The Ups and Down of Medication Adherence

The Ups and Downs of Medication Adherence

Episode 134 – Podcast Transcript

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[(0:19)] Stephanie Buxhoeveden: Welcome to the Can Do MS Podcast. I’m your host, Stephanie Buxhoeveden. I live with MS and I’m also a clinician and MS researcher. This is episode number 134. Today, we’re going to talk about the topic of Medication Adherence. I’m excited to welcome our guests, Megan Winebrenner, who is a pharmacist and the clinical Pharmacy lead at CenterWell Specialty Pharmacy. Megan has been a pharmacist for 15 years, and we’re excited for her to share her expertise with us. Welcome, Megan.

[(0:46)] Megan Winebrenner: Hi there. Thanks for having me. Glad to be here today.

[(0:50)] Stephanie: Before being diagnosed with MS, I had no idea Specialty Pharmacies even existed. Can you tell me how Specialty Pharmacies and the services provided by pharmacists such as yourself differ from what’s available at my neighborhood pharmacy?

[(1:24)] Megan: Yeah, absolutely. Um, so, Specialty Pharmacies are different than your traditional or maybe retailer neighborhood pharmacies in the sense that they’re going to spend Specialty medications. And so, specialty medications are often used to treat chronic complex disease states, uh, one of which is multiple sclerosis. Um, and so, a lot of times these disease states often require high touch support um, from our clinical staff and, and our pharmacies. So, we really aim to support these patients throughout their treatment journey. Um, as CenterWell Specialty Pharmacy we have a number of ways in which we can support the patient’s filling Specialty Pharmacy specialty prescriptions with us. Um, one of those ways is we offer a lot of clinical programs, um, and one of them as it relates to multiple sclerosis is our Neuromuscular Center of Excellence. So, our Neuromuscular Center of Excellence really aims to support patients that are filling our prescriptions for any type of neuromuscular condition, one of which is multiple sclerosis.

Um, with our, our Center of Excellence, we have a dedicated staff. So, we have dedicated financial specialists, dedicated nurses, dedicated pharmacists that really help to provide holistic management for the patients. So, really trained to look for opportunities and any other barriers that could potentially impact the way the patient um, does on therapy or how, how long they stay on therapy. So, really trained to, to assess the patient individually, figure out what that individual patient’s needs are, and really help to remove and, and improve those barriers um, that could potentially get in the way of, of treatment.

So, you know, really, I think, from a specialty pharmacy, I think they provide, provide holistic management. There’s a care team here, um, that you know, is made up of several different team members um, that offers a little bit of expertise and, and kind of that area. So, financial specialists are going to help in, you know, for, for funding. Um, there’s obviously a more cost associated a lot of times with specialty medications, and maybe those traditional prescriptions that you might fill through our neighborhood pharmacy. Um, but really, you know, our patients often require high touch support, and we provide the information, care and support they need in order to stay on with therapy.

[(3:35)] Stephanie: That’s so important. Like you said, it’s really hard to navigate, A; living with multiple, and B; all of these medications that we have to take. So, I think that’s a fantastic resource.

[(3:47)] Megan: Yeah, and I think that for us, it goes beyond just dispensing medication, right? We’re going to follow patients throughout the entire time they’re on therapy in making sure because, you know, needs will change over time too. So, making sure that you know, the patient’s needs are assessed each and every time, um, and that we can help to support them throughout that entire treatment.

[(4:09)] Stephanie: Yep. MS is a lifetime disease.

[(4:11)] Megan: It is.

[(4:13)] Stephanie: So, as a pharmacist, what do you see as barriers that prevent people from taking their medications as prescribed?

[(4:21)] Megan: So, there’s a number of barriers. Every patient is different, right? There’s a number of factors that can influence uh, each individual. I think from a, a patient level, you know, there could be certain comorbidities or other disease states that maybe can affect the patient, you know, within the MS space. There are some injectable medications. So for instance, if a patient maybe has rheumatoid arthritis, and is having a hard time administering the medication, some types of dexterity issues, that could potentially impact adherence. You know, for, for the patients, sometimes, if they’ve been on therapy for a while, they might have refilled fatigue.

