Clinical UM Guideline

 

Subject: Beta Interferons and Glatiramer Acetate for Treatment of Multiple Sclerosis
Guideline #:  CG-DRUG-03 Publish Date:    12/27/2017
Status: Reviewed Last Review Date:    11/02/2017

Description

This document addresses the following beta interferon (interferon [IFN) beta-1a and IFN beta-1b) and glatiramer acetate injectables used for the treatment of multiple sclerosis (MS) in an effort to decrease relapse rates and delay disease progression:

IFN beta-1a agents:

IFN beta-1b agents:

Glatiramer acetate:

Clinical Indications

I.  Beta Interferons (IFN beta-1a [Avonex, Plegridy, Rebif] or IFN beta-1b [Betaseron, Extavia])

Medically Necessary:

Treatment of MS with IFN beta-1a or IFN beta-1b is considered medically necessary for individuals with any of the following conditions:

Not Medically Necessary:

Treatment of MS with IFN beta-1a or IFN beta-1b is considered not medically necessary for individuals with either of the following conditions:

Treatment of MS with IFN beta-1a or IFN beta-1b in combination with glatiramer acetate or in combination with natalizumab is considered not medically necessary for all conditions.

II.  Glatiramer acetate (Copaxone or Glatopa)

Medically Necessary:

Treatment of MS with glatiramer acetate is considered medically necessary for individuals with relapsing-remitting MS (RRMS), including those who have experienced a first clinical episode and have MRI features consistent with MS.

Not Medically Necessary:

Treatment of MS with glatiramer acetate is considered not medically necessary for individuals with either of the following conditions:

Treatment of MS with glatiramer acetate in combination with any IFN-B agent or in combination with natalizumab is considered not medically necessary for all conditions.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

HCPCS

 

J1595

Injection, glatiramer acetate, 20 mg [Copaxone, Glatopa]

J1826

Injection, interferon beta-1a, 30 mcg [Avonex, Rebif]

J1830

Injection, interferon beta-1b, 0.25 mg [Betaseron, Extavia]

J3490

Unclassified drugs [when specified as peginterferon beta-1a Plegridy]

Q3027

Injection, interferon beta-1a, 1 mcg for intramuscular use [Avonex, Rebif]

Q3028

Injection, interferon beta-1a, 1 mcg for subcutaneous use [Avonex, Rebif]

S9559

Home injectable therapy, interferon, including administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment; per diem

 

 

ICD-10 Diagnosis

 

G35

Multiple sclerosis

Discussion/General Information

MS is an autoimmune disease of the central nervous system (CNS). During the MS disease process, inflammation of nervous tissue causes the loss of myelin, a fatty material that acts as a protective insulation for the nerve fibers in the brain and spinal cord. This demyelination leaves multiple areas of hard scarred tissue (plaques) along the covering of the nerve cells. Another characteristic of MS is the destruction of axons, which are the long filaments that carry electric impulses away from a nerve cell. The demyelination and axon destruction disrupts the ability of the nerves to conduct electrical impulses to and from the brain, and produces the various symptoms. Common symptoms of the disease include fatigue, numbness, coordination and balance problems, bowel and bladder dysfunction, emotional and cognitive changes, spasticity, vision problems, dizziness, sexual dysfunction, and pain. Classifications of MS are relapsing remitting (RRMS), primary progressive (PPMS), progressive relapsing (PRMS), and SPMS. Most individuals with MS have a relapsing course and their first attack may present as a clinically isolated syndrome (CIS). A CIS is a single demyelinating episode with consistent MRI findings (indicating inflammation/demyelination in one or more sites in the CNS). Individuals with this syndrome are at high risk for developing clinically definite MS.

