Arani Nitkunan MA (Cantab), MRCP (UK)(Neurology), PhD

February 12th 2015

First Fit Pathway&

Multiple Sclerosis

Overview

• Ajay Boodhoo• First fit• Multiple sclerosis

Ajay Boodhoo

First Fit Pathway

http://www.croydonhealthservices.nhs.uk

Questions

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

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

Videos

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?