If they’re on an injectable medication, you know, it’s possible that, you know, they’re having injection site reactions, pain with injection. Um, you know, the side effects are associated with the administration, and so they might be kind of getting tired of that, and we might start to see adherence issues pop up because of that. There’s also oral medications in MS phase two, and so, you know, we do have to make sure that either the side effects or tolerability, isn’t getting in the way of, of how well a patient is um, their adherence to, to the medications.

So, there’s, there’s definitely a number of factors um, that come into play, you know, the administration we mentioned, different disease states. Even sometimes cognitive issues, you know? If maybe a patient is starting um, to maybe just forget to take their medication. We really try to assess all these reasons as to why a patient may be showing some adherence issues, even sometimes depression and anxiety can play a role there too. So, there’s a number of reasons, and it’s different for every individual.

[(5:55)] Stephanie: Yeah, I think you nailed it. It’s difficult. You know, as a healthcare provider and a patient, I understand why I need to take these medications, and I do need to take them, but like you mentioned, I found it really hard to inject myself with a needle every day, just the injection site pain. And then in times where I felt really good and kind of forgot that I had MS, it’s hard to stop and remember to take medication that you actually still need every day. So, we see it both ways. We see it because medications can be hard to tolerate, or hard to administer, but also because it’s kind of difficult to just remember to take care of yourself and stop daily life sometimes.

[(6:35)] Megan: Absolutely. Completely agree there.

[(6:37)] Stephanie: So, speaking of that, why is adherence so important to someone living with MS?

[(6:43)] Megan: So, a, um, one of medications that, that we’ll dispense here uh, typically for MS is a disease modifying therapy. So, these are the medications that really are aimed to slow the progression of the disease and slow disability. You know, really aim it at improving the patient’s quality of life here. Um, so, adherence is going to be critical to their success in order for, um, for a patient to, to respond as they had anticipated, then we really need the patient to take it as it’s prescribed. Um, and so you know, this goes with most drugs is, is to taking it as it’s prescribed. So, if there’s ways that we can help patients throughout therapy to make sure that, you know, that kind of adherence issues are addressed, you know, we’re here to support them.

[(7:31)] Stephanie: I think that’s great, and I always told my patients, “Your medication shouldn’t have more of a negative impact on your quality of life than your MS does.” So, if there is something keeping you from taking medication, if it makes you feel sick, or you don’t like the injections, it’s really important to bring that up. And you could bring that up to the Specialty pharmacist [crosstalk]

[(7:47)] Megan: Absolutely.

[(7:48)] Stephanie: … as the first person.

[(7:50)] Megan: Absolutely. Absolutely, hmm, hmm.

[(7:51)] Stephanie: Now sometimes, life just gets hectic or as you said, cognitive symptoms can make us forgetful. Are there any tools that can help with medication adherence?

[(8:01)] Megan: Absolutely, there’s, there’s a lot of them available right now. So, I will say CenterWell Specialty Pharmacy first off is going to help with refill reminders. We do telephonic refill reminders. We also do text messaging capabilities as well, if patients choose to um, to text and go that route. Um, so that just in general to the pharmacy, the Specialty Pharmacy. Um, I do think it helps a lot of times with adherence, you know, just getting that refill reminder, you have a refill that’s due at the Specialty Pharmacy. But then also, you know, within the um, context of the conversation that are within our Center of Excellence, our Neuromuscular Center of Excellence, that clinical staff, either the nurses and pharmacists on the line will really be assessing the patient for any type of adherence risk. And that’s when they can also offer suggestions as, as to what can really help with that individual’s needs.