The treatment goal for MS is to prevent relapses and progressive worsening of the disease. To date, a cure remains elusive and current therapies fail to reverse degenerative processes and deficits. Current disease-modifying drugs are most effective for the relapsing-remitting form of MS and less effective for secondary progressive decline. The American Academy of Neurology (AAN), the Multiple Sclerosis Council for Clinical Practice Guidelines and the National Multiple Sclerosis Society suggest starting disease-modifying therapy (DMT) (drug treatment) in those with relapsing remitting disease and recent relapses; however, opinions may vary widely on when to initiate treatment (AAN, 2002). The 2017 consensus paper by the Multiple Sclerosis Coalition includes the following initiation of treatment recommendation with a United States Food and Drug Administration (FDA) approved DMT:

Disease modifying drugs have been shown to delay the progression of MS, reduce the incidence of relapses and also reduce the MRI activity thought to be linked to the underlying inflammation of the disease (Freedman 2008). IFN beta-1a, IFN beta-1b and glatiramer acetate are all FDA approved DMTs. In 1993, the first DMT, IFN beta-1b (Betaseron) was approved for RRMS to reduce the rate and severity of relapses. This was followed by approval of IFN beta-1a (Avonex) in 1996 and glatiramer acetate (Copaxone) in 1997. Another formulation of IFN beta-1a (Rebif) was approved in 1998 in Europe and Canada and in 2002 in the United States. In August 2009, the FDA approved Extavia, a new branded version of interferon beta-1b which has the same medicinal product as Betaseron. In August 2014, the FDA approved Plegridy (peginterferon beta-1a) for the treatment of relapsing forms of MS. Plegridy is a long-acting formulation of interferon beta-1a that has the advantage of less frequent administration than the other injectables. More recently, the FDA approved another branded version of glatiramer acetate, Glatopa in June 2015.

IFN beta-1a, IFN beta-1b and glatiramer acetate are all FDA approved for relapsing forms of MS. In addition, their efficacy has been demonstrated in individuals who have experienced a first clinical episode and have MRI features consistent with MS.

The AAN (2002 [reaffirmed 2008]) recommends beta interferon (beta 1a and beta 1b) for the management of individuals with RRMS, relapsing forms of secondary progressive MS, and in those with MS or with a CIS who are at high risk of developing clinically definite MS. The AAN notes that there are several consistent Class I studies (prospective, randomized, controlled clinical trials with masked outcome assessments, in a representative population) in which beta interferon has been demonstrated to reduce the attack rate (whether measured clinically or by MRI) in individuals with MS or with CIS who are at high risk for developing MS (Type A recommendation). A “Type A recommendation” is the highest rating assigned by the AAN.

The National Clinical Advisory Board of the National Multiple Sclerosis Society Treatment Recommendations for Physicians (2008) Expert Opinion Paper states that “there are no direct comparative data to allow a fully informed choice of the best immunomodulatory drug class (interferon beta or glatiramer acetate) with which to initiate therapy in relapsing forms of MS.”

Lublin and colleagues (2013), in a randomized controlled trial, compared efficacy of the combined use of interferon beta-1a (IFN) 30 μg intramuscularly weekly and glatiramer acetate 20 mg daily to either agent alone in RRMS. A total of 1008 participants were randomized and followed until the last enrolled participant completed 3 years of treatment. The primary endpoint was reduction in annualized relapse rate utilizing a strict definition of relapse. Secondary outcomes included time to confirmed disability, Multiple Sclerosis Functional Composite (MSFC) score, and magnetic resonance imaging (MRI) metrics. It was reported that combining the two most commonly prescribed therapies for MS (IFN+glatiramer acetate) did not produce a significant clinical benefit over 3 years. However, an effect was seen on some MRI metrics. In a test of comparative efficacy, glatiramer acetate was superior to IFN in reducing the risk of exacerbation. In a post hoc analysis, combination therapy resulted in a higher proportion of participants attaining disease activity-free status (DAFS) compared to either single arm, driven by the MRI results. The extension phase for CombiRx will address whether the observed differences in MRI and DAFS findings predict later clinical differences.

La Mantia and colleagues (2014) conducted a systemic review of randomized controlled trials (RCTs) comparing the effectiveness of IFNs-beta and glatiramer acetate on MS. A total of 5 trials were reviewed consisting of 2858 total participants with active RRMS randomly assigned to interferons (IFNs) (n=1679) and glatiramer acetate (n=1179). Study duration ranged from 2 to 3 years. The effects of IFNs-beta and glatiramer acetate were similar except that IFNs-beta appeared to limit the increase in MRI lesion load as compared to glatiramer acetate. There was insufficient evidence to compare the effects of individually-reported outcomes, such as quality of life measures.

