Arani Nitkunan MA (Cantab), MRCP (UK)(Neurology), PhD
February 12th 2015
First Fit Pathway&
Multiple Sclerosis
Overview
• Ajay Boodhoo• First fit• Multiple sclerosis
http://www.croydonhealthservices.nhs.uk
Multiple sclerosis – why?
• Prevalence - 1 in 600
Multiple sclerosis – why?
Multiple sclerosis – why?
• Multiple new drugs and NICE guidance
Multiple sclerosis – why?
Case
• 21 year old• Previously well• May 2013– Progressive blurred vision in right eye over two
weeks that then improved to 50% of normal– 3 weeks later, awoke with dizziness, vomiting,
vertigo, numbness in arms and difficulty walking
O/E
VAFieldsIshiharaRAPDFundi
R6/36
central scotomaNo C
RAPD N
L 6/9
N C + 7/7
NN
Examination of her limbs (including proprioception) was normal apart from brisk reflexes, mild finger-nose and truncal ataxia.
Investigations
Normal• Blood tests
Abnormal• Low B12 – 157• Scan
Diagnosis
• Based on demonstrating inflammatory lesions separated in time and space
Types of multiple sclerosis
85%
5% 10%
Diagnosis
• Clinically isolated syndrome
Management
• Methylprednisolone 500mg od for 5 days
After CIS
• If MRI normal (apart from lesion causing CIS), 1 in 5 will have another attack within 20 year
• If MRI abnormal, then 4 in 5 will have another attack within 20 years
Diagnosis
• Clinically isolated syndrome
Case
• 9 months later - Feb 2014– Eyes went “funny” – couldn’t move her eyes to the
left
Diagnosis
• Relapsing remitting multiple sclerosis
Management
• Methylprednisolone 500mg od for 5 days• Disease modifying therapy
Steroids
• For functionally disabling symptoms• Ensure no infective trigger
ABN 2001
NICE 2002
Risk Sharing Scheme
2002
ABN 2007
ABN 2009Revised ABN Guidelines for MS 2009
Eligibility Criteria for Disease Modifying Therapy
1 Age ≥ 182 Ambulant (EDSS ≤ 6.5 ie walking unaided for
≥ 10m)3 2 clinically significant relapses in the last 2
years
NB Not for primary or secondary progressive MS – symptomatic therapy
Disease modifying therapiesFirst line
Rice, Practical Neurology 2014
Disease modifying therapiesFirst line
Yes
Yes
Rice, Practical Neurology 2014
Disease modifying therapiesFirst line
Rice, Practical Neurology 2014
Disease modifying therapies Second line
Criteria– ≥ 2 disabling relapses in 1 year with • ≥1 enhancing lesion• Significant increase in lesion load
Disease modifying therapies Second line
Yes
Rice, Practical Neurology 2014
Cost of disease modifying therapies
Drug Cost (£ per month)Avonex 654Rebif 1104Betaferon 592Copaxone 550Dimethyl fumarate 1373Teriflunomide 1037Natalizumab 1130Fingolimod 1470Alemtuzumeb 2935
Case
• Doing well on Rebif
Summary – Multiple Sclerosis
• When to refer• “Relapse”• Disease modifying therapy
Acknowledgements
• Felicity Pearce• Andrew Thompson• Bridget MacDonald• Fred Schon
References
• Masterclass Evidence Based Updates for GPs – MS Society 2011
• www.mssociety.org.uk• www.msdecisions.org.uk
Thank you & Questions?