The recent NICE guideline on management of multiple sclerosis in primary and secondary care brings together for the first time advice about managing all aspects of the disease. Although it is relatively short, it sets standards and pathways of care and deals in detail with diagnosis and management.
As with all NICE guidance there is a useful introduction outlining the basics of the disease including its incidence.This is 1 in 1000 individuals, with new cases occurring at the rate of 3-7 per 100 000 per year - certainly more than I had thought.
The guideline then outlines a ‘recipe’ for good care. Much of this will necessarily take place in specialist settings, but the importance of general practice is recognised, with the emphasis on teamwork. The GP will normally be the patient’s first point of access and he or she has a responsibility to ensure that the patient has access to the appropriate resources.
Communication with patients and relatives is given particular prominence, and it is here that the GP’s role will be most important. GPs will need to give patients clear information about the condition, offer emotional support, encourage independence and autonomy and identify the needs of carers.
The need for speedy and accurate diagnosis is emphasised. GPs should consider the condition in patients who have any neurological markers of demyelination, and refer them quickly. The guideline recommends that diagnosis should be confirmed in a specialist neurological setting.
Multidisciplinary neurological rehabilitation should be available to support the patient if necessary. While there are many neurological centres with extensive experience in MS management, the challenge will be to offer a comprehensive team approach in district hospitals and local communities and to keep GPs ‘in the loop’.
Many patients with relapsing/remitting MS will be followed up by their GPs. The guideline emphasises the need to refer these patients again for reassessment if their condition changes. Indeed, GPs are encouraged to seek neurological advice for any MS patient who experiences a significant new symptom or change.
In the past, drug treatment has been a contentious issue, and patients and doctors will welcome the clarity the guideline brings to the topic. It states that acute episodes may be treated with high dose methylprednisolone for 3-5 days.This may be useful while awaiting neurological review, but the guideline warns against excessive use. Daily linoleic acid is recommended as it may slow disease progression.
Several treatments should be avoided, because research evidence does not show any beneficial effects on the course of the condition, or used only in special circumstances. One to avoid is hyperbaric oxygen, a treatment currently used by a few of my patients because there is a local facility.
Interferon beta and glatiramer acetate are recommended for patients with specific types of MS, and a summary of the criteria suggested by the Association of British Neurologists for use of these treatments is included.
The guideline stresses the importance of rehabilitation and support in the community, and GPs recognise this need. However, I suspect that given the shortage of therapists it may be one of the hardest recommendations to deliver on. It is certainly an area that causes many GPs considerable frustration.
As with any guideline,setting standards will not automatically mean that they are delivered, but they represent a useful tool to help push for service development, a blueprint for those who commission services and a gauge of how delivery is progressing.
NICE Clinical Guideline 8. Multiple sclerosis: management of multiple sclerosis in primary and secondary care can be downloaded from the NICE website: www.nice.org.uk