And so, there are a number of mobile apps, um, smartphone apps, calendar reminders. Um, sometimes they even have just tips and tricks as part of, you know, making your medication part of your daily routine so that you know, it’s not, um, it’s just maybe a little easier to remember to take it, right? So, there’s a number of things that are available out there now. There’s pill cases, they’re smart pill bottles. Um, and another thing that I, you know, and, and our clinical staff typically will recommend too is to make sure that the patient feels support from their family um, as well, or, you know, friends. So, make sure that they have, you know, support as far as you know, adherence reminders from, from family and friends maybe in the home setting, so.

[(9:35)] Stephanie: Yeah, and I really love those pill organizers that tell you, A.M.-P.M. and afternoon and the, like you were saying, the smart pill cases that will show you the last time that pill bottle was opened. So, even if you have trouble remembering whether you took that medication in the morning or you’re a caregiver, care partner, and you want to make sure the person you love is taking their medication on time, those are pretty awesome resources.

[(9:59)] Megan: Yes. I agree there. Sometimes, you know, your day gets so busy, you have to stop and think like, “Did I take that?” And it’s nice to have, you know, different resources like that to kind of check in on that. So, I agree.

[(10:12)] Stephanie: Now, over the last decade, our DMT options have really exploded. And having so many options, while it being a very good thing, can also be very overwhelming at times. What do you think people should consider when picking their first DMT, or even just switching medications?

[(10:35)] Megan: Sure. So, I think first off, communication is really bad to assess the risks and benefits of each DMT. It’s really important to make sure that the patient and the physician are discussing the values and preferences for the patient, um, just making sure that they determine what’s the best treatment option for them. You know, there’s all different types of medications in, in relative medication out there. There’s injectables. There are some that the frequency is maybe um, not as frequent, or some that are maybe once a week, you know, every, every couple days.

So, really trying to evaluate just the needs of the patient and their lifestyle I think is very important.
You know, obviously, we want to consider effectiveness um, but also want to make sure that tolerability because that, you know, as you mentioned earlier, impacts quality of life too. We want to make sure that the patient is taking it and, you know, it’s being taken as it should um, to make sure that, you know, it is effective. Side effects, making sure that they talk to their prescriber. Making sure that you know, everything um, is, is conveyed and, and that conversation making sure that any doses have been skipped, you know, we want to know why.

You know, relative administration is obviously very important to fit lifestyle needs, you know? If someone, if someone uh, who travels quite a bit, you know, it might be challenging to take a refrigerated injectable with them. And so, just things that, that patient needs to make sure that they tell the prescriber. But also don’t be afraid to speak up, and just, you know, that shared decision-making is really important, but I think that that really is the key to adherence too.

[(12:10)] Stephanie: Absolutely, and like you said, there are so many options in terms of how frequent these medications are taken, whether they’re a pill, an injection, an infusion, and there are pros and cons to all of them. And it just comes down to what best fits you, and your lifestyle.

[(12:25)] Megan: Absolutely.

[(12:28)] Stephanie: So obviously, MS, medications are expensive. We all know that, but now several are generic. Can you explain what the difference between a generic and a brand disease-modifying therapy are?

[(12:40)] Megan: Sure. So, we are starting to see a lot more generics in the MS space right now. We’ve had a couple actually added this year, um, hit the market. So, when the patent runs up on a brand, a generic manufacturer can come in and start manufacturing a generic of, of that branded product. And so, what these generics will, will be, we have to make sure that when they’re approved, they’re verified as safe and effective showing their equivalent to the brand product. So, that’s going to be an active ingredient, dose, dose form, the response that it’ll take in the body as well, too. So, it does have to go through quite a bit of a, a um, a process to be approved, but once again, that, that patent is up on the brand, that’s really when we’re going to start seeing generic manufacturers come in with their product. Generics can be substituted for the brand. So, um, unless the prescriber writes for brand only, then a generic can come in and be substituted.

