Simple Algorithm Reduces Racial Disparities in MS

A simple algorithm to aid in the selection of appropriate disease modifying therapies (DMTs) reduces racial disparities in patients with relapsing multiple sclerosis (MS), early new research showed.

This risk-stratified algorithm led to an increase in the use of highly efficacious treatments (HETs), and a decrease in relapse rates, among Hispanic, Black, and White patients with MS.

“This study basically shows that if you give the good stuff to the people who need it, whether they’re Black, Hispanic, or White, you can get similar levels of disease control or improvement in their disease activity,” study investigator, Annette Langer-Gould, MD, PhD, regional lead for Clinical Translational Neuroscience, Kaiser Permanente Southern California (KPSC), Los Angeles, told Medscape Medical News.

The algorithm offers clear, measurable guidance on prescribing HETs, prioritizing lower-cost DMTs, and supporting individuals with MS who encounter financial or other barriers to DMT use.

This study will be presented at the American Academy of Neurology (AAN) 2025 Annual Meeting in April.

Higher Disability, Lower HET Rates

Research indicated that racial minorities with MS experience higher levels of disability than white patients, yet they are less likely to be prescribed a HET such as rituximab which is used off-label for MS, said Langer-Gould.

Growing evidence suggests the use of HETs in all MS patients reduces the risk for long-term disability. However, HETs such as monoclonal antibodies such as rituximab and natalizumab continue to be underutilized even in relapsing-remitting MS patients with continued disease activity on beta-interferons or glatiramer acetate, said Langer-Gold.

Rituximab, an anti-CD20 monoclonal antibody, is approved in the United States in the treatment of certain blood cancers and autoimmune diseases including rheumatoid arthritis. Multiple studies have demonstrated its efficacy in MS, and it is commonly used off-label in this patient population.

Langer-Gould emphasized the long-standing deficiencies in the current approach to MS treatment. She told Medscape Medical News that when she joined Kaiser in 2009, she observed that patients with MS were being treated randomly, without a structured system for managing care or selecting therapies.

In 2012, she and other experts set out to create a new standardized model of care aimed at improving the efficacy, affordability, and equity of MS therapies.

The algorithm they developed categorizes patients with relapsing MS into high, intermediate, or low risk for disability based on the best available evidence. It also classifies DMTs by their effectiveness, grouping them as highly effective, moderately effective, or having low/uncertain efficacy.

A DMT is considered highly effective if it has demonstrated superiority over an active comparator in at least one head-to-head randomized controlled trial (RCT) and/or has shown to be highly effective. This includes evidence of a significant treatment effect in an RCT involving patients with highly active disease or a positive RCT outcome in individuals with MS who experienced relapses despite using moderately effective DMTs.

When developing the algorithm, the team prioritized factors that clinicians could easily access in practice. These included social considerations like work schedules and transportation barriers, along with available MRI results, noted Langer-Gould.

The algorithm also takes costs into account, as medications have become increasingly unaffordable, Langer-Gould noted. She emphasized that evidence indicates out-of-pocket healthcare expenses disproportionately affect Black and Hispanic individuals in the United States which likely contributing to delays in initiation and maintenance of DMTs.

However, race and ethnicity are not factors in the algorithm. “There’s no evidence that these alone are associated with worse outcomes independent of treatment,” Langer-Gould explained.

The goal is to help clinicians quickly assess a patient’s underlying risk and long-term disability by taking a comprehensive history. This includes determining whether the patient has experienced a severe relapse, spinal cord involvement, or breakthrough disease activity while on a modestly effective DMT.

“Then you can decide whether they need a highly effective therapy, or whether they could potentially be controlled with a modestly effective therapy,” said Langer-Gould.

DMT selection also depends on factors such as affordability, pregnancy, and the patient’s likelihood of treatment adherence.

The algorithm was implemented at KPSC from 2012 to 2023.

To evaluate whether a health system intervention aimed at increasing the use of HETs was implemented fairly and resulted in similar improvements in MS outcomes across different racial and ethnic groups, the researchers analyzed electronic health record data from Kaiser Permanente.

This included information on DMT use and annual relapse rates (ARRs) prior to implementation of the algorithm (2009-2011) and during its implementation.

Investigators identified 978 Black, 1741 Hispanic, and 3400 White patients with MS receiving DMT treatment. Before the intervention, Hispanic patients had a higher ARR per 1000 person-years (245.1; 95% CI, 205.5-284.8) than White patients (156.3; 95% CI, 137.8-174.7).

Black patients had higher ARRs than their White counterparts before and during early implementation, but this was only significant in 2015.

Over the 12-year implementation period, the use of HETS, primarily rituximab, increased the most among Hispanic patients (89.3%), followed by Black patients (87.4%) and White patients (82.9%).

The decline in age- and sex-adjusted ARR was greatest among Hispanic (90%; 95% CI, 89%-91%), then White (86%; 95% CI, 85%-87%) and Black (82%; 95% CI, 80%-84%) patients between 2011 and 2023.

By 2023, the ARR showed no clinically significant differences between the study groups, with rates of 35.5, 19.0, and 18.1 per 1000 person-years in Hispanic, Black, and White patients, respectively.

“The results show that if you focus on whether or not your patient needs a highly effective therapy based on their clinical characteristics, and choose one that they can adhere to, you can get great disease control, regardless of their race and ethnicity,” said Langer-Gould.

Kudos, Caveats

Commenting on the research for Medscape Medical News, Dennis Bourdette, MD, professor emeritus and former chair of Department of Neurology, Oregon Health & Science University in Portland, Oregon, characterized the findings as “impressive.” He added that he hopes these results will encourage neurologists to adopt this, or a similar algorithm, to guide treatment decisions in patients with MS.

Bourdette emphasized that most patients with MS should begin HET early in their disease course to prevent long-term disability.

Unfortunately, he added, neurologists, particularly those who do not specialize in MS, often delay using HET in their patients with MS.

However, he cited several barriers to the broader adoption of this or similar treatment algorithms, pointing out that Kaiser Permanente operates as a “closed system” where enrolled patients must see Kaiser-affiliated physicians.

The support of Kaiser Permanente provided a level of assurance that neurologists within the system would adhere to the algorithm. In contrast, he noted that implementing such a framework among neurologists in community-based or nonintegrated healthcare settings remains a significant challenge.

Bourdette noted Langer-Group’s team previously showed this algorithm improves the quality of care of patients with MS while lowering costs, primarily by employing off-label use of rituximab.

“While published studies show the efficacy of rituximab in MS and it appears comparable to the much more expensive anti-CD20 monoclonal antibodies such as ocrelizumab that are FDA [US Food and Drug Administration] approved for MS, many neurologists outside of the Kaiser system may be reluctant to use rituximab” in place of these approved agents.

Patients outside the Kaiser system with private insurance can receive copay assistance for FDA-approved MS therapies but not for off-label use of rituximab. As a result, rituximab often ends up costing patients more than FDA-approved anti-CD20 monoclonal antibodies for MS, Bourdette noted.

This study had no outside funding. Langer-Gould and Bourdette reported no relevant conflicts of interest.

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