Who is responsible for keeping UK neurologists up-to-date about prescribing policy? #ClinicSpeak #MSBlog #MSResearch
“Unfortunately, this post is for UK, and possibly English and Welsh, MSers only. The MSer who contacted me last week about her frustrations about getting onto a DMT for CIS has forwarded me her email correspondence she has had with her MS team and the Commissioners who pay for the drug. It is clear that nobody really understands what policy they should apply when prescribing DMTs for CIS and other forms of MS. It looks as if some of the neurologists are still prescribing interferon-beta and glatiramer acetate according to the Department of Health’s Risk Sharing Scheme (RSS) for Disease Modifying Therapies in MS (2002). The RSS scheme uses the Association of British Neurologists (ABN), Guidelines for the use of Beta Interferons and Glatiramer Acetate in Multiple Sclerosis (January 2001). The following is the paragraph from these guidelines that refers to CIS.”
B.1.2 Clinically isolated syndromes
Because: (i) the treatment effect on relapse rate appears similar but not superior to that seen in established relapsing remitting MS, and (ii) many patients will not have new relapses in the early years (e.g. 50% of placebo patients in the CHAMPS trial did not have further relapses during the 3 years of follow up), treatment is not currently recommended at presentation with a clinically isolated syndrome. Should a relapse occur during the first two years of follow up, the patient then has relapsing remitting MS and the treatment criteria in B.1.1. should be used. Current efforts are being made to develop MRI criteria which enable an earlier diagnosis of MS at or near presentation with a clinically isolated syndrome and to identify those who have a high probability of early clinical relapses; such criteria may lead in future to guidelines for earlier treatment after the first clinical event.
“What this patients MS Team and Commissioner’s don’t appreciate is that since April 2013 the RSS guidance has been superseded by NHS England’s policy; ‘Clinical Commissioning Policy: Disease Modifying Therapies for Patients with Multiple Sclerosis (MS) (First published: April 2013, revised May 2014)‘. The policy document states that Neurologists may, in certain other circumstances where the evidence for efficacy is less secure, also consider advising treatment after discussion with the patient concerning the risks and benefits. For (i) patients within 12 months of a clinically significant clinically isolated syndrome when MRI evidence predicts a high likelihood of recurrent episodes (i.e. development of MS); (ii) patients with only a single major relapse in the preceding two years, but combined with MRI evidence of continuing disease activity (i.e. meet the revised McDonald criteria for MS); and (iii) individuals aged less than 18. These guidelines are based on the ‘ABN Revised Guidelines for Prescribing in Multiple Sclerosis (2009).”
“The NHS guidelines are clear to me; neurologists in England and Wales can prescribe interferon-beta, but not glatiramer acetate, for patients with CIS provided they have (1) an abnormal MRI that predicts a high likelihood of recurrent episodes, (2) had a discussion with the patient about the benefits and risks of treatment and (3) start the interferon within 12 months of the clinical attack. The guidelines are not too prescriptive and allow the neurologist to make his/her call on what constitutes an abnormal MRI that predicts a high likelihood of recurrent episodes.”
“The question we should be asking is whose responsibility is it to make sure MSologists are aware of the change in prescribing policy? Surely as in this case it should not be the responsibility of the patient themselves?”