Can we afford not to afford treatment of multiple sclerosis in India?

Can we afford not to afford treatment of multiple sclerosis in India?
Neha Pandita 1, MD, Anuradha Batra 1, MD, Prahlad K Sethi 1, MD, Nitin K Sethi 2, MD

1 Department of Neurology, Sir Ganga Ram Hospital, New Delhi (India)
2 Department of Neurology, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY (U.S.A.)

 

Multiple sclerosis (MS) is a chronic neurological disease which affects men and women in the prime of their youth. The disease can present in relapsing-remitting, secondary progressive, progressive relapsing and primary progressive forms and leads to increasing disability during the course of the patient’s lifespan. Symptoms such as muscle weakness, gait and balance problems, coordination problems, visual impairment, diplopia, bladder and bowel disturbances, sensory symptoms, cognitive dysfunction and fatigue can be disabling at times and lead to poor health related quality of life, neurological disability and high health care costs. Progressive disease can be paricularly disabling leading to a wheel chair chair dependent on caregivers for activities of daily living. In India; till a few years ago, MS was thought to be rare and a disease of the Western hemispher. It is unclear why now we are seeing more and more MS patients in India. Is it because with advances in health care and diagnostics, we are diagnosing more cases which earlier remained undiagnosed or is the incidece of this disease actually increasing in the Indian population? This still needs to be determined and it would behoove us well to start a national MS registry and keep a track of MS cases and coregister with dietary and enviromental variables. Many low and middle income countres such as India have a huge population with limited accessibility and affordability to health care facilities. About 70% of India’s 1.3 billion population lives in rural areas with 30% living below the poverty line. In a country like India, a disease like MS can have a particularly devastating impact not just because of its chronicity and propensity to affect the young but also due to its high treatment cost burden. A study published in April, 2015 found that the cost of first generation disease modifying medications for MS increased from between $8000 to $11000 annually in the 1990s to approximately between $60000 to S90000 per year currently. Newer disease modifying MS drugs cost even more.In the west, patients with MS commonly pay for their MS treatment in one of the following ways:

1. Job (employer) based health insurance plan
2. Individual health insurance plan
3. Medicare
4. Medicaid or state children’s health insurance program
5. Other state and federal government funded programs for the uninsured and underinsured

In India, where illiteracy, unemployment and poverty remain major social problems, state and federal supported health insurance schemes benefit only a small fraction of the population. As in India at present there is no National Health Insurance program, patients have to pay out of pocket for health care. The purpose of writing this commentary is to draw attention to the cost burden associated with a chronic disease like MS and start a discussion on treatment solutions that may benefit our MS population without causing unbearable financial burden.
We calculated the average health care cost to a patient who is first time admitted for any demyelinating disease, in a corporate health care institution. A patient with spastic paraparesis was admitted to Sir Ganga Ram Hospital (SGRH) with provisional diagnosis of acute myelitis later confirmed as MS. We found that the entire hospitalization cost him around Rs. 1.8 lac ($2560).

Breakdown of costs:

Investigations:
–contrast enhanced MRI brain and cervical spine (Rs. 26000/ $ 416)
–visual evoked potential (VEP) (Rs. 2000/$ 32 )
–lumbar puncture (CSF analysis) (Rs. 8000/ $ 128)
–ancillary investigations like autoimmune encephalitis panel (Rs. 40000/ $ 464).
Treatment costs:
—pulse IV steroid therapy x 5 days (Rs. 70000/ $ 1120)
Hospital stay costs:
–room cost plus ancillary expenditure (Rs. 70000/ $ 1120)

It is important to remember that this is the financial burden borne out of pocket by an average middle class patient admitted to SGRH. Patients who live below the poverty line cannot afford such costs and the financial burden forces family members to take loans or at times sell their home and property to pay for the treatment. Unlike a case of post infectious myelitis, a patient with MS may suffer an acute exacerabation or relapse leading to another hospitalization and additional costs. The various MS disease modifying agents are so expensive that few patients in India can afford the drugs. Many as a result discontinue treatment regimens and self medicate with medications such as oral steroids.

We also calculated the average cost to the patient of various disease modifying agents available in India.