In 2016, La Mantia and colleagues updated their systemic review of RCTs comparing the effectiveness of IFNs-beta and glatiramer acetate on MS. A total of 5 trials were reviewed consisting of 2904 total participants with active RRMS treated with (IFNs) (n=1704) or glatiramer acetate (n=1200). Treatment duration varied between three years (n=1) and two years (n=4). One study was stopped early. In regards to the primary outcome, number of participants with relapse, both therapies showed similar clinical efficacy at 24 months. At 36 months, one study showed increased relapse rates in the IFN group compared to the glatiramer acetate group. Evidence quality for the primary outcome was considered moderate, while safety and some MRI outcomes was considered low. The authors concluded that the clinical effects of both treatments were similar or only slightly different.

The BENEFIT (BEtaferon/BEtaseron in Newly Emerging MS for Initial Treatment) study was a 2 year prospective, multi-center, randomized placebo controlled phase 2 trial with a maximum of 5 years of follow-up. The original phase of the study consisted of individuals with a first neurological event suggestive of MS (CIS) who were randomized to either placebo or IFNB-1b subcutaneously every other day. After 2 years or after having progressed to clinically definite MS, all subjects were offered open-label IFNB-1b for a duration of up to 5 years. In 2014, Edan and colleagues reported on the 8 year long-term impact of interferon beta-1b. Of the original 468 subjects in the BENEFIT trial, 284 (IFNB-1b [n=178], placebo [n=106]) participated in the extension phase. Outcomes were favorable supporting early treatment with IFNB-1b in individuals with CIS. Those who had been randomized to IFNB-1b had a longer median time of progression to clinically definite MS by 1345 days, a reduced risk of developing clinically definite MS over the 8 year time period by 32.2%, and a lower annual rate of relapse.

Multiple studies have demonstrated the efficacy of the beta interferon products or glatiramer acetate in the treatment of MS (Barkhof, 2007; Comi, 2009; Comi, 2013; Edan, 2014; Ford, 2010; Kinkel, 2006; Kinkel, 2012; Lampl, 2013; Reder, 2010). However, current data remains insufficient to make a recommendation regarding the use of one of the beta interferon products (Avonex, Plegridy, Rebif, Betaseron, and Extavia) over another. Also, current data remains insufficient to make a recommendation regarding the use of the beta interferon products (Avonex, Rebif, Betaseron, and Extavia) over glatiramer acetate (Copaxone or Glatopa) in the treatment of RRMS.

Off Label Indications:

Diagnostic criteria for MS have evolved in recent years. Although the diagnosis can be made on clinical grounds alone, MRI of the CNS can support, supplement, or even replace some clinical criteria (Pohlman, 2011). The McDonald Criteria, a tool for the diagnosis of MS, was updated in 2010 by the International Panel on Diagnosis of MS (the Panel). The Panel stressed that the McDonald criteria should only be applied in those individuals who present with a typical CIS suggestive of MS or symptoms consistent with a CNS inflammatory demyelinating disease. This is because the development and validation of the criteria was limited to individuals with such a presentation. The 2010 McDonald criteria as documented in the table below include clinical presentations as well as additional data needed for MS diagnosis including MRI findings for demonstration of dissemination of CNS lesions in space and time.

The 2010 McDonald Criteria for Diagnosis of MS

 (Polman, 2011)

 

Clinical Presentation

Additional Data Needed for MS Diagnosis

2 or more attacksa; objective clinical evidence of 2 or more lesions or objective clinical evidence of 1 lesion with reasonable historical evidence of a prior attackb.

