The proposed new NHS England MS Prescribing Guidelines will stop the current wide variation in DMT prescribing across England. Yes! Dr David Paling Royal Hallamshire Hospital, Sheffield NIHR Sheffield Biomedical Research Centre Translational Neuroscience #MSdebate
Disclosures pt 1 • I have been offered travel support and honoraria for educational activites from Sanofi Genzyme, Biogen, Teva, Celgene, Merrk, MedDay • Our unit has been provided with research support from Genzyme and Biogen. #MSdebate
Disclosures Pt 2 • Over the weekend I realised that we were both preparing the same side of the debate. • Gavin Giovannoni immediately changed sides • You are not voting for the nicest person #MSdebate
#MSdebate Pubmed – accessed 13/03/2018
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When you stand on the shoulders of gods, it is difficult to comprehend the banality of the common man How hard this is for the new neurologist #MSdebate
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Evidence Number of papers in PubMed per year for multiple sclerosis with drug name in the title 140 120 100 80 60 40 20 0 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Glatiramer Acetate and Beta Interferon Natalizumab Fingolimod Di Methly Fumarate Alemtuzumab Cladribine #MSdebate
Evidence Number of papers in PubMed per year for multiple sclerosis with Beta Interferon, Glatiramer, Natalizumab, Fingolimod, Fumarate, or Cladribine in the title 350 300 250 200 150 100 50 0 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Total Does not include Ocrelizumab, Siponimod, Posenimod, Ofatunumab #MSdebate
Oh Dear yes no PHEW #MSdebate
YES YES - BUT NO #MSdebate
YES What about Glatiramer? NO #MSdebate
NO NO#### YES - but #MSdebate
Yes - BUT #MSdebate
YES YES YES #MSdebate
YES Yes but be carefulNO #MSdebate
YES - but #MSdebate
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2016/17 NHS England Spend on MS DMTs £249,417,164 5000 physiotherapists 150 per MS centre 15 new schools Courtesy of Prof Coles, Cambridge #MSdebate
2016 MS Society Report #MSdebate
NHS England spend on MS drugs, 2016-2017: Ten highest spending Trusts INTERFERON BETA TERIFLUNOMIDE DIMETHYL FUMARATE FINGOLIMOD NATALIZUMAB ALEMTUZUMAB 15 10 5 0 Courtesy of Prof Coles, Cambridge #MSdebate
NHS England spend on MS drugs, 2016-2017: Ten middling spending Trusts INTERFERON BETA TERIFLUNOMIDE £ Million DIMETHYL FUMARATE FINGOLIMOD 4.5 NATALIZUMAB ALEMTUZUMAB 4 3.5 3 2.5 2 1.5 1 0.5 0 Courtesy of Prof Coles, Cambridge #MSdebate
NHS England spend on MS drugs, 2016-2017: Ten lowest spending Trusts INTERFERON BETA TERIFLUNOMIDE £ DIMETHYL FUMARATE FINGOLIMOD 0.007 Million NATALIZUMAB ALEMTUZUMAB 0.006 0.005 0.004 0.003 0.002 0.001 0 Courtesy of Prof Coles, Cambridge #MSdebate
DMT decisions • Existing guidance is complex and contradictory • Amount of evidence is overwhelming • Stick to what you know #MSdebate
MS All Stars MS Advisory Committee • Alasdair Coles, Cambridge (Chair) • Neil Robertson, Cardiff (Vice chair) • Adnan Dr Adnan Al-Araji, North Midlands • Belinda Waller, Edinburgh • Bob Brenner, London 896 papers in MS • Brendan Mclean, Cornwall 1 paper a day • Bruno Gran, Nottingham • Gavin Giovannoni, London 2.5 years • Sian Price, Sheffield • Waqar Rashid, Sussex #MSdebate
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What does the algorithm do • Shows you all the rules and will inform Blueteq • Tells all regions to make all disease modifying therapies available • Tells you what you need for your service • MS specialist consultant neurologist • MS specialist nurse • Specialist MS centre and its multi-disciplinary team. #MSdebate
Blueteq #MSdebate
MDT meetings • Complex cases or those where higher-risk disease- modifying therapies (currently cladribine and the monoclonal antibody therapies) are proposed, should be discussed at a multi-disciplinary team meeting (MDT), • two MS specialist consultant neurologists • one specialist MS nurse, • access to neuro-radiology expertise. #MSdebate
MDT meetings • Set up in 2000 in cancer services to address inequalities of care • Improve survival for endometrial 1,2 and ovarian cancers 3 • Get better with time 4 1. Br J Cancer. 2013;109:2295–2300 2. Diseases of the Esophagus, vol. 19, no. 3, pp. 164–171, 2006 3. British Journal of Cancer, vol. 70, no. 2, pp. 363–370, 1994 #MSdebate 4. MDT development. Available at https://www.england.nhs.uk/wp-content/uploads/2015/01/mdt-dev-guid-flat-fin.pdf
Will MDT meetings affect practise #MSdebate
Why will all this reduce disparities • Principle of obedience to authority • What those in power who you respect do • 10 of the finest minds in MS created the algorithm • Principle of social proof • What those around you do. • MDT enables this #MSdebate
The proposed new NHS England MS Prescribing Guidelines will stop the current wide variation in DMT prescribing across England. Yes! Dr David Paling Royal Hallamshire Hospital, Sheffield NIHR Sheffield Biomedical Research Centre Translational Neuroscience #MSdebate
It’s only the start #MSdebate
MS Academy #MSdebate
The proposed new NHS England MS Prescribing Guidelines will stop the current wide variation in DMT prescribing across England. Yes! Dr David Paling Royal Hallamshire Hospital, Sheffield NIHR Sheffield Biomedical Research Centre Translational Neuroscience #MSdebate
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