1. Injectable DMTs like Avonex (beta interferon) given at a dose of 30mcg I/M once a week costs Rs. 30000/ $ 480 dollars monthly.
2. Copaxone (glatiramer acetate) Rs. 20000/ $ 320 monthly.
3. Mitoxantrone Rs. 400/ $ 5 per vial
4. Tysabri (natalizumab) costs a whopping Rs. 1,40,800/ S 2184 monthly.
5. Oral DMTs like fingolimod costs around Rs. 3,00,000/ S 4790 dollar for 30 capsules, teriflunomide Rs. 2,90,000/ $ 4500 for 1 month supply, and dimethyl fumarate Rs. 3,40,000/ $ 5300 for 1 month supply.
6. Azathioprine costs Rs. 600/ $ 9.6 per month

The per capita income in India is estimated at just short of Rs. 6000 per month which equals $ 90 per month. That means the per capita income for a family of 4 would be less than $ 400 a month, but the reality is that most people live on much less than that and struggle to provide for the basic needs of food, clothing and shelter. Both the interferons and the oral DMTs are accessible to only a few in India due to their exorbant cost. As a result, many Indian MS patients cannot afford treatment and are left behind untreated with significant neurological disability impairing their quality of life. In India, where it is estimated that around 100,000-200,000 people have MS, finding cost effective treatment options is very important.

What are the solutions?

1. Methylprednisolone (Solumedrol) is an effective drug used to treat an acute attack of MS. Once the diagnosis of MS is confirmed, and patient presents to the hospital with an acute exacerbation, first dose of methylprednisolone can be administered in the emergency department followed by rest of the doses at home. The outpatient administration can be carried out by trained nurses via patient outreach programs. This will greatly reduce the cost of treating an acute attack of MS without requiring admission.

2. An initial MS diagnostic and treatment package should be constituted, including all the necessary initial investigations and treatment. This shall help drive down the initial costs incurred by patients and family members.

3. A MRI package should be constituted. This should include the cost of MRI brain and cervical spine imaging at least once a year and help in reducing the diagnostic cost associated with repeated neuroimaging in patients with MS.

4. A National Health Insurance scheme geared towards chronic neurological diseases such as MS should be formulated. While many good insurance schemes have been recently launched by the government, unfortunately they remain on paper only.

5. Pharmaceutical companies manufacturing and marketing MS drugs should be approached by the government and the cost of MS drugs should be negotiated so that more patients can afford these medications and avail their benefits. Recently 3 Indian pharaceutical companies have launched generic versions of Tecfidera (dimethyl fumarate) costing under Rs.4000/month. Intas pharmaceuticals generic version of Aubagio (teriflunomide) costs only Rs. 2000/month.

6. There are various studies documenting the effectiveness of azathioprine in MS patients. A multicentre randomized non inferiority trial was conducted comparing azathioprine vs beta interferons for relapsing remitting multiple sclerosis and it was found that efficacy of azathioprine is not inferior to that of beta interferon for patients with relapsing remitting multiple sclerosis 1. Massacesi et al conducted a study evaluating the efficacy of azathioprine therapy on new brain lesions evaluated using magnetic resonance imaging and concluded that azathioprine administered at lymphocyte suppressing doses, is effective in reducing MS new brain inflammatory lesions and is well tolerated 2. In a study by Casetta et al in 698 patients with MS, it was concluded that azathioprine is a fair alternative to interferon beta for treating MS patients 3. In SGRH, we have around 20 patients with MS who are on azathioprine for the past 10 years, doing well and tolerating the medication well. Considering the convenience of oral administration, low cost and good efficacy, azathioprine may represent an alternative to interferon and oral DMTs. This should be studied further in the Indian context.

Conclusions

In India, there is a large unmet disease burden of MS. We can’t afford not to afford the treatment of MS in India as it affects our young population who are the backbone of our nation. To tailor to the requirements of the Indian population, drug trials with large sample size using cheaper drugs such as azotioprine are needed. Large academic medical centers in India should take the lead in this initiative and run head to head trials of azothioprine against more established injectables and oral DMTs.

A question about oligoclonal bands (OCBs) in multiple sclerosis and a reply

Recently one of the readers of my blog asked me a question about the presence of oligoclonal bands (OCBs) in multiple sclerosis. I am reproducing her question here and my reply to is follows. Hope it helps some of you out there.

 

Hello Dr. Sethi:
I found your informative blog Brain Care Foundation online, and I wanted to get in touch with you about the neurological symptoms I have been experiencing in hopes that you can provide some guidance to me.

I am a 28-year-old Indian-American female who was recently diagnosed with optic neuritis. An MRI of my brain showed one unspecified speck and a lumbar puncture showed three oligoclonal bands that were also present in the blood, ruling out multiple sclerosis, according to my doctor. All other blood work is normal.

She has recommended that I see a rheumatologist to rule out other autoimmune diseases.

I have been very concerned about underlying diseases that may have causes the optic neuritis and my question to you is whether I should be concerned about the presence of three oligoclonal bands in the cerebral spinal fluid. Ideally, I understand there would be none, but it seems somewhat arbitrary to me that 1 or 2 would be considered normal and 3 would be considered an abnormally high level.