[(13:36)] Stephanie: So, I think the hope for patients and providers was that when generics hit the market, all of these medications would become less expensive. But I’ve recently been hearing stories about some people with MS being switched to the generic DMTs like you were saying, getting to the pharmacy and finding out that their co-pays are now hundreds or even thousands of dollars for the generic because they were using a co-pay assistance program for the brand. And once something goes generic, that co-pay assistance for the brand is no longer available. So, often it is a medication that they’ve been stable on for years, so this has understandably caused a lot of fear and anxiety in our community. What advice do you have for patients in this position?

[(14:21)] Megan: Yes. Um, so, my advice here would be to talk to the Specialty pharmacist and/or the financial specialists within the Specialty Pharmacy. So, you know, there are many factors that are really going to affect the co-payment cost to the patient. Formulary, a lot of times, plays, plays a role here, and it’s different for each individual’s insurance, right? So, my advice would be to talk to that financial specialist within the Specialty Pharmacy. You know, that team is really knowledgeable within the funding within different spaces. And so particularly, you know, our Center of Excellence here, that team is really knowledgeable within the funding within the MS space.

And so, while brands can have copay cards, you know, there are also grants and foundations available too. And so, you know, that team really, you know, they do a lot of research to find out what is out there for patients. And they do explore all options, and they don’t just check once, they continue to check. So, so maybe let’s say, um, funding wasn’t available on the first fill, or you know, something along those lines, they’re going to continue to check. And so, it might become available at my next fill. So, they’re, they’re always keeping that open, and they’re always exploring that for the patient.

So, there, there are other options out there, you know? But like I said there’s a number of factors that really in-influence the, the cost and the co-pays for each patient. I’ll say the nice thing too about those financial specialists, they also will help to um, apply for some of the, the grants and the foundations for patients. So, we’re starting to get that paperwork started, which is nice because that’s always, you know, one extra thing to do and one, you know, kind of hurdle to get through.

So, it’s nice to kind of have someone walk you through that process and know what to expect. I also, you know, would definitely recommend, don’t stop taking the medication. Make sure you talk to your entire care team. Let them know what’s going on. Talk to your prescriber. Talk to the specialty pharmacist and, and you know, this financial team to make sure that, you know, the pharmacy can connect with the prescriber in making sure that they’re aware of the situation too. So, we don’t want anyone to just abruptly stop. We want to make sure that, you know, all parties in care team members are involved in the process.

[(16:34)] Stephanie: Yeah, I think that’s so important. This is not something that can wait until your next follow-up visit with your neurologist. This is something that you would call your provider immediately and alert them that they can’t afford their copay before you would just not fill it, and not say anything. So, is there anything else you would like to share with our listeners?

[(16:58)] Megan: No. I think I just would like to reiterate, you know, what’s in the Specialty Pharmacy? There are so many ways for you know, the Specialty Pharmacy to support patients. Like I mentioned with our Neuromuscular Center of Excellence, we have so many different team members that helped us for patients. We talked about financial Specialists. We have nurses and pharmacists that are knowledgeable, you know, on the, on the medications and the education involved with the disease state as well too. Also, social workers that can really help too, you know, any type of barriers within the social aspect. You know, everyone here to support the patient through their journey.

So, you know, the best way is to take, you know, advantage of, of those support programs, as really, to make sure you’re being open and honest with the Specialty Pharmacy. So, we want to help you in the best way we can and connect you with the resources that are really going to be able to support you best.

[(17:43)] Stephanie: Thank you so much, Megan, for joining us today.

[(17:46)] Megan: Thank you so much for having me. Appreciate your time.

[(17:52)] Stephanie: Thank you for tuning in to this episode of the Can Do MS podcast. To learn more about CenterWell Specialty Pharmacy and the role of the pharmacists in your MS care, please check out the description of this podcast episode where we share link to CenterWell Specialty Pharmacy and videos that dive into this topic further. We’d like to thank CenterWell for their support of this podcast episode. We’d also like to thank Biogen and all our generous sponsors for their support of the 2023 Can Do MS Podcast series. Thank you. Until next time, be well and have a great day.

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