Stakeholder Insight: Multiple Sclerosis - Disease-modifying efficacy and side effects guide treatment choice

Table of Contents

• ABOUT HEALTHCARE
  • About the CNS pharmaceutical analysis team
• CHAPTER 1 EXECUTIVE SUMMARY
  • Scope of the analysis
• CHAPTER 2 INTRODUCTION AND SCOPE
  • Coverage of the Stakeholder Insight Survey
    • Disease definition & epidemiology
    • Presentation and diagnosis
    • Treatment
    • Key prescribing influences
    • Unmet needs
• CHAPTER 3 COUNTRY TREATMENT TREES
  • US
  • France
  • Germany
  • Italy
  • Spain
  • UK
• CHAPTER 4 EPIDEMIOLOGY AND PATIENT SEGMENTATION
  • Disease definition
    • There is no universal course for multiple sclerosis
    • Researchers have attempted to classify multiple sclerosis according to the clinical course of the disease
  • Epidemiology of multiple sclerosis
    • Young female adults are most at risk of developing multiple sclerosis
    • Other genetic and environmental factors appear to play a role in onset of MS
    • Prevalence of multiple sclerosis
      • Over 800,000 individuals across the US and 5EU are estimated to suffer from MS
      • US
      • 5EU
    • The majority of patients suffer from relapse remitting multiple sclerosis
• CHAPTER 5 PRESENTATION AND DIAGNOSIS
  • Presentation
    • Symptoms typically first emerge in relapsing-remitting course of multiple sclerosis
    • Fatigue and depression are most common symptoms
    • Less than half of new patients present to a physician at the time they suffer from first symptoms of MS
    • The majority of patients present to a primary care physician
  • Diagnosis
    • Diagnostic criteria
    • Only half of patients with multiple sclerosis symptoms receive an accurate diagnosis on initial presentation to a physician
• CHAPTER 6 TREATMENT OPTIONS AND GUIDELINES
  • Treatment options
    • Symptomatic treatment
    • Disease-modifying drug treatments
    • Acute relapse treatment
  • Treatment guidelines
    • There are no official international guidelines for the chronic treatment of multiple sclerosis and use of disease-modifying therapies
    • Several treatment guidelines are in place for the management of acute relapses of multiple sclerosis
• CHAPTER 7 PRESCRIBING TRENDS IN MULTIPLE SCLEROSIS
  • Treatment of multiple sclerosis with disease-modifying drug treatments
    • Across all stages of MS, 53% of total diagnosed patients receive disease modifying therapies
    • First-line therapy
      • Approximately one third of patients prescribed first-line therapy move to second-line therapy
    • Second-line therapy
      • Approximately one quarter of patients prescribed second-line therapy move to third-line therapy
    • Third-line therapy
      • Only one fifth of patients prescribed third-line therapy move to fourth-line therapy
    • Fourth-line therapy
    • Summary of treatment lines according to country
    • Novantrone (mitoxantrone)
      • Novantrone is the only treatment US Food and Drug Association-approved treatment for worsening MS
      • Approximately half of respondents prescribe mitoxantrone to their patients
      • The majority of current mitoxantrone prescriptions are reserved for last line therapy
      • In the future, mitoxantrone is unlikely to change from being reserved as a last line therapy
    • Tysabri (natalizumab)
      • Tysabri is the first humanized monoclonal antibody approved for the treatment of multiple sclerosis
      • Cases of progressive multifocal leukoencephalopathy led to withdrawal after only three months on the market
      • Tysabri has been relaunched albeit under tight controls
      • The majority of interviewed neurologists would consider prescribing Tysabri
      • Tysabri administered as an infusion presents a small barrier to use
      • A potential risk of progressive multifocal leukoencephalopathy with Tysabri would create a barrier to its use
      • Respondents expect to prescribe Tysabri predominantly to their patients with RRMS
      • There is no clear point for when Tysabri will be prescribed in the treatment algorithm
  • Treatment for acute relapse of multiple sclerosis
    • Steroids have historically been the mainstay of treatment
    • Interviewed neurologists consider intravenous methylprednisolone the number one treatment for acute relapses
    • Interviewed neurologists use numerous other therapies
      • Oral steroids are used by almost a quarter of patients but may increase risk of side effects
      • Intravenous dexamethasone offers a cheaper alternative to intravenous methylprednisolone