I specifically wanted to seek your advice because I read in your blog that “greater than 3” would be the amount of concern.

Thank you in advance for any insight you can provide.

Sincerely,
R

p.s. please feel free to post this question on your blog without using my name

Dear R,

thank you for writing in to me. You ask me a very specific question regarding the presence of OCBs in multiple sclerosis (MS) and I shall be happy to answer it for you. OCBs can be seen in multiple other conditions apart from MS. What we look for in MS is that the oligoclonal bands should be only present in the cerebrospinal fluid (CSF) and not in the blood. As you are aware MS is a demyelination disease of the central nervous system (brain and spinal cord). So it reasons that the bands should only be present in the spinal fluid and not in the blood. We refer to this as intrathecal synthesis of OCBs. If OCBs are present in both the spinal fluid and the blood, one needs to rule out diseases that may cause passive transfer of OCBs from the blood into the spinal fluid. Now to your second question. Just how many OCBs are considered abnormal or worrisome for MS? This is a tough one to answer as studies have shown conflicting results. Some studies have indicated that a higher number of OCBs in the spinal fluid is more specific for MS (aka increases the risk for conversion of a clinically isolated syndrome into a clincally definite MS). In other studies this has not been conclusively proven.

Hope that answers your queries. I wish you my ver best.

 

Personal Regards,

Nitin Sethi, MD

Multiple sclerosis: making the diagnosis

So let us start from where we left off. Just how do we (doctors) go about making (confirming) the diagnosis of MS.

MRI scan: Well one of the test most commonly requested (infact done in nearly every patient) is a MRI scan of the brain and at times of the cervical spinal cord. What are we looking for you may ask? Well multiple sclerosis on the MRI is characterized by plaques (lesions) which are disseminated in space and in time. What does that mean? In a typical patient of MS, the MRI scan shall show evidence of disease activity which is scattered around in different parts of the brain. Meaning there are MS lesions seen in different parts of the brain white matter (typically MS is a white matter disease though recent research indicates involvement of the grey matter too). So for example a typical MRI scan shall show plaques scattered  in the white matter of the frontal lobe, parietal, temporal lobe, cerebellum and so forth. Moreover the MRI scan shall indicate that these plaques are of different age (which indicates that the disease has been present for sometime now). Remember what I said –relapsing and remitting MS. Sometimes to help secure the diagnosis, your doctor shall also order a MRI scan of the spine most commonly cervical spine. The intention is the same and that is to see evidence of dissemination of the disease process in the brain and spinal cord.

Spinal tap: a lumbar puncture is usually carried out. Does every patient need a spinal tap to help secure the diagnosis of MS? No. Remember the diagnosis of MS can be made clinically in some patients. In patients where the characteristic history is not forthcoming and in whom the MRI scan does not prove helpful (does not evidence of dissemination of disease process in space and time), a spinal tap may be warranted.  The spinal fluid of MS patients is analyzed for certain proteins which suggest evidence of disease process. These include myelin basic protein (MBP), oligoclonal bands (OCBs) and IgG index.

Other tests: these tests may be requested in special circumstances (usually when the diagnosis remains elusive inspite of MRI scans and spinal tap).

1) Visual evoked potential (VEP), brainstem auditory evoked potential (BAEP) and somatosensory evoked potentials (SSEP):  these tests usually involve testing the integrity of different pathways in the brain. VEP tests the visual pathway from the eye to the occipital (visual) cortex, BAEP–tests the brainstem auditory pathways while SSEP check for the integrity of the white matter tracts carrying somatosensory information (vibration, joint sense and position sense) from the periphery (arm or leg) to the somatosensory cortex.  MS lesions involving any of these pathways cause a delay in the rate of conduction of nerve impulse and provide ancillary evidence of involvement of white matter tracts of the brain by a demyelinating disease process.

I hope these two posts help you all in understanding how the diagnosis of MS is made.

 

Nitin Sethi, MD

Multiple Sclerosis–making the diagnosis

I still continue to get many questions from the readers of my blog regarding multiple sclerosis (MS). A significant majority of them write to me because they are concerned they may have MS either because of white matter lesions found on a MRI scan of the brain or because they are plagued by various non-specific signs and symptoms. Though I have written about this before, I thought this shall be a good time to go over how the diagnosis of MS is made. What are the symptoms that raise the suspicion for MS, what are the clinical signs on examination that suggest MS and finally what are the tests that may help to confirm the diagnosis.

