Time from ‘treatment decision’ to ‘actual start of DMT’ in MS – a local clinical survey

by Dr Yoga Bindu

Background

Multiple Sclerosis (MS) is an immunologically diverse disease and its behaviour is incommensurable in the affected population.  This makes the choice of treatment difficult for both the neurologists and the patients. The disease modifying treatment (DMT) can make a huge impact on MS by reducing the disease activity and reducing relapses. The Association of British Neurologists (ABN) and NICE guidelines states that, the Disease modifying treatment should be commenced as soon as possible in the eligible patients. However, there is no standardised time length specified. It was of interest to see how long it takes from the ‘time of decision to treat’ to ‘the actual commencement of the Disease modifying treatment’ locally.

Introduction

Bradford Teaching Hospitals NHS Trust is a satellite centre for the West Yorkshire Treatment Centre. There are approximately 800 patients with the diagnosis of MS, out of which approximately 350 patients are on Disease modifying treatments. The usual pathway in the management of MS once the diagnosis is confirmed are, to check the eligibility for DMT, select the appropriate drug (both patient and neurologist), then the treatment is ordered and the drug is delivered by post to the patient or to the hospital where appropriate. The drug delivery is facilitated by the Leeds pharmacy.

Selection & Methodology
  • All the patients who started or due to start new DMT between September 2016 to January 2017 at Bradford were selected.
  • Total number of patients – 25
  • Diagnosis of patients – all were Relapsing Remitting type of MS (RRMS) except one case of Primary Progressive MS (PPMS) with superimposed relapses.
  • Method – Retrospective review of the clinic letters and local data base maintained by the MS co-ordinator.

DMTs prescribed were Tecfidera (Dimethyl fumarate), Avonex (Interferon beta-1a), Plegridy (Peginterferon beta-1a), Copaxone (Glatiramer acetate) and Tysabri (Natalizumab).

  • 10 patients started DMT for the first time with no previous DMTs.
  • Among these ten, six were Tecfidera, and one each of Avonex, Plegridy, Copaxone, and Tysabri.
Results

We noted that the duration from the treatment decision to start of DMT was 4 weeks in 28% cases, 4 to 8 weeks in 28% cases, beyond 8 weeks in 44% of cases. There were two definite relapses, two query relapses and one patient with worsening symptomatology while waiting to start DMT.

Conclusion

The existing data does not specify the date of order of the drug and date of delivery/receival by patient. Patients are usually given information regarding the DMTs and they may take some time to choose the DMT. This can in turn delay the start of the treatment.

Recommendations

We recommend establishing a robust data base to specify date of decision by clinician, patient, date of order, date of delivery and reason for delay. At the same time, to encourage patients to report any relapses to MS team. We propose that a national audit may prove to be propitious in exploring the nationwide practice and could drive the MS centres to standardise the treatment pathway.