Nonec

 

2 or more attacksa; objective clinical evidence of one lesion

 

Dissemination in space, demonstrated by:

  • 1 or more T2 lesion in at least 2 of 4 MS-typical regions of the CNS (periventricular, juxtacortical, infratentorial, or spinal cord)d; or
  • Await further clinical attacka implicating a different CNS site

1 attacka; objective clinical evidence of two or more lesions

 

Dissemination in time, demonstrated by:

  • Simultaneous presence of asymptomatic gadolinium-enhancing and nonenhancing lesions at any time; or
  • A new T2 and/or gadolinium-enhancing lesion(s) on follow-up MRI, irrespective of its timing with reference to a baseline scan; or
  • Await a second clinical attacka

1 attacka; objective clinical evidence of one lesion (clinically isolated syndrome)

 

Dissemination in space and time, demonstrated by:

For dissemination in space (DIS):

  • 1 or more T2 lesion in at least 2 of 4 MS-typical regions of the CNS (periventricular, juxtacortical, infratentorial, or spinal cord)d; or
  • Await a second clinical attacka implicating a different CNS site; and

For dissemination in time (DIT), demonstrated by:

  • Simultaneous presence of asymptomatic gadolinium-enhancing and nonenhancing lesions at any time; or
  • A new T2 and/or gadolinium-enhancing lesion(s) on follow-up MRI, irrespective of its timing with reference to a baseline scan; or
  • Await a second clinical attacka

Insidious neurological progression suggestive of MS (PPMS)

 

1 year of disease progression (retrospectively or prospectively determined) plus

2 of 3 of the following criteriad:

  1. Evidence for DIS in the brain based on one or more T2 lesions in the MS-characteristic (periventricular, juxtacortical, or infratentorial) regions
  2. Evidence for DIS in the spinal cord based on 2 or more T2 lesions in the cord
  3. Positive CSF (isoelectric focusing evidence of oligoclonal bands and/or elevated IgG index)

If the Criteria are fulfilled and there is no better explanation for the clinical presentation, the diagnosis is ‘‘MS’’; if suspicious, but the Criteria are not completely met, the diagnosis is ‘‘possible MS’’; if another diagnosis arises during the evaluation that better explains the clinical presentation, then the diagnosis is ‘‘not MS.’’
aAn attack (relapse; exacerbation) is defined as patient-reported or objectively observed events typical of an acute inflammatory demyelinating event in the CNS, current or historical, with duration of at least 24 hours, in the absence of fever or infection. It should be documented by contemporaneous neurological examination, but some historical events with symptoms and evolution characteristic for MS, but for which no objective neurological findings are documented, can provide reasonable evidence of a prior demyelinating event. Reports of paroxysmal symptoms (historical or current) should, however, consist of multiple episodes occurring over not less than 24 hours. Before a definite diagnosis of MS can be made, at least 1 attack must be corroborated by findings on neurological examination, visual evoked potential response in patients reporting prior visual disturbance, or MRI consistent with demyelination in the area of the CNS implicated in the historical report of neurological symptoms.
bClinical diagnosis based on objective clinical findings for 2 attacks is most secure. Reasonable historical evidence for 1 past attack, in the absence of documented objective neurological findings, can include historical events with symptoms and evolution characteristics for a prior inflammatory demyelinating event; at least 1 attack, however, must be supported by objective findings.
cNo additional tests are required. However, it is desirable that any diagnosis of MS be made with access to imaging based on these Criteria. If imaging or other tests (for instance, CSF) are undertaken and are negative, extreme caution needs to be taken before making a diagnosis of MS, and alternative diagnoses must be considered. There must be no better explanation for the clinical presentation, and objective evidence must be present to support a diagnosis of MS.
dGadolinium-enhancing lesions are not required; symptomatic lesions are excluded from consideration in subjects with brainstem or spinal cord syndromes.

MS = multiple sclerosis; CNS = central nervous system; MRI = magnetic resonance imaging; DIS = dissemination in space; DIT = dissemination in time; PPMS = primary progressive multiple sclerosis; CSF = cerebrospinal fluid; IgG = immunoglobulin G.

2010 McDonald MRI Criteria for Demonstration of DIS:
DIS can be demonstrated by one or more T2 lesiona in at least two of four areas of the CNS:

  1. Periventricular
  2. Juxtacortical
  3. Infratentorial
  4. Spinal cordb

Based on Swanton et al 2006, 2007.
aGadolinium enhancement of lesions is not required for DIS.
bIf a subject has a brainstem or spinal cord syndrome, the symptomatic lesions are excluded from the Criteria and do not contribute to lesion count.
MRI = magnetic resonance imaging; DIS = lesion dissemination in space; CNS = central nervous system

2010 McDonald MRI Criteria for Demonstration of DIT:
DIT can be demonstrated by:

  1. A new T2 and/or gadolinium-enhancing lesion(s) on follow-up MRI, with reference to a baseline scan, irrespective of the timing of the baseline MRI
  2. Simultaneous presence of asymptomatic gadolinium-enhancing and nonenhancing lesions at any time

Based on Montalban et al 2010.
MRI = magnetic resonance imaging; DIT = lesion dissemination in time.