Before I dwell deeper into this topic, please remember: THE DIAGNOSIS OF MS IS A CLINICAL ONE. Meaning that it can be made on the basis of a history and clinical examination itself. No tests are needed in such a situation to confirm the diagnosis.  Of course as it is often in medicine–it is always not that easy.

So let us begin—

Clinical history: Are there any points in the clinical history of the patient that suggest the diagnosis of MS? Patients with MS may give a history of neurological symptoms and signs (remember signs are elicted on clinical examination-meaning when the doctor examines you) that wax and wane (relapsing and remitting MS). A patient may present with acute loss of vision in one eye along with pain in the eye  (I am talking about optic neuritis). As the doctor dwells deeper into the history, the patient volunteers that a couple of years ago he had a similar problem in the other eye which had resolved on its own and he had not been investigated further. Hmmm–now we have history of 2 attacks separated in time. As a neurologist this makes me think of MS as a possible diagnosis. The problem with MS though is that it may present with non-specific signs or symptoms or rather it may present with signs and symptoms that localize to different parts of the central nervous system (CNS). By CNS I mean the brain and the spinal cord. So for example patients may present with numbness on weakness on one side of the body (this localizes to the contralateral motor or sensory cortex), problems with the bladder (incontinence–this usually localizes to the spinal cord), problems with balance and coordination (their gait is off and they may have a prominent tremor in their limbs–this localizes to the cerebellum or the brain stem), double vision (this localizes to the cranial nerves which control the movement of the eyes). Virtually any part of the central nervous system can be involved–hence the presentation is at times non-specific. BUT WHAT HELPS US AS DOCTORS IS WHEN WE GET HISTORY WHICH SUGGESTS A DISEASE DISSEMINATED IN SPACE AND IN TIME. Meaning a disease process which is involving different parts of the central nervous system and which has shown evidence of multiple attacks separated by time. REMEMBER MS IS NOT A MONOPHASIC ILLNESS (it relapses and remits!!!)

Clinical examination: So what are the clinical examination findings which make me as a neurologist think of MS in  a patient. There are certain neurological signs which have been said to be pathogonomic of MS (meaning the presence of these signs virtually seals the diagnosis of MS). These include certain eye signs. Bilateral internuclear opthalmoplegia (INO) (who said neurology was easy!!!) is one such sign. This is an eye-sign in which the patient’s eyes do not move as directed by the examiner. One eye fails to adduct (that is move inwards) while the other eye  abducts (moves outwards) but the abducting eye shows a nystagmus (shaky side to side movement). Other eye signs such as an afferent pupillary defect (this is elicted by shining a penlight into the eye) also raise suspicion for MS. What we as neurologists look for though is this–we look for signs that suggest the disease is disseminated in the CNS. REMEMBER WHAT I TOLD YOU ABOUT MS. IT IS A DISEASE WHICH IS DISSEMINATED IN TIME AND SPACE.

Tests: so when a diagnosis of MS cannot be made on the basis of history and examination alone, we as doctors have to fall back on tests to rule in or rule out the diagnosis. No test seals the diagnosis of MS by itself. They just help to add to our certainity. I shall discuss the various tests namely –imaging studies such as MRI scan of the brain and spinal cord., evoked potential studies such as visual evoked potential (VEP), somatosensory evoked potential (SSEP), brain stem auditory evoked potential (BAEP), spinal fluid (CSF) examination in the next post.

 

Nitin Sethi, MD

I have multiple sclerosis. Do I need to take MS medications? Discussing the pros and cons

Nitin K Sethi, MD

 

Assistant Professor of Neurology

New York-Presbyterian Hospital

Weill Cornell Medical Center

New York, NY 10065

 

 

The decision of taking MS medications is one which requires consideration of multiple factors by both the patient as well as the treating physician. At times the decision to go on medications is relatively straight forward, at other times it requires consideration of multiple factors before deciding on the best course of action.

Let me try to explain this by using a 29-year-old patient whom we shall refer to as Janet.

YOU CAN READ THE COMPLETE ARTICLE ON THE HEALTH CENTRAL WEBSITE.

http://www.healthcentral.com/multiple-sclerosis/c/73302/62597/make-ms

An interview about Multiple Sclerosis

“Merely me” is a mother, a writer and a staunch MS patient advocate. I have had the good fortune of getting to know her recently. She has an amazing drive and feels strongly about issues related to multiple sclerosis. She recently interviewed me.

Here is the link to her site and the interview. I hope you find the information presented there helpful.

http://www.healthcentral.com/multiple-sclerosis/c/73302/54272/doctor

Personal Regards,

Nitin Sethi, MD