1. Arani Nitkunan MA (Cantab), MRCP (UK)(Neurology), PhD February 12th 2015 First Fit Pathway & Multiple Sclerosis

2. Overview Ajay Boodhoo First fit Multiple sclerosis

3. Ajay Boodhoo

4. First Fit Pathway

6. http://www.croydonhealthservices.nhs.uk

7. Questions

8. Multiple sclerosis – why? Prevalence - 1 in 600

10. Multiple sclerosis – why?

12. Multiple new drugs and NICE guidance Multiple sclerosis – why?

13. 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

14. O/E VA Fields Ishihara RAPD Fundi R 6/36 central scotoma No C RAPD N L 6/9 N C + 7/7 N Examination of her limbs (including proprioception) was normal apart from brisk reflexes, mild finger-nose and truncal ataxia.

15. Investigations Normal Blood tests Abnormal Low B12 – 157 Scan

17. Diagnosis

18. Based on demonstrating inflammatory lesions separated in time and space

20. Types of multiple sclerosis 85% 5% 10%

21. Diagnosis Clinically isolated syndrome

22. Management Methylprednisolone 500mg od for 5 days

23. 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

25. Diagnosis Clinically isolated syndrome

26. Case 9 months later - Feb 2014 – Eyes went “funny” – couldn’t move her eyes to the left

27. Videos

30. Diagnosis Relapsing remitting multiple sclerosis

31. Management Methylprednisolone 500mg od for 5 days Disease modifying therapy

32. Steroids For functionally disabling symptoms Ensure no infective trigger

33. ABN 2001NICE 2002 Risk Sharing Scheme 2002 ABN 2007ABN 2009 Revised ABN Guidelines for MS 2009

34. Eligibility Criteria for Disease Modifying Therapy 1Age ≥ 18 2Ambulant (EDSS ≤ 6.5 ie walking unaided for ≥ 10m) 32 clinically significant relapses in the last 2 years NB Not for primary or secondary progressive MS – symptomatic therapy

35. Disease modifying therapies First line Rice, Practical Neurology 2014

36. Disease modifying therapies First line Yes Rice, Practical Neurology 2014

37. Disease modifying therapies First line Rice, Practical Neurology 2014

38. Disease modifying therapies Second line Criteria – ≥ 2 disabling relapses in 1 year with ≥1 enhancing lesion Significant increase in lesion load

41. Disease modifying therapies Second line Yes Rice, Practical Neurology 2014

42. Cost of disease modifying therapies DrugCost (£ per month) Avonex654 Rebif1104 Betaferon592 Copaxone550 Dimethyl fumarate1373 Teriflunomide1037 Natalizumab1130 Fingolimod1470 Alemtuzumeb2935

43. Case Doing well on Rebif

44. Summary – Multiple Sclerosis When to refer “Relapse” Disease modifying therapy

45. Acknowledgements Felicity Pearce Andrew Thompson Bridget MacDonald Fred Schon

46. References Masterclass Evidence Based Updates for GPs – MS Society 2011 www.mssociety.org.uk www.msdecisions.org.uk

47. Thank you & Questions?