2. Activity Faculty Charles H. Bombardier, PhD, ABPP Professor and Head, Division of Clinical and Neuropsychology Department of Rehabilitation Medicine University of Washington School of Medicine Seattle, WA Aaron E. Miller, MD Professor of Neurology Medical Director Corinne Goldsmith Dickinson Center for Multiple Sclerosis Icahn School of Medicine at Mount Sinai New York, NY

3. 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

4. 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.

5. FDA-Approved MS Treatments: Injectables and Infusions Agent Dose & Route Major or Common Side Effects or RisksMonitoring 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 acetate 40 mg TIW ISR, post-injection reaction, Preg Cat B No lab or other monitoring recommended Natalizumab 300 mg IV Q4W PML, Preg Cat CFDA-approved REMS program, Monitor anti-JCV antibody status Alemtuzumab 12 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.

6. FDA-Approved MS Treatments: Injectables and Infusions (cont.) Agent Dose & Route Major or Common Side Effects or RisksMonitoring 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 acetate 40 mg TIW ISR, post-injection reaction, Preg Cat B No lab or other monitoring recommended Natalizumab 300 mg IV Q4W PML, Preg Cat CFDA-approved REMS program, Monitor anti-JCV antibody status Alemtuzumab 12 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.

7. FDA-Approved MS Treatments: Oral Agents Prescribing information: WKH. http://online.factsandcomparisons.com; NMSS. www.nationalmssociety.org. Agent Dose & Route Major or Common Side Effects or RisksMonitoring 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 PEARL Involve your patients in making decisions about their treatment

8. 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 PEARL Rather 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

9. 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.

10. Four Foundational Processes of MI Engaging Introductions. Ask open question(s). Chief concerns. Listen and reflect. Activate the patient. Focusing Ask for permission to discuss a topic. Give a menu of options. Eliciting Elicit importance of change and confidence to change. Give advice with permission. Planning Ask key questions. Elicit commitment. Implementation intentions. “SMART” goals. 1 2 3 4

11. Four Foundational Processes of MI (cont.) Engaging Introductions. Ask open question(s). Chief concerns. Listen and reflect. Activate the patient. Focusing Ask for permission to discuss a topic. Give a menu of options. Eliciting Elicit importance of change and confidence to change. Give advice with permission. Planning Ask key questions. Elicit commitment. Implementation intentions. “SMART” goals. 1 2 3 4

12. “On a scale from 0 to 10, how ready are you to change?” Plant Seeds Plan for Action Low readinessHigh readiness Tip The Balance Toward Change Build Relationships Moderate readiness

13. 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?”

14. 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?”

15. 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 PEARL What 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.

16. High Readiness: Action Planning—SMART  S pecific: What am I going to do? When? How do I do it?  M easurable: How often? How much?  A ttainable: How confident am I that I can do this? What could help?  R ealistic: What barriers might make this tough? What can I do?  T ime-related: What day and time am I going to do this?

17. 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

18. Thank You!