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Arani Nitkunan MA (Cantab), MRCP (UK)(Neurology), PhD February 12th 2015 First Fit Pathway & Multiple Sclerosis
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Overview Ajay Boodhoo First fit Multiple sclerosis
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Ajay Boodhoo
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First Fit Pathway
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http://www.croydonhealthservices.nhs.uk
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Questions
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Multiple sclerosis – why? Prevalence - 1 in 600
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Multiple sclerosis – why?
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Multiple new drugs and NICE guidance Multiple sclerosis – why?
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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
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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.
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Investigations Normal Blood tests Abnormal Low B12 – 157 Scan
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Diagnosis
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Based on demonstrating inflammatory lesions separated in time and space
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Types of multiple sclerosis 85% 5% 10%
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Diagnosis Clinically isolated syndrome
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Management Methylprednisolone 500mg od for 5 days
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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
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Diagnosis Clinically isolated syndrome
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Case 9 months later - Feb 2014 – Eyes went “funny” – couldn’t move her eyes to the left
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Videos
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Diagnosis Relapsing remitting multiple sclerosis
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Management Methylprednisolone 500mg od for 5 days Disease modifying therapy
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Steroids For functionally disabling symptoms Ensure no infective trigger
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ABN 2001NICE 2002 Risk Sharing Scheme 2002 ABN 2007ABN 2009 Revised ABN Guidelines for MS 2009
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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
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Disease modifying therapies First line Rice, Practical Neurology 2014
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Disease modifying therapies First line Yes Rice, Practical Neurology 2014
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Disease modifying therapies First line Rice, Practical Neurology 2014
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Disease modifying therapies Second line Criteria – ≥ 2 disabling relapses in 1 year with ≥1 enhancing lesion Significant increase in lesion load
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Disease modifying therapies Second line Yes Rice, Practical Neurology 2014
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Cost of disease modifying therapies DrugCost (£ per month) Avonex654 Rebif1104 Betaferon592 Copaxone550 Dimethyl fumarate1373 Teriflunomide1037 Natalizumab1130 Fingolimod1470 Alemtuzumeb2935
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Case Doing well on Rebif
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Summary – Multiple Sclerosis When to refer “Relapse” Disease modifying therapy
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Acknowledgements Felicity Pearce Andrew Thompson Bridget MacDonald Fred Schon
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References Masterclass Evidence Based Updates for GPs – MS Society 2011 www.mssociety.org.uk www.msdecisions.org.uk
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Thank you & Questions?
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