Then I would add one other thing that can sometimes be a complication from the payer aspect, that now many of our patients switch insurances very frequently. They used to grandfather in therapy. If I had a patient who was very stable on a therapy for 7 or 8 years, if they switched insurance, then we could appeal and get that same therapy. Now that is not guaranteed, and so sometimes we have to switch therapies because they may have a new insurance and we’re unable to access their previous therapy. That can be a complication we encounter that sometimes can be detrimental to our patient, so again, something else that we keep in mind.

Dana McCormick, RPh: Continuity of care and transition of care is a super important consideration for patients who are living with chronic disease. So again, the more we can have that concept and idea realized by payers who are creating policies, that can have such a positive or negative impact. That’s a super important point, I’m glad you brought it up.

Amanda Hickman, PharmD, MPH, MSCS: For sure. The thing to probably consider also when switching is the medication-specific details. Do they need a washout period?

Mitzi Joi Williams, MD FAAN: Yes.

Amanda Hickman, PharmD, MPH, MSCS: Or there are some medications, if they go too long, they could have progression of disability. So trying to, again, we’re talking timelines a lot here, but to make that timeline work of, we’ve had progression, we need to switch, but do we need to wait a bit, or do we need to do it immediately?

Transcript edited for clarity.