GP Dr Graham Archard's key points on diagnosis and management
1. Multiple sclerosis (MS) is on the increase – primarily in women and no-one knows why.
Young adults get the disease, predominantly women, with most recent studies showing a ratio of 3:1 to 4:1. Current prevalence is 1:600-800 in the UK. Peak incidence is between 20-40, with potential implications for family life and career. It can present in childhood, but onset over 60 is rare.
2. A young adult presenting with episodic neurological symptoms should make us think of MS.
The most common symptoms are limb numbness and weakness, visual disturbance (blurred or double vision) and imbalance. Non-specific fatigue is common. In older patients, usually those over 45, symptoms can be progressive in onset, often reflected by gradually evolving mobility difficulties.
3. Watchful waiting is an appropriate strategy for those with milder symptoms.
For patients with disabling or persistent symptoms, early referral for neurological review and investigation is paramount. However, patients with mild, transient or non-specific symptoms are unlikely to be disadvantaged by delayed referral. A period of ‘watchful waiting' for more clear-cut neurological symptoms in such patients may be appropriate.
4. Consider the possibility of ‘pseudo-relapse'.
Relapses are usually sub-acute in onset, evolving over days rather than hours, and may be a deterioration in pre-existing symptoms or a presentation with new problems. In those patients with a worsening of prior symptoms, particularly those with long-standing MS, the possibility of a ‘pseudo-relapse' caused by intercurrent illness should always be considered. If infection is excluded and symptoms are disabling or persistent, steroids may be appropriate – does the local MS service operate a relapse clinic? MS nurses locally should advise. If assessment in secondary care is not available, NICE guidelines recommend methylprednisolone 500mg daily for five days, with good evidence that steroids accelerate recovery.
5. Use of disease-modifying therapy depends on disease type.
A range of immunomodulatory therapies is now being used to modify the course of MS. There is growing consensus that early treatment – in the first two to three years – is most likely to positively influence the disease. Patients likely to benefit from these drugs are those with active relapsing-remitting disease – usually reflected by one or more significant relapse in the past year on a background of stable disease. For patients with long-standing, gradually progressive MS, management remains symptomatic. There are around 70 centres across the UK offering assessment and treatment – details are available on the MS Society website (www.mssociety.org.uk).
6. GPs are in a prime position to provide continuity of care by acting as a patient's advocate, getting access to the right services at the right time.
The GP's role is vital in ensuring the patient has a clear point of access to hospital services, knows how to contact their neurologist or MS nurse, and in being responsive to the patient's needs and facilitating access to the surgery.
7. The most common symptom is fatigue.
Check for exacerbating factors such as drug side-effects or symptoms of depression. Are they woken by pain, spasms or bladder symptoms? Are they following a healthy diet? Suggest management strategies including planning and pacing and relaxation techniques. If fatigue remains an issue, drug treatment can be helpful – both modafinil and amantidine at doses of 100mg or 200mg morning or lunchtime help some patients.
8. Offer an annual review appointment in primary care to review overall progress.
An annual review provides the chance to ask directly about symptomatic issues that may be amenable to treatment. It also offers the opportunity to consider other issues – such as hypertension and lipids – that can be overlooked in the presence of a chronic illness. A local register of MS patients and annual review forms the core of the enhanced service for MS.
9. Know your local services.
There are likely to be a variety of services available in the community and secondary care for your MS patients – know who and where they are. Check what services are available at your nearest specialist centre. Resources include the MS Society (www.mssociety.org.uk) and the MS Trust (www.mstrust.org.uk).
10. Bear in mind that fit notes and the changes to the Disability Living Allowance (DLA) may pose problems for MS patients.
The MS Society has warned that the new four-page DLA renewal form should be approached carefully. Almost seven out of 10 claimants moving onto employment and support allowance (ESA) are being found fit for work on assessment. With regard to fit notes, the society has also expressed scepticism that the use of tick boxes is sufficient to ensure a gradual and safe return to work for people with MS.
Dr Graham Archard has recently retired as a GP in Christchurch, Dorset, is immediate past vice-chair of the RCGP and has a particular interest in MS
Lesions in the spine (highlighted)in a patient with MS Multiple sclerosis plaques in the spine
