Update on Multiple Sclerosis Helen Ford Consultant Neurologist Leeds Teaching Hospitals NHS Trust
Dec 28, 2015
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