2010 McDonald Criteria for Diagnosis of Multiple Sclerosis in Disease with Progression from Onset:

  1. One year of disease progression (retrospectively or prospectively determined)
  2. Plus two of the three following criteriaa:
    1. Evidence for DIS in the brain based on one or more T2b lesions in at least one area characteristic for MS (periventricular, juxtacortical, or infratentorial)
    2. Evidence for DIS in the spinal cord based on two or more T2b lesions in the cord
    3. Positive CSF (isoelectric focusing evidence of oligoclonal bands and/or elevated IgG index)

aIf a subject has a brainstem or spinal cord syndrome, all symptomatic lesions are excluded from the Criteria.
bGadolinium enhancement of lesions is not required.
MS = multiple sclerosis; PPMS = primary progressive MS; DIS = lesion dissemination in space; CSF = cerebrospinal fluid; IgG = immunoglobulin G.

In 2016, the European collaborative research network that studies MRI in multiple sclerosis (MAGNIMS) proposed revisions and clarifications to the 2010 McDonald criteria. A summary of revisions and clarifications proposed by MAGNIMS is as follows:

Recommended 2016 MAGNIMS modifications to the 2010 McDonald criteria for MRI in the diagnosis of MS

Proposed revisions:

Additional clarifications and summary statements:

The McDonald criteria are currently undergoing revisions based in part on the revised MAGMIMS criteria. The updated criteria are anticipated to be submitted for publication at the end of summer in 2017.

Definitions

Attacks: The appearance of new symptoms or the aggravation of old ones, lasting at least twenty-four hours (synonymous with exacerbation, relapse, flare-up, or worsening); usually associated with inflammation and demyelination in the brain or spinal cord.

Clinical lesion: An area of inflamed or demyelinated central nervous system tissue; synonymous with plaque.

Clinically isolated syndrome (CIS): A single demyelinating episode with consistent MRI findings (indicating inflammation/demyelination in one or more sites in the CNS). Individuals with this syndrome are at high risk for developing clinically definite MS.

Primary progressive MS (PPMS): A clinical course of MS characterized by progression of disability from onset without superimposed relapses.

Progressive relapsing MS (PRMS): A primary progressive clinical course of MS characterized by clear, acute relapses, with or without full recovery from those relapses.

Relapsing-remitting MS (RRMS): A clinical course of MS characterized by clearly defined, acute relapses with full or partial recovery; no disease progression or worsening of disability develops between relapses.

Secondary progressive MS (SPMS): A clinical course of MS demonstrating sustained progression of physical disability occurring separately from relapses in individuals who previously had RRMS.

References

Peer Reviewed Publications:

  1. Barkhof F, Polman CH, Radue EW, et al. Magnetic resonance imaging effects of interferon beta-1b in the BENEFIT study: integrated 2-year results. Arch Neurol. 2007; 64(9):1292-1298.
  2. Comi G, Martinelli V, Rodegher M, et al. Effects of early treatment with glatiramer acetate in patients with clinically isolated syndrome. Mult Scler. 2013; 19(8):1074-1083.
  3. Comi G, Martinelli V, Rodegher M, et al.; PreCISe study group. Effect of glatiramer acetate on conversion to clinically definite multiple sclerosis in patients with clinically isolated syndrome (PreCISe study): a randomised, double-blind, placebo-controlled trial. Lancet. 2009; 374(9700):1503-1511.
  4. Edan G, Kappos L, Montalbán X, et al; BENEFIT Study Group. Long-term impact of interferon beta-1b in patients with CIS: 8-year follow-up of BENEFIT. J Neurol Neurosurg Psychiatry. 2014; 85(11):1183-1189.
  5. Ford C, Goodman AD, Johnson K, et al. Continuous long-term immunomodulatory therapy in relapsing multiple sclerosis: results from the 15-year analysis of the US prospective open-label study of glatiramer acetate. Mult Scler. 2010; 16(3):342-350.
  6. Freedman MS, Hughes B, Mikol DD, et al. Efficacy of disease-modifying therapies in relapsing remitting multiple sclerosis: a systematic comparison. Eur Neurol. 2008; 60(1):1-11.
  7. Kappos L, Polman CH, Freedman MS, et al. Treatment with interferon beta-1b delays conversion to clinically definite and McDonald MS in patients with clinically isolated syndromes. Neurology. 2006; 67(7):1242-1249.
  8. Kinkel RP, Dontchev M, Kollman C, et al.; Controlled High-Risk Avonex Multiple Sclerosis Prevention Study in Ongoing Neurological Surveillance Investigators. Association between immediate initiation of intramuscular interferon beta-1a at the time of a clinically isolated syndrome and long-term outcomes: a 10-year follow-up of the Controlled High-Risk Avonex Multiple Sclerosis Prevention Study in Ongoing Neurological Surveillance. Arch Neurol. 2012; 69(2):183-190.
  9. Kinkel RP, Kollman C, O'Connor P, et al.; CHAMPIONS Study Group. IM interferon beta-1a delays definite multiple sclerosis 5 years after a first demyelinating event. Neurology. 2006; 66(5):678-684.
  10. Lampl C, Nagl S, Arnason B, et al. Efficacy and safety of interferon beta-1b sc in older RRMS patients--a posthoc analysis of the BEYOND study. J Neurol. 2013; 260(7):1838-1845.
  11. Li DK, Zhao GJ, Paty DW, et al. Randomized controlled trial of interferon-beta-1a in secondary progressive MS: MRI results. Neurology. 2001; 56(11):1505-1513.
  12. Lublin FD, Cofield SS, Cutter GR, et al.; CombiRx Investigators. Randomized study combining interferon and glatiramer acetate in multiple sclerosis. Ann Neurol. 2013; 73(3):327-340.
  13. Mikol DD, Barkhof F, Chang P, et al.; REGARD study group. Comparison of subcutaneous interferon beta-1a with glatiramer acetate in patients with relapsing multiple sclerosis (the REbif vs Glatiramer Acetate in Relapsing MS Disease [REGARD] study): a multicentre, randomised, parallel, open-label trial. Lancet Neurol. 2008; 7(10):903-914.
  14. Miller A, Spada V, Beerkircher D, Kreitman RR. Long-term (up to 22 years), open-label, compassionate-use study of glatiramer acetate in relapsing-remitting multiple sclerosis. Mult Scler. 2008; 14(4):494-499.
  15. Montalban X, Tintoré M, Swanton J, et al. MRI criteria for MS in patients with clinically isolated syndromes. Neurology. 2010; 74(5):427-434.
  16. Polman CH, Reingold SC, Banwell B, et al. Diagnostic criteria for multiple sclerosis: 2010 revisions to the McDonald criteria. Ann Neurol. 2011; 69(2):292-302.
  17. PRISMS Study Group and the University of British Columbia MS/MRI Analysis Group. PRISMS-4: long-term efficacy of interferon beta-1a in relapsing MS. Neurology. 2001; 56(12):1628-1636.
  18. Reder AT, Ebers GC, Traboulsee A, et al.; Investigators of the 16-Year Long-Term Follow-Up Study. Cross-sectional study assessing long-term safety of interferon-beta-1b for relapsing-remitting MS. Neurology. 2010; 74(23):1877-1885.
  19. Schrempf W, Ziemssen T. Glatiramer acetate: mechanisms of action in multiple sclerosis. Autoimmun Rev. 2007; 6(7):469-475.
  20. SPECTRIMS Study Group. Randomized controlled trial of interferon-beta-1a in secondary progressive MS: clinical results. Neurology. 2001; 56(11):1496-1504.
  21. Swanton JK, Fernando K, Dalton CM, et al. Modification of MRI criteria for multiple sclerosis in patients with clinically isolated syndromes. J Neurol Neurosurg Psychiatry. 2006; 77(7):830-833.