      • Aspirin and nonsteroidal anti-inflammatory drugs may help reduce side effects
      • Plasmapheresis should be considered for patients who fail to respond to intravenous methylprednisolone
      • Use of intramuscular adrenocortropic hormone is no longer the preferred treatment for treating acute relapse
      • Intrathecal steroids are not recommended for treating acute relapse
• CHAPTER 8 INFLUENCING FACTORS ON PRESCRIBING TRENDS IN MULTIPLE SCLEROSIS
  • Current market overview
    • The disease-modifying drugs have continued to perform well in terms of revenues
  • Factors driving prescribing choice
    • Disease-modifying efficacy is the number one influential factor
    • Side effects are accepted as an inherent outcome of taking any disease-modifying drug but the nature and severity of the side effects are key influencers
    • Speed of onset of action is desirable
    • Ability to combine a drug with other therapies is heavily influenced by prescribing practices and trends
    • Drugs are used over a long period of time and must be considered safe for extended use
    • Dosing frequency and delivery methods may compromise patient compliance
    • In Europe cost typically has a greater influence on prescribing choice than formulary / reimbursement status
      • UK restricts use of disease-modifying drugs based on clinical versus cost-effectiveness
    • In the US formulary / reimbursement status is considered a greater influence on prescribing choice than cost
• CHAPTER 9 IMPROVING TREATMENT OUTCOMES
  • Performance of prescribed drugs against attributes
    • Neurologists in the US and UK are most satisfied with current therapies
    • Avonex is perceived to perform slightly better across all attributes than the other disease-modifying therapies
    • Tysabri is perceived to perform best on disease modification efficacy
    • Higher dosed interferons are perceived to have a faster onset of action
    • None of the drugs are perceived to have a very good side-effect profile
    • Ability to combine with other therapies
    • A higher dosing frequency is perceived to more efficacious
    • Intravenous delivery methods are perceived less favorable
    • Interferons and Copaxone are considered safe for extended use
    • There is room to improve patient treatment compliance
    • Formulary / reimbursement status
    • Drugs with increased disease-modifying efficacy are considered to perform better on cost
  • Reasons for discontinuing therapy/switching to alternative drug therapy
    • Lack of efficacy and intolerable side effects are the key reasons for discontinuing or switching treatment
    • Occurrence of any side effect if poorly managed can lead to treatment discontinuation
  • Unmet needs
• BIBLIOGRAPHY
  • References
  • Websites
• APPENDIX A
  • Physician research methodology
    • Physician sample breakdown
    • US
    • France
    • Germany
    • Italy
    • Spain
    • UK
  • Contributing experts
• APPENDIX B
  • The survey questionnaire
    • Physician details
    • Introduction
    • Section 1-Epidemiology and diagnosis of multiple sclerosis
    • Section 2-Treatment of multiple sclerosis
      • First-line therapy
      • Second-line therapy
      • Third-line therapy
      • Fourth-line therapy
    • Section 3-Key prescribing factors
    • Disclaimer
  • List of Tables
    • Table 1: Prevalence of MS in the US and 5EU markets, 2006
    • Table 2: Most common signs and symptoms of RRMS, 2006
    • Table 3: Poser criteria for the diagnosis of clinically definite MS and laboratory supported MS
    • Table 4: Key facts for marketed disease-modifying drug for MS
    • Table 5: Key recommendations for treatment of multiple sclerosis relapses: EFNS task force:
    • Table 6: Percentage of patients diagnosed with each stage of MS who receive disease-modifying drug therapy, 2006
    • Table 7: Percentage of all interviewed neurologists who prescribe each disease-modifying drug/ combination for first-line treatment of MS, 2006
    • Table 8: Percentage of all interviewed neurologist' s patients who are prescribed disease modifying drugs / combinations for first-line treatment of MS, 2006
    • Table 9: Proportion of patients prescribed disease modifying treatments as monotherapy versus combination therapy at first-line, 2006
    • Table 10: Percentage of all interviewed neurologists who prescribe each disease-modifying drug/ combination for second-line treatment of MS, 2006
    • Table 11: Percentage of all interviewed neurologist' s patients who are prescribed disease modifying drugs /combinations for second-line treatment of MS, 2006
