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• Are the new ABN guidlines for MS of any use in clinical practice?
  Julian N Furby
  Published on: 14 April 2016

• Published on: 14 April 2016

  Are the new ABN guidlines for MS of any use in clinical practice?

  • Julian N Furby, Consultant Neurologist

  As a jobbing MS neurologist in Southampton I am really not sure how these guidelines are going to assist in my clinical practice.

  Perhaps first and foremost, if I was to follow these guidelines I would find myself frequently in breach of NHS commissioning criteria with perhaps severe implications for both myself and my hospital trust given the cost of these therapies. As such I feel the authors should have give...

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  As a jobbing MS neurologist in Southampton I am really not sure how these guidelines are going to assist in my clinical practice.

  Perhaps first and foremost, if I was to follow these guidelines I would find myself frequently in breach of NHS commissioning criteria with perhaps severe implications for both myself and my hospital trust given the cost of these therapies. As such I feel the authors should have given a little more attention to this issue, highlighting where guidance is against what we are actually allowed to do.

  My experience of multiple sclerosis patients is that they do not simply fall into two broad categories of active vs more active and therefore I find the division of the drugs into two broad categories equally unhelpful and unnecessary. Perhaps the most obvious example is that fingolimod has considerably more potency than some of the other category one drugs and by these guidelines own definitions fingolimod could easily be classed as a category two treatment and therefore be a good option for more active patients, as it is already under the NHS commissioning criteria.

  The guidelines recommend using alemtuzumab or natalizumab in patients with more active disease as defined by one relapse in the previous year on interferon with MRI criteria. In clinical practice treatment decisions in such patients are heavily influenced by factors such as disease duration, treatment duration, relapse severity, prior relapse frequency on and off treatment, and gadolinium enhancement on MRI (with number of T2 lesions not being particularly useful). These guidelines could and should have been more progressive in discussing a correct approach for different patient types. Among other considerations that should have been discussed include treating young women with highly active multiple sclerosis for whom alemtuzuamb now provides the possibility of potent treatment and pregnancy at the same time, and JC virus negative patients for whom natalizumab offers a virtually risk free high potency therapy assuming that JCV status is regularly monitored whilst on treatment.

  Finally in non-relapsing established progressive disease there is absolutely no evidence to support immunomodulation and given the costs of therapy I really think this guidance could have taken a bolder approach in making firm recommendations about cessation of treatment to support clinicians in their discussions with such patients.

  Overall I feel these guidelines offer a fairly simplistic and non- commital approach, that as UK neurologists we are often unable to follow due to commissioning restrictions, and with the wide range of therapies now available a more progressive, customised approach that addresses a wide range of patient characteristics is what is required.

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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