Chester Clinic

Community.mssociety.org.uk

– summarising clinical guidelines for primary care
Endorsed by
Symptomatic management of multiple
sclerosis in primary care
This guideline was developed by a multidisciplinary expert panel: Rashid W et al with the support of a grant from both Bayer Healthcare and Novartis. The Multiple Sclerosis Society has endorsed this working party guideline. See inside front cover for full disclaimer.
The development of this working party guideline has been supported by a grant from both Bayer Healthcare and Novartis. The Multiple Sclerosis Society has endorsed this working party guideline.
This guideline has been developed by MGP Ltd, the publisher of Guidelines, and the Working Party was convened by them. The guideline was developed by a multidisciplinary expert panel decided by the Chair. This working party guideline has been funded by both Bayer Healthcare and Novartis, but neither of the sponsors had any influence over the content of the guideline. Bayer Healthcare and Novartis were sent the scope and background reading documents for their information, however, final decisions rested with the Multiple Sclerosis Society and the Chair. The content is independent of any sponsorship, but has been reviewed and endorsed by the Multiple Sclerosis Society.* * Please see the MS Society working with industry policy at www.mssociety.org.uk
Date of preparation: October 2013 CENTRAL NERVOUS SYSTEM
Symptomatic management of multiple
sclerosis in primary care
• Working Party – Rashid, Cox, Jackson, McFadden, Merriman & Vernon •
This guideline was developed by
• Bear in mind the typical patient profile for MS a multidisciplinary expert panel:
but do not limit suspicion to such patients: Rashid W et al with the support of
a grant from both Bayer Healthcare
– Young (20–50 years) and Novartis. The Multiple Sclerosis
– No other significant comorbidity/ Society has endorsed this working party
guideline. See page 7 for full disclaimer.
– Post-partum (or no children in the presence of urinary dysfunction) • The fol owing symptoms indicate the need for immediate referral to a specialist neurologist: • The cause of MS is currently unknown. – Optic neuritis The condition usual y becomes apparent – Transverse myelitis (motor weakness, in early adult life, being diagnosed most sensory disturbance, sphincter disturbance) often in people aged 20–40 years—in whom it is the most common cause of • The fol owing symptoms indicate the need neurological disability—and only rarely in for referral on a less urgent basis, depending young children and adults aged >65 years on rate of accumulation and severity of symptoms (usual y within 6 weeks): • Multiple sclerosis affects both sexes, – Evolving sensory problems although women are three times as – Brainstem/cerebellar symptoms likely to develop the disease as men – Sphincter problems without other cause (e.g. post-partum) • There are four different patterns of – Evolving neurological problems (particularly MS—see full guideline for details ataxia and spastic paraparesis) • For patients with the fol owing symptoms, watch and wait for about 6 weeks with a suspicion of MS in mind (consider • Diagnosis of MS is difficult, as there is no referral if symptoms are not resolving simple diagnostic test, each patient has a or new symptoms emerge): different pattern of disease and symptoms, – Sensory problems excluding other causes none of the symptoms occur only in patients – Vertigo (look out for evolution/ with MS, and at least two episodes are other brainstem signs) needed before a definitive diagnosis of MS can be made (until then the patient might be – Pain in association with other said to have clinical y isolated syndrome [CIS]) neurological symptoms • Early treatment can be beneficial for • The fol owing symptoms when present in long-term prognosis, so it is important for isolation are unlikely to result from MS:
primary care HCPs to identify patients with symptoms suspicious or indicative of MS CENTRAL NERVOUS SYSTEM
– Bowel disturbance in the absence – Pain is often secondary to other symptoms, of urinary dysfunction such as fatigue, gait problems, and – Trigeminal neuralgia (except in atypical – Transcutaneous electrical context; refer to NICE CG 96) nerve stimulation (TENS) – Cognitive deficits • Topical and oral pharmacological agents • Almost every patient with a recent diagnosis may be used to manage pain in MS: of MS will see their GP soon after diagnosis – Topical treatments are used first- and will often have many questions: line for focal pain and as adjuncts – Patients do not always want to know to pharmacological agents: everything, especial y in the early stages Lidocaine plasters when they may feel overwhelmed, so Capsaicin—make patients aware give them essential information including of the potential associated points of contact, information leaflets, and discomfort and advise patients to details of patient support organisations check for skin abrasions and to – Ask them to notify you if they develop wear gloves when applying any new symptoms, have any Some patients report benefits with questions or concerns, or if they feel topical rubefacient heat rubs that they need additional support – Oral drugs are the main approach for pain: Basic analgesics can be useful for relief of • Ensure patients with a confirmed diagnosis general pain, including neuropathic pain of MS are referred to secondary care and pain after beta-interferon injections, for appropriate therapy, rehabilitation, using (in order of escalation) paracetamol, and specialist assessment ibuprofen, cocodamol, and tramadolTricyclic antidepressants are particularly useful for patients with sleep problems Treatment options for the