  22. Swanton JK, Rovira A, Tintore M, et al. MRI criteria for multiple sclerosis in patients presenting with clinically isolated syndromes: a multicentre retrospective study. Lancet Neurol. 2007; 6(8):677-686.
  23. Wolinsky JS, Narayana PA, O'Connor P, et al. Glatiramer acetate in primary progressive multiple sclerosis: results of a multinational, multicenter, double-blind, placebo-controlled trial. Ann Neurol. 2007; 61(1):14-24.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. Avonex [Product Information], Cambridge, MA. Biogen Idec, Inc.; March 2016. Available at: https://www.avonex.com/content/dam/commercial/multiple-sclerosis/avonex/pat/en_us/pdf/Avonex%20US%20%20Prescribing%20Information.pdf. Accessed on September 16, 2017.
  2. Betaseron [Product Information], Whippany, NJ. Bayer HealthCare Pharmaceuticals Inc.; April 2016. Available at: http://www.accessdata.fda.gov/drugsatfda_docs/label/2016/103471s5157lbl.pdf. Accessed on September 16, 2017.
  3. Copaxone [Product Information], North Wales, PA. TEVA Pharmaceuticals USA, Inc.; August 2016. Available at: https://www.copaxone.com/resources/pdfs/prescribinginformation.pdf?s_mcid=urlredirect. Accessed on September 16, 2017.
  4. Extavia [Product Information], East Hanover, NJ. Novartis Pharmaceuticals Corp.; May 2016. Available at: http://www.pharma.us.novartis.com/product/pi/pdf/extavia.pdf. Accessed on September 17, 2017.
  5. Filippini G, Del Giovane C, Clerico M, et al. Treatment with disease-modifying drugs for people with a first clinical attack suggestive of multiple sclerosis. Cochrane Database Syst Rev. 2017; 4:CD012200.
  6. Glatiramer Acetate. In: DrugPoints ® System [electronic version]. Truven Health Analytics, Greenwood Village, CO. Updated August 25, 2017. Available at: http://www.micromedexsolutions.com. Accessed on September 16, 2017.
  7. Glatiramer Acetate Monograph. Lexicomp® Online, American Hospital Formulary Service® (AHFS®) Online, Hudson, Ohio, Lexi-Comp., Inc. Last revised December 13, 2012. Accessed on September 16, 2017.
  8. Glatopa [Product Information], Princeton, NJ. Sandoz Corp.; April 2016. Available at: https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=5f01e40a-b6f6-40fb-b37c-3d06f1428e86&type=display. Accessed on September 17, 2017.
  9. Goodin DS, Frohman EM, Garmany GP Jr., et al. Disease modifying therapies in multiple sclerosis: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology and the MS Council for Clinical Practice Guidelines. Neurology. 2002 (reaffirmed 2008); 58(2):169-178. Available at: http://www.neurology.org/cgi/reprint/58/2/169.pdf. Accessed on September 16, 2017.
  10. Interferon Beta-1a. In: DrugPoints® System [electronic version]. Truven Health Analytics, Greenwood Village, CO. Updated August 29, 2017. Available at: http://www.micromedexsolutions.com. Accessed on September 16, 2017.
  11. Interferon Beta-1b. In: DrugPoints® System [electronic version]. Truven Health Analytics, Greenwood Village, CO. Updated December 6, 2016. Available at: http://www.micromedexsolutions.com. Accessed on September 16, 2017.
  12. Interferon Beta Monograph. Lexicomp® Online, American Hospital Formulary Service® (AHFS®) Online, Hudson, Ohio, Lexi-Comp., Inc. Last revised December 15, 2014. Accessed on September 16, 2017.
  13. La Mantia L, Di Pietrantonj C, Rovaris M, et al. Interferons-beta versus glatiramer acetate for relapsing-remitting multiple sclerosis. Cochrane Database Syst Rev. 2016; 11:CD009333..
  14. National Multiple Sclerosis Society.
  1. Peginterferon Beta-1a. In: DrugPoints® System [electronic version]. Truven Health Analytics, Greenwood Village, CO. Updated August 12, 2016. Available at: http://www.micromedexsolutions.com. Assessed on September 15, 2017.
  2. Plegridy [Product Information], Cambridge, MA, Biogen Idec Inc.; July 2016. Available at: https://www.plegridy.com. Accessed on September 17, 2017.
  3. Rebif [Product Information], Rockland, MA. EMD Serono, Inc.; November 2015. Available at: http://www.emdserono.com/ms.country.us/en/images/Rebif_PI_tcm115_140051.pdf. Accessed on September 17, 2017.
  4. Wattjes MP, Rovira À, Miller D, et al; MAGNIMS study group. Evidence-based guidelines: MAGNIMS consensus guidelines on the use of MRI in multiple sclerosis--establishing disease prognosis and monitoring patients. Nat Rev Neurol. 2015; 11(10):597-606.
Websites for Additional Information
  1. National Multiple Sclerosis Society. What is MS. Available at: http://www.nationalmssociety.org/about-multiple-sclerosis/index.aspx. Accessed on September 16, 2017.
Index

