Monday, 29 June 2015

Neurologists are too blue.... ABN 2015 guidlelines

Association of British Neurologists: revised (2015) guidelines for prescribing disease-modifying treatments in multiple sclerosis Scolding N et al. Pract Neurol doi:10.1136/practneurol-2015-001139

The Association of British Neurologists (ABN) revised prescribing guidelines for the treatment of relapsing-remitting MS (RRMS) have been published. 
The whole document can be read online 




So in brief you and your neurologist, who should be an MS specialist, can come up with the right choice for you

You should be on treatment if you have relapsing disease with one of the "high" or "low" efficacy drugs, or to be more PC "moderate" efficacy drugs or if you have progressive MS you should have nothing. However, I wonder to what extent this is guided by price. On a cost effective basis then it is clear that that are not slowing progression, but it is clear that T an B cells are in the brains of progressive MSers and they should be there. If the MS drugs got in the brain, they could kill them and stop any more arriving. Maybe when generics arrive and the prices drop, this will change. 

There are only two types of drugs according to the categories, 
I am sure that the marketing departments of pharma will not be too happy that there drugs are lumped into one of two efficacy groups, when the data so clearly shows that there are differences in efficacy, convenience, safety etc.  However one in the eye for marketing.

There is a view that is expressed there is no for a reason to strive for "No evidence of Disease Activity", because there is no evidence that it is of value....However there is surely logic that does not need evidence before one attempts to do it and surely all neurologists should surely want to do it for the people in their care as "Time is your brain" not theirs, whilst they sit on the fence.

Unfortunately, the UK is ranked 25 out of 27 European countries on the proportion of people with RRMS using DMT. 

With incoming budget limitations coming from NHS England, which will have the effect of incentivising the local trusts to not prescribe expensive drugs, will the members of the ABN have their hands tied?

As ProfG says if you try and design a horse by committee you get a Camel


As many people don't read comments, here is a few arising from this post.

"If normalising atrophy is so important....given that it's one of the biggest correlates with disability.....why would you issue guidelines that a) don't even mention it and b) seemingly recommends first line treatments, for a majority of patients, which have close to zero impact on atrophy? Feels like these guidelines are going to lead to many patients committing to a path which leads to SPMS (for which you have no treatments), when there are drugs which can apparently delay (or maybe even prevent) SPMS when given early.......Really, in 2015, knowing what we know, why would a neurologist give anyone interferon beta, the lowest efficacy drug which bears almost no prospect of long term normalisation of atrophy, prevention/delay of SPMS, etc...............neurologist/the field in general needs a good kick up the arse and a reality check for being too conservative... And then you go and deliver a paper like this!

Also, "it is not yet clear whether treatment should aim for a target such as No Evidence of Disease Activity"..... WHAT???!! In what possible scenario could NEDA not be a better target than EDA?!"

"Fair enough if you are stable on injectables why change but a newly diagnosed young person starting them what?!??@& 
Its been shown aggressive treatment early in the disease can massively effect the progression and the quality of life for that person. For the life of me I don't understand why all newly diagnosed are not at least being offered alemtuzumab. Fair enough they may decide the side effects outweigh benefits but at least let them make that informed choice and then work down the scale. Neuro's are not even mentioning aggressive treatments to the newly diagnosed.... That's not their choice to make its the person living with the disease and its consequences. Ugh rant over sorry"

CoI: TeamG neuros were involved 

3 comments:

  1. "if you try and design a horse by committee you get a Camel"
    so true...

    ReplyDelete
  2. So - of the currently licensed therapies - which ones have any measurable impact on brain and/or spinal cord atrophy? It sounds like I-Beta doesn't. I get that alemtuzumab does. What about treatments like Copaxone and DMF?

    ReplyDelete

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