    • Table 12: Proportion of patients prescribed disease-modifying treatments as monotherapy versus combination therapy at second-line, 2006
    • Table 13: Percentage of all interviewed neurologists who prescribe each disease-modifying drug / combination for third-line treatment of MS, 2006
    • Table 14: Percentage of all interviewed neurologist' s patients who are prescribed disease modifying drugs /combinations for third-line treatment of MS, 2006
    • Table 15: Proportion of patients prescribed disease modifying treatments as monotherapy versus combination therapy at third-line, 2006
    • Table 16: Percentage of all interviewed neurologists who prescribe each disease-modifying drug / combination for fourth-line treatment of MS, 2006
    • Table 17: Percentage of all interviewed neurologist' s patients who are prescribed disease modifying drugs /combinations for fourth-line treatment of MS, 2006
    • Table 18: Proportion of patients prescribed disease modifying treatments as monotherapy versus combination therapy at fourth-line, 2006
    • Table 19: Percentage of total mitoxantrone prescriptions that fall under each treatment strategy, 2006
    • Table 20: Percentage of total mitoxantrone prescriptions that interviewed neurologists in the US and 5EU markets would ideally like to see fall under each treatment strategy in the future treatment of MS, 2006
    • Table 21: Percentage of neurologists in each country who provided each rating, 2006
    • Table 22: Percentage of neurologists in each country who provided each rating, 2006
    • Table 23: Likely use of how Tysabri will be prescribed where 1= strongly disagree and 5= strongly agree, 2006
    • Table 24: Total of mean scores for likely use of how Tysabri will be prescribed- before, with or after other disease modifying therapies, 2006
    • Table 25: Percentage of treated patients receiving therapy specifically for the treatment of a relapse of MS, 2006
    • Table 26: Sales of disease-modifying drugs across the seven major markets, 2005
    • Table 27: Factors which influence drug choice for the management of multiple sclerosis, 2006
    • Table 28: Overall performance of each disease-modifying drug against 10 attributes according to interviewed neurologists in the US and 5EU markets, 2006
    • Table 29: Performance of disease-modifying drugs on disease modification efficacy (where 1= very poor performance; 10 = very good performance) , 2006
    • Table 30: Performance of disease-modifying drugs on onset of action (where 1= very poor performance; 10 = very good performance), 2006
    • Table 31: Performance of disease-modifying drugs on side-effect profile (where 1= very poor performance; 10 = very good performance), 2006
    • Table 32: Performance of disease-modifying drugs on ability to combine with other therapies (where 1= very poor performance; 10 = very good performance) , 2006
    • Table 33: Dosing frequency of disease modifying drugs
    • Table 34: Performance of disease-modifying drugs on dosing frequency (where 1= very poor performance; 10 = very good performance), 2006
    • Table 35: Performance of disease-modifying drugs on delivery method (where 1= very poor performance; 10 = very good performance), 2006
    • Table 36: Performance of disease-modifying drugs on safe for extended use (where 1= very poor performance; 10 = very good performance), 2006
    • Table 37: Performance of disease-modifying drugs on patient compliance (where 1= very poor performance; 10 = very good performance), 2006
    • Table 38: Performance of disease-modifying drugs on formulary / reimbursement status (where 1= very poor performance; 10 = very good performance), 2006
    • Table 39: Cost analysis of disease-modifying therapies (based on patient receiving treatment for one year)
    • Table 40: Performance of disease-modifying drugs on cost (where 1= very poor performance; 10 = very good performance), 2006
    • Table 41: Reasons for patients discontinuing a therapy / switching to an alternative drug therapy on a scale of 1 to 10, where 1 = factor of low influence and 10 = factor of high influence, 2006
    • Table 42: Influence of side effects on discontinuing a therapy / switching to an alternative drug therapy, where 1 = factor of low influence and 10= factor of high influence, 2006
    • Table 43: Priority assigned by interviewed neurologists to unmet needs or improvements which need to be made in the diagnosis, pharmacological treatment, management or awareness of MS, by country, 2006
    • Table 44: US physician sample breakdown, 2006