Avonex
Beta Interferons
Betaseron
Copaxone
Extavia
Glatiramer Acetate
Glatopa
IFN beta-1a
IFN beta-1b
Interferon Beta Agents
Plegridy
Rebif

The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

History

Status

Date

Action

Reviewed

11/02/2017

Medical Policy & Technology Assessment Committee (MPTAC) review. The document header wording updated from “Current Effective Date” to “Publish Date.” Updated Discussion, Reference and Websites sections.

Reviewed

11/03/2016

MPTAC review. Description, Discussion and Reference sections updated.

Revised

11/05/2015

MPTAC review. Position statement updated with the addition of Glatopa. Description, Discussion, Reference and Index sections updated.

Revised

11/13/2014

MPTAC review. Position statement updated with the addition of Plegridy. Description, Coding, Discussion, Reference and Index sections updated.

Reviewed

08/14/2014

MPTAC review. Description, Discussion and Reference sections updated.

 

01/01/2014

Updated Coding section with 01/01/2014 HCPCS changes; removed Q3025, Q3026 deleted 12/31/2013.

Reviewed

08/08/2013

MPTAC review. Rationale and Reference sections updated.

Reviewed

08/09/2012

MPTAC review. Discussion and Reference sections updated.

Reviewed

08/18/2011

MPTAC review. Description, Discussion (including McDonald Criteria), Reference, and Definition sections updated.

 

01/01/2011

Updated Coding section with 01/01/2011 HCPCS changes; removed code J1825 deleted 12/31/2010.

Revised

08/19/2010

MPTAC review. Clinical indication section reformatted. Clarified glatiramer acetate not medically necessary statement by removing duplicative secondary progressive MS wording. References and discussion updated.

Revised

08/27/2009

MPTAC revision. Drug brand names removed from clinical indications section. Removed table of FDA approved drugs with dosing and labeling information from discussion section. Removed not medically necessary statement regarding dosages greater than approved by the U.S. Food and Drug Administration (FDA). Description, discussion, references, and index updated. Information regarding Extavia added to document contents.

Revised

05/21/2009

MPTAC revision. Clinical indications for glatiramer acetate updated to include patients who have experienced a first clinical episode and have MRI features consistent with multiple sclerosis. Deletion of section of not medically necessary statement for glatiramer acetate referring to those with an initial demyelinating event. Place of service section deleted. Discussion and references updated.

Reviewed

02/26/2009

MPTAC review. Discussion and references updated. Moved “Summary of the FDA Approved Pharmaceutical Agents for the Treatment of MS” and the “International Panel Criteria” charts to the discussion/general information section of the document. Title updated.

Reviewed

08/28/2008

MPTAC review. Description, discussion and references updated.

 

04/01/2008

References updated to reflect change from USP DI® to new DrugPoints® compendia.

Reviewed

08/23/2007

MPTAC review. Title revised. Clinical indications clarified. Definitions and references updated.

Revised

09/14/2006

MPTAC revision. Update of guideline to include concomitant usage of beta interferons and glatiramer acetate or natalizumab is considered not medically necessary.

Revised

06/08/2006

MPTAC revision. Update of McDonald diagnostic criteria. Coding and references updated. No change to guideline position. 

New

07/14/2005

MPTAC initial guideline development.