Nice | Multiple sclerosis

Nice's latest MS guideline does not cover DMARDs, and a lot of this is not new to us.

Take home messages

Diagnosis should be made by a neurologist, so refer if you suspect it

  • Tests to do in GP before referral
    • FBC, LFT, TFT, Bone profile, UE, glucose
    • ESR and CRP
    • B12
    • HIV
  • Relapses - all relapses should be discussed with a specialist before steroids are prescribed. Patients should not be given stand-by courses of steroids to hold at home.

And a little bit more detail

Symptoms to suggest MS

  • Loss or reduction of vision in 1 eye with painful eye movements
  • Double Vision
  • Ascending sensory disturbance and / or weakness
  • Problems with balance / unsteadiness / clumsiness
  • Lhermitte’s symptom (when the patient leans their head forwards, they get altered sensation down their back and sometimes into their limbs)

NB – beware younger patients, where symptoms develop over 24 hrs, with a history of previous neurological symptoms and where symptoms persist for days or weeks and then resolve.

General advice to patients

  • Support Groups (e.g. MS Society)
  • Driving - need to inform DVLA (Advice for Medical Professionals)
  • Exercise - may be beneficial
  • Smoking - may increase progression to disability
  • Pregnancy and pre-conception advice
  • Vaccines - some live vaccines may be contraindicated. Flu vaccine may increase risk of relapse.

Managing specific symptoms

I haven't discussed all the treatments here as much of this will be managed in secondary care, but I have outlined some of the first line treatments and things that we may be initiating in primary care.

  • Fatigue. Consider other medical causes. Exercise may help, Consider amantadine.
  • Spasticity. Baclofen and Gabapentin should be first line and can be used in combination. Benzodiazepines can be useful, especially for nocturnal spasticity.
  • Oscillopsia (I hadn't heard of this symptom - Wikipedia explains). Gabapentin can be considered first line.
  • Emotional Lability. Consider amitriptyline
  • Pain. As per NICE guideline on neuropathic pain
  • Cognitive Problems. Can occur with MS, but consider anxiety, depression and sleep problems too.

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