    • Table 45: France physician sample breakdown, 2006
    • Table 46: Germany physician sample breakdown, 2006
    • Table 47: Italy physician sample breakdown, 2006
    • Table 48: Spain physician sample breakdown, 2006
    • Table 49: UK physician sample breakdown, 2006
  • List of Figures
    • Figure 1: US MS patient population split by physician estimated diagnoses by subtype, disease-modifying therapy treated population and first- and second-line disease-modifying drug usage, 2006
    • Figure 2: France MS patient population split by physician estimated diagnoses by subtype, disease-modifying therapy treated population and first- and second-line disease-modifying drug usage, 2006
    • Figure 3: Germany MS patient population split by physician estimated diagnoses by subtype, disease-modifying therapy treated population and first- and second-line disease-modifying drug usage, 2006
    • Figure 4: Italy MS patient population split by physician estimated diagnoses by subtype, disease-modifying therapy treated population and first- and second-line disease-modifying drug usage, 2006
    • Figure 5: Spain MS patient population split by physician estimated diagnoses by subtype, disease-modifying therapy treated population and first- and second-line disease-modifying drug usage, 2006
    • Figure 6: UK MS patient population split by physician estimated diagnoses by subtype, disease-modifying therapy treated population and first- and second-line disease-modifying drug usage, 2006
    • Figure 7: Age that MS patients experience their first episode of MS, 2006
    • Figure 8: Percentage of patients who experience their first episode of MS within each specific age range, 2006
    • Figure 9: Prevalence rate of multiple sclerosis in the general population in each of the US and 5EU markets, 2006
    • Figure 10: Percentage of diagnosed MS patients who suffer from each type of MS, 2006
    • Figure 11: Emergence of symptoms with disease progression
    • Figure 12: Percentage of new patients who suffer from their first symptoms of multiple sclerosis that present to a physician, 2006
    • Figure 13: Average time from the onset of symptoms of multiple sclerosis to initial presentation to a physician, 2006
    • Figure 14: Stages in the diagnosis of MS leading to a confirmed diagnosis
    • Figure 15: Percentage of patients presenting to a physician with multiple sclerosis symptoms that receive an accurate diagnosis, 2006
    • Figure 16: The average time from presentation to a physician to receiving an accurate diagnosis of multiple sclerosis, 2006
    • Figure 17: Timeline: launch dates of disease modifying therapies for treatment of MS, 1993-2006
    • Figure 18: Percentage of patients diagnosed with each stage of MS who receive disease-modifying drug therapy, 2006
    • Figure 19: Percentage of patients receiving first-line disease-modifying therapy that move to second-line therapy, 2006
    • Figure 20: Average number of months patient continues on first-line therapy before moving to second-line therapy, 2006
    • Figure 21: Percentage of patients receiving second-line disease-modifying therapy that move to third-line therapy, 2006
    • Figure 22: Average number of months patient continues on second-line therapy before moving to third-line therapy, 2006
    • Figure 23: Percentage of patients receiving third-line disease-modifying therapy that move to fourth-line therapy, 2006
    • Figure 24: Average number of months patient continues on third-line therapy before moving to fourth-line therapy, 2006
    • Figure 25: Interviewed neurologists who prescribe mitoxantrone to their MS patients, 2006
    • Figure 26: Physicians who would consider prescribing Tysabri for the treatment of multiple sclerosis when it is launched / relaunched, 2006
    • Figure 27: Mean score indicating the extent to which Tysabri administered as an infusion would be a barrier to use, 2006
    • Figure 28: Mean score indicating the extent to which PML with Tysabri would be a barrier to use, where 1= a significant barrier and 5 = no barrier at all, 2006
    • Figure 29: Patient group that interviewed neurologists are likely to prescribe Tysabri for, 2006
    • Figure 30: Percentage of treated patients in the US and 5EU markets receiving therapy specifically for the treatment of a relapse of MS, 2006
    • Figure 31: Overview brand map of attributes versus brand perception, 2006
    • Figure 32: Priority of clinical unmet needs in MS according to interviewed neurologists, where 1 = unmet need of low priority and 10 = high priority, 2006