Findings from a survey of academic neuroimmunologists report that most feel comfortable prescribing the recently approved therapies for neuromyelitis optica spectrum disorder (NMOSD); however, insurance and cost issues are often perceived barriers to accessing these treatments. For patients stable on another agent, most neuroimmunologists have not switched to a recently FDA-approved therapy.1
Posted in Multiple sclerosis and related diseases, 33 respondents from 18 countries completed the survey, with participants self-reporting treating a median number of 15 patients (IQR, 8-21). Overall, participants had a median duration of 8 years (IQR, 3-20) of independent practice after fellowship. The 14-question survey asked neuroimmunologists about their experience and training, a cohort of patients with neuromyelitis optica (NMO), the percentage of patients who started treatment with eculizumab (Soliris; Alexion), satralizumab (Enspryng; Genentech), or inebilizumab (Uplizna; Horizon Therapeutics) ). ) in different clinical scenarios and the barriers to the use of these treatments.
Led by Dr. Jesse M. Ton, a vascular neurologist at Cooper University Health Care, not a single respondent indicated they were uncomfortable prescribing any of the new NMOSD treatments (NNTs). Study data showed no association between years of independent practice and comfort prescribing either agent, although there were associations between total NMOSD patients and comfort with inebilizumab (ρ = 0.5594; Padj<0.01) and satralizumab (ρ = 0.4657; Padj = 0.04), but only a trend with eculizumab (ρ = 0.4275; Padj = 0.08).
Nearly half of respondents (48%) reported wanting to start an NNT patient but not being able to, with insurance coverage or cost being the most common reason. In terms of specific agents, these 2 specific barriers accounted for 42%, 30%, and 21% of those seeking treatment with eculizumab, inebilizumab, and satralizumab, respectively. No patient reported safety concerns as a barrier to treatment, and some patients refused treatment altogether. Pharmacy/formulary availability and lack of medication experience documented in 6% and 15% of each agent were also considered barriers to treatment.
READ MORE: IL-6 inhibitor tocilizumab is effective in treating NMOSD, meta-analysis suggests
A total of 4 respondents reported not using NNTs in any clinical scenario and 5 reported not using these agents in newly diagnosed patients with aquaporin-4-positive NMO. Of the 26 respondents who reported using NNTs in newly diagnosed patients, half (n = 13) indicated treatment with these agents in 1% to 25% of patients with NMOSD, while fewer (19%; n = 5 ) reported using these agents for at least 75% of their patients screened.
A large proportion of respondents (21 of 24; 84%) claimed to have used NNTs for patients who relapsed while on a B-cell suppressor or other steroid-sparing agent. A total of 15 of 21 respondents used 1 of these agents in at least 75% of their relapse patients, while the remaining 6 respondents used them in only 1% to 25% of their relapse patients. Study results showed no significant relationship between the likelihood of a provider switching to NNT after a relapse and length of independent practice (ρ = –0.1454; Padj = 0.49) or number of patients treated by this provider (ρ = 0.3026; Padj = 0.14).
Off-label use of NNT in AQP4-negative NMOSD patients was uncommon, with only 5 of 30 (16%) reporting NNT use in any of their antibody-negative patients; however, more than three-quarters (25 of 33; 76%) reported that they would use NNTs if the FDA approved them for this patient population.
Issues with access to NMOSD therapies have been echoed in the community before. At the recently concluded MSMilan 2023, the joint ECTRIMS-ACTRIMS meeting held October 11-13 in Milan, Italy, October 11-13 in Milan, Italy, Bruce Cree, MD, PhD, MAS, FAAN, the director of clinical research from the Center for of UCSF Multiple Sclerosis, discussed the challenges in affordability of the 3 approved therapies for NMOSD caused by third-party payer resistance. In the video below, he explained why third-party payers are resistant to using expensive drugs despite FDA approval.
1. Use of FDA-approved treatments for neuromyelitis optica spectrum disorder in clinical practice: a survey of academic neuroimmunologists. Multiple sclera and a congenital disorder. 2023;80:105076. doi:10.1016/jmsard.2023.105076