and neuropathic pain. Low doses should major symptoms in MS
be used initial y, with slow uptitration as needed and patients should be advised • Once MS has been confirmed by a why these drugs are being prescribed neurologist, continue to exclude other possible Duloxetine, which is indicated for causes of symptoms before treatment neuropathic pain in patients with diabetes, is a useful alternative Anticonvulsant (antiepileptic) medications are reported to be useful, • Pain is common, occurring in 30–90% of although clinical evidence is weak: patients with MS; it often evolves over time ƒ Gabapentin is the traditional first choice, but NICE recommends • Patients often describe ‘the MS hug'—a first-line pregabalin feeling of tightness around the trunk that ƒ Minimise side-effects with a low is associated with transverse myelitis starting dose (100 mg gabapentin or 50 mg pregabalin three times daily) • Non-pharmacological options can be useful: and slow uptitration (every 2 weeks – Light and loose clothing, e.g. silk, can in small increments, or more quickly help with al odynia for pregabalin if pain is severe) – Changes to footwear can help with foot pain ƒ Pregabalin does have abuse potential – Identify and avoid trigger factors, where in comparison to gabapentin CENTRAL NERVOUS SYSTEM
ƒ No guidance is available on switching – Consider early referral to the community between gabapentin and pregabalin, so mental health team/psychological services the working party group recommend – Non-pharmacological options: Online and face-to-face cognitive ƒ Carbamazepine is the drug of behavioural therapy (CBT) choice for trigeminal neuralgia ƒ Lamotrigine is well tolerated, has a Neurologists can provide mood-stabilising effect, and provides additional expert support occasional benefit, although there is no firm evidence in neuropathic pain Opiates can be helpful for neuropathic pain but side-effects including • Identify and manage modifiable causes, constipation and sedation are a concern: including sleep hygiene, depression, thyroid ƒ Fentanyl patches dysfunction, anaemia, infection, vitamin B12 ƒ Oral tramadol and oxycodone and folate deficiency, vitamin D deficiency, ƒ Stronger opioids should be prescribed lifestyle/work pattern, support, and drugs by the specialist pain team only • Patients should be advised about self- management programmes, such as FACETS—if fatigue still persists, refer to other • Refer to pain clinic if background or members of the MDT and liaise with the breakthrough pain is causing functional or neurology team for further specialist advice social deficits, if adherence is poor due to side-effects, or for chronic pain syndrome • Refer to neurologist for facial pain, • Look for and manage concurrent conditions dermatomal pain, and distal lower leg pain that could be causing spasticity, including due to possible nerve entrapment infection (particularly urinary tract infection [UTI]), constipation, skin integrity issues/ Depression and anxiety
pressure sores, and malnourishment • Clinical depression is more common • Assess lifestyle for helpful modifications in patients with MS than in patients with other chronic diseases: • Pharmacological options: – Lifetime prevalence of major depressive – The NICE guideline on MS provides useful disorder in patients with MS is 50% advice on options for the management – Suicide is 7.5-fold more common in patients of spasticity, for example with baclofen, with MS than the general population cannabis-based oromucusal spray, gabapentin, and tizanidine • Depression affects carers as well as patients – Cannabis-based oromucusal spray is a licensed treatment for spasicity in patients Diagnosis and management
with MS. However, it has not undergone a formal NICE technology appraisal • Manage depression as for any patient, while bearing in mind the high risk of severe • Refer the patient to the neurologist or MS depression and suicide in patients with MS: rehabilitation team if two different agents – MS nurses provide valuable support fail to control spasticity and can coordinate with GPs CENTRAL NERVOUS SYSTEM
Motor function impairment
– Rapid progression of cognitive dysfunction or signs of psychosis • Rule out other causes of motor weakness, – Cognitive dysfunction in the early stages of MS such as spinal cord injury and stroke Bowel and bladder problems
• Non-pharmacological approaches include adapting the patient environment, e.g. using • Bladder problems are common in people walking aids, lifestyle modifications, and with MS but can be effectively managed. functional electrical stimulation Some people with MS will not experience any problems with the bowel, but • Refer to local therapy services for constipation and bowel incontinence may specialist support affect people with MS at some stage • Refer to neurologist if patients experience rapid • Urinary incontinence (UI) affects progression or acute onset of new symptoms, or about 75% of people with MS: fail to respond to non-pharmacological options – May be related to bladder overactivity or incomplete bladder emptying: Cognitive function impairment
Detrusor muscle instability is more common in early MS; as MS progresses, • Cognitive dysfunction is common, affecting efficiency of bladder emptying reduces around 50% of patients,even those with early – Can be due to causes other than MS: MS. It often presents as problems with executive In men UI may result from prostatic disease function, organisational ability, and sequencing, In women UI often fol ows childbirth but other symptoms can develop over time. It is May develop due to medicines prescribed not related to disease severity or progression.
