by Prof Gavin Giovannoni
As we approach the end of another year it is time to reflect of the highs and lows of the last 12 months and its achievements. As austerity continues to pummel the NHS, it is clear that we have to learn to do more with less. NHS management are asking us to look critically at how we practice and to try and do things in a different way. We need to change and challenge the status quo. The way we deliver many of our services are similar to what was around in the Victorian era. The need to think laterally and to challenge the current model is one of the reasons we started the MS Academy and its MS MasterClasses. These initiatives are bringing together trainees, experienced consultant neurologists and other healthcare professionals involved in the care and management of people with multiple sclerosis with the express aim of challenging the status quo. We are asking trainees to focus on the patient and to imagine what a reactive MS service should look like. “If you had MS what would you want from your MS service?”
The MasterClasses are designed to be informal and interactive. The speakers use cases to highlight pitfalls in the diagnosis and management of MS. Examples are used to highlight why it is important to adopt a more proactive approach to the management of MS. Time matters in the management of MS and the consequences for individual patients can have major consequences.
The informal camaraderie that develops between the delegates is what separates out the Academy from other continuing medical education programmes. Attendees swap email addresses and are encouraged to join a WhatsApp group to allow exchange of ideas and to ask each other questions. Part of the agenda is to use technology creatively as a force for good.
Over the last 12 months there have been many advances in MS. A new set of MS diagnostic criteria are due to published. The main change in these criteria is the use of intrathecal or CSF oligoclonal IgG bands as part of the criteria for defining dissemination in time. The criteria do not yet allow for the presymptomatic diagnosis of MS. Another important development this year was the recent EMA licensing of oral cladribine tablets (Mavenclad) and the rapid NICE and NHS England approval for its use in patients with highly-active relapsing MS. Oral cladribine is a semi-selective immune reconstitution therapy (IRT) and will join alemtuzumab and AHSCT (autologous haemopoietic stem cell transplantation) that are non-selective IRTs. The non-selective IRTs suppress innate immunity and put treated patients at risk of bacterial infections such as Listeriosis during the depletion phase. The latter is preventable by avoiding environmental exposure to sources of food that may be contaminated with Listeria, or by the use of prophylactic antibiotics (cotrimoxazole).
Another widely anticipated development is the CHMP recommendation that EU licenses ocrelizumab (Ocrevus) for both active relapsing and early primary progressive MS (PPMS). Ocrelizumab is a humanised anti-CD20 monoclonal antibody and works by depleting circulating B-cells. Whether, or not, NICE will approve ocrelizumab will depend on its cost-effectiveness. This is unlikely to be a problem in relapsing MS. However, because the cost-effectiveness of ocrelizumab will be assessed using incremental costs, it is unlikely to be deemed cost-effectiveness in PPMS as the comparator will be best supportive care.
Another anticipated development is the imminent publication of new NHS England guidelines on the prescribing of disease-modifying therapies (DMTs) in MS. The latest guidelines have been developed in conjunction with the MS specialist interest group of the ABN (Association of British Neurologists). These guidelines are a pragmatic attempt to make sense of the many different technology appraisals covering the varied MS DMTs. One the underpinning principles of the new guidelines is to try and reduce the wide variation in prescribing that occurs across the NHS. Variation will be assessed using blueteq the online database that NHS England uses to monitor the use of high-cost specialist drugs in the NHS.
The focus on DMTs in the development and assessment of MS services is something we are trying to avoid. The management of MS is more than just the prescribing and monitoring of DMTs. We need an holistic approach to the management of MS. This includes optimising the diagnosis of MS and also managing the complications of MS.
It is an exciting time to be a healthcare professional engaged with the management of MS. We have many effective DMTs and the emergence of therapies that are effective in slowing the worsening of more advanced MS. I sincerely hope you have a very happy festive season and take the time to reflect on the year and what the new year will bring for ourselves and our patients.
Read the full Neurology Academy 2017 newsletter here