Update on Multiple Sclerosis

Helen Ford

Consultant Neurologist

Leeds Teaching Hospitals NHS Trust

Overview

• Background

• Symptoms and signs of MS

• Diagnosis

• Update on treatments

• Moving On and Beyond

Background

• MS is the most common cause of neurological disability in young adults in the UK

• Working age population

• Prevalence 80-100,000 people with MS in UK

• Leeds – population 750,000 - 858 people with MS and 45 new cases per year

What is MS?

• MS is a disease of the central nervous system (CNS)

• An inflammatory reaction in the CNS causes loss of myelin and slowing of nerve conduction

• Areas of demyelination

• Loss of axons

Sites that are vulnerable to demyelination

• Optic nerves

• Brainstem

• Cervical cord

• Periventricular regions

Optic neuritis

• Blurred vision or loss of vision in one eye – often central

• Pain on moving the eye

• Impaired colour vision

• Reduced visual acuity• Normal or swollen

disc• Central scotoma• Pupil relatively dilated • ‘Afferent pupillary

defect’

Brainstem demyelination

• Double vision• Loss of balance• Clumsiness

• Eye movement disorder

• Nystagmus• Intention tremor• Ataxia

Spinal cord

• Limping or dragging one leg

• Numbness, tingling, tight band-like sensation

• L’Hermittes• Bowel and bladder

symptoms

• Increased tone, pyramidal weakness, brisk reflexes, extensor plantars

• Loss of vibration sense

• Sensory level

‘Invisible symptoms’

• Cognitive impairment – even at early stages of disease

• Fatigue – first and worst

• Pain

• Unpleasant or disabling sensory symptoms

MS disease course

Favourable prognostic indicators

• Early age at onset

• Female sex

• Relapsing remitting course

• Optic neuritis or sensory symptoms at onset

• Few attacks during the first 5 years

Making the diagnosis

• Clinical diagnosis• History: neurological

events separated in time• Examination: Signs of

damage to different areas of the CNS i.e. neurological signs separated in space

• Investigations: supportive not diagnostic

Aims of treatment

• Reverse existing impairments and disability

• Prevent long-term disability

• Reduce relapse rate

April 1993

Pivotal trial of Betaseron

Disease modifying treatments

• Interferon beta 1-b• Interferon beta 1-a• Copaxone• Natalizumab• Fingolimod

Interferon beta

• Reduces the number of relapses by a third

• Effective early in the disease course

• Eligibility -2 clinically significant relapses in previous 2 years

• No evidence of long-term effect on disability

Outcomes for the West Yorkshire treated population

• Does treatment with a disease-modifying drug influence the quality of life of people with MS?

• Do certain groups of patient respond better than others?

42

43

44

45

46

47

48

49

0 5 10 15 20 25 30

Months on treatment

Qo

L

All MS

Quality of life

Different MS subtypes

40

41

42

43

44

45

46

47

48

0 5 10 15 20 25 30

Months on treatment

Qo

L All MSSPMSRRMS

42

43

44

45

46

47

48

49

0 5 10 15 20 25 30

Months on treatment

Qo

L

All MS

Quality of life

P<0.0001

P=0.04

P=0.0007

Natalizumab

• Humanised monoclonal antibody

• Inhibits trafficking of leucocytes across blood brain barrier

• Recommended for treatment of Rapidly Evolving Severe MS

• Risk of PML

New oral treatments

• Fingolimod - licensed by EMA 2011 -(Sphingosine 1-phosphate (S1P) receptor modulator which reduces peripheral blood lymphocytes due to the inhibition of S1P(1)-dependent lymphocyte egress from secondary lymphoid organs and thymus)

• Reduces relapse rate by 60%

Summary of current treatment

• Course of relapsing-remitting MS can be modified

• Uncertain/if any impact on later disease progression

• Newer drugs have different side effect profiles eg PML, cardiotoxicity

• New oral drug licensed and awaiting NICE approval

Severe Progressive MS

• Cognitive problems

• Speech and swallowing difficulty, PEG feeding

• Tremor affecting upper limb function

• Severe spasticity

• Urinary and faecal incontinence, catheterisation

Moving On and Beyond

• New programme for people with MS, MND and Heart failure

• ‘Empowering people with life limiting conditions to take control and live a new life to the full’

Objectives• Improve access to the Hospice for non cancer

patients • Develop opportunity for peer

support/empowerment for service developers & course attendees

• Collaborative working to address survivorship and Specialist Palliative Care for non cancer patients.

• Focus on survivorship, coping & advance care planning.

Programme Content

Session NamesIntroductionGoal Setting

Sue Cooke (Facilitator), Sally Coppock (project lead) Linda (observer)

Physical coping Sue Cooke (Facilitator), Gill Fulton/Sally Noble, Linda (observer)

Communications Sue Cooke (Facilitator), Sue Smith, Gale (observer)

Advance Care Planning Sue Cooke (Facilitator), Sally Coppock, Gale (observer)  

Psychological coping Sue Cooke (Facilitator), Gill Fulton, Gale (observe

Goal Setting and Closing Sue Cooke (Facilitator), Sally Coppock (project lead)

Motivation

Future Worries

Benefits

• Staff– Sharing knowledge– Learning new skills– Provide cross boundary holistic approach to

care

• Patients– Improved quality of life– Peer support– Increased motivation