Proposed surveillance decision

Proposed surveillance decision

We propose to update the guideline on multiple sclerosis in adults: management. The update will focus on multiple sclerosis (MS) diagnosis, symptom management and rehabilitation.

The following table gives an overview of how evidence identified in surveillance might affect each area of the guideline, including any proposed new areas.

Section of the guideline

New evidence identified

Impact

1.1 Diagnosing MS

Diagnosing MS

Yes

Yes

Diagnosing optic neuritis and neuromyelitis optica

Yes

No

1.2 Providing information and support

Providing information and support

Yes

Yes

1.3 Coordination of care

Coordination of care

Yes

No

1.4 Modifiable risk factors for relapse or progression of MS

Modifiable risk factors for relapse or progression of MS

No

No

1.5 MS symptom management and rehabilitation

Fatigue

Yes

Yes

Mobility

Yes

Yes

Mobility and/or fatigue with balance problems

Yes

Yes

Treatment programmes for mobility and/or fatigue

Yes

No

Spasticity

Yes

Yes

Pain

Yes

Yes

Cognition including memory

Yes

Yes

Assessment

Yes

No

1.6 Comprehensive review

Comprehensive review

Yes

No

1.7 Relapse and exacerbation

Treating a relapse

Yes

No

1.8 Other treatments

Vitamin D

Yes

No

Omega fatty acids compounds

No

No

Reasons for the decision

This section provides a summary of the areas that will be updated and the reasons for the decision to update.

Updated diagnostic criteria for MS will have an impact on recommendation 1.1. The implications of the changes in diagnostic criteria and MS classification on the information and support patients receive in recommendation 1.2 should be also be considered.

Recommendation 1.5 on MS symptom management and rehabilitation needs updating in the areas of pharmacological management of fatigue, mobility and spasticity and also for non-pharmacological management of fatigue, mobility, balance, pain and cognition. At present, the recommendation addresses each symptom separately, and has not considered how different interventions may address multiple symptoms, or the possible interactive effects of prescribing multiple pharmacotherapies for different symptoms. Therefore, a more integrated, patient-centred rehabilitation approach addressing multiple aspects of care should be considered when this recommendation is updated.

Pharmacological management of symptoms

  • Recommendation 1.5.4 recommends offering amantadine to treat fatigue in people with MS, however new evidence indicates that amantadine may not be an effective treatment.

  • Recommendation 1.5.10 recommends that fampridine is not a cost-effective treatment for lack of mobility in people with MS. While no cost-effectiveness studies were identified, there is new evidence concerning the effectiveness of fampridine on mobility in people with MS which indicates that fampridine significantly improves mobility when compared with placebo, but not when compared with gait training interventions. Given the new evidence on effectiveness, it is recommended that assessment of the cost effectiveness of fampridine for treating mobility in people with MS is considered for update.

  • Recommendation 1.5.23 recommends that Sativex is not used as a treatment for spasticity as it was found to be not cost effective, however there is new cost-effectiveness evidence which indicates that it may be cost effective. Evidence was also identified that supports the use of botulinum toxin in treating spasticity; botulinum is not currently recommended, but is within scope.

Non-pharmacological management of symptoms

  • Recommendation 1.5.5 recommends that mindfulness‑based training, cognitive behavioural therapy or fatigue management are considered for treating MS‑related fatigue. New evidence indicates that these interventions are effective in reducing fatigue in people with MS; and so an update could consider whether the strength of this recommendation could change to offering these interventions to people with MS (see wording the recommendations in developing NICE guidelines: the manual).

  • New evidence was identified which indicates that falls management, balance rehabilitation and aquatic exercises can lead to improvements in balance for people with MS. This evidence should be considered in an update as currently only vestibular rehabilitation is recommended for managing balance problems in people with MS (recommendation 1.5.12).

  • There are currently no recommendations concerning the non-pharmacological management of pain, however there is a small body of evidence which indicates that transcutaneous electrical nerve stimulation (TENS) is effective in relieving pain in people with MS and there is an ongoing Cochrane review on non-pharmacological interventions for chronic pain in people with MS (see ongoing research).

  • There are currently no recommendations concerning interventions that may be beneficial for people with MS who experience cognitive problems, however there is new evidence which indicates that rehabilitation programmes can lead to improvements in memory in people with MS.

  • New evidence was identified on mobility rehabilitation programmes for people with MS that addresses research recommendation 2.3 on determining the optimal frequency, intensity and form of rehabilitation for mobility problems in people with MS.

Research recommendations

There is also new evidence that is relevant to the research recommendations on:

  • Cognitive rehabilitation: new evidence was identified which indicates that rehabilitation programmes can lead to improvements in memory in people with MS, evidence for which should be considered in the guideline update. However, as no cost-effectiveness studies were identified, the research recommendation is unlikely to be fully addressed in the update.

  • Continued relapses: new evidence was identified which indicates that there is no difference in the clinical effectiveness of intravenous methylprednisolone when compared with oral methylprednisolone in the treatment of a relapse in people with MS; however as no cost-effectiveness studies were identified, the research recommendation is unlikely to be fully addressed in the update.

  • Vitamin D: new evidence was identified which indicates that the use of vitamin D supplementation in people with MS provides no significant benefit in slowing the progression of disability in MS. This supports the content of recommendation 1.8.1 