for fatigue, anxiety, and depression • Check that the patient has true cognition problems rather than depression/anxiety – Refer for post-void scan (via continence • Have medication reviewed to minimise advisory service or MS specialist nurse) iatrogenic cognitive losses, look out for anti-cholinergics and sedating agents • Management varies depending on whether the patient has bladder overactivity • Check thyroid function, vitamin B12 and or incomplete bladder emptying: folate levels, and treponemal serology – The NICE guideline on management of lower urinary tract dysfunction in • Rule out other causes of cognitive dysfunction, neurological disease is a useful guide which can still develop in MS – Refer for neurological opinion if the patient has frequent UTIs or UI is resistant to treatment, • Rule out UTI, which is a common cause of or if UI is associated with loss of sensation cognition problems • Most patients with MS experience • Liaise with the MS nurse constipation; diarrhoea also occurs but is often secondary to constipation: • Refer to the neurologist or specialist – Bowel dysfunction rarely develops before MS team if the patient experiences: urinary problems in patients with MS – Acute worsening of cognition in the – MS nurses can provide advice on lifestyle absence of underlying causes, e.g. UTI modifications including dietary modifications, exercise, and regarding fluid intake CENTRAL NERVOUS SYSTEM
Impact on sex, intimacy, and relationships
• Only certain forms of ß-interferon may be used for secondary progressive MS with relapses, • Sexual dysfunction is common, affecting as per UK guidelines, with other therapies 50–90% of men with MS and 40–80% of used only for relapsing-remitting MS • DMTs are prescribed by the hospital MS team—contact the specialist MS team and/or MS nurse for information about these drugs • A relapse is a new episode of symptoms or • None of these therapies are disability in the absence of fever or infection, licenced for pregnancy which lasts at least 24 hours, is a neurological disturbance typical of MS, and occurs ≥30 days since the start of a previous episode: – Rule out infections and other reasons • The decision to stop treatment will always be for worsening of symptoms made by a member of the MS team; however, – Patients may be on any of the medications GPs can re-refer back to the team if you are • Only certain forms of beta interferon may be used for secondary progressive MS with relapses, with other therapies • Refer to pal iative care if patients are not used only for relapsing-remitting MS responding to usual symptom management and the following symptoms are progressing: Steroids
– Reduced mobility – Speech and swallowing difficulties • There is no role for long-term maintenance steroids, but short courses of high-dose steroids are used to hasten recovery from relapse – Hospital admissions– Reduction in function • Seek advice from the neurology/MS team – Breathing difficulties before prescribing steroids for MS relapses – Pain – Spasms and spasticity Disease modifying therapies (DMTs)
• DMTs reduce the frequency and severity – ß-interferon – Glatiramer acetate about this working party guideline. This guideline has been developed by MGP Ltd, the publisher of Guidelines, and the Working Party was convened by them. The guideline was developed by a multidisciplinary expert panel decided by the Chair. This working party guideline has been funded by both Bayer Healthcare and Novartis, but neither of the sponsors had any influence over the content of the guideline. Bayer Healthcare and Novartis were sent the scope and background reading documents for their information, however, final decisions rested with the Multiple Sclerosis Society and the Chair. The content is independent of any sponsorship, but has been reviewed and endorsed by the Multiple Sclerosis Society.
working party members – Waqar Rashid (Chair, Consultant Neurologist), Adrienne Cox (Multiple Sclerosis Nurse), Katy Jackson (Head of Prescribing and Medicines Commissioning), Estel e McFadden (GPwSI Neurology), Honor Merriman (General Practitioner), Karen Vernon (Multiple Sclerosis Nurse) further information – call MGP Ltd (01442 876100) for a copy of the full guideline

Source: https://community.mssociety.org.uk/sites/default/files/resources/resource_files/Symptomatic%20management%20of%20MS%20in%20primary%20care%20-%20MGP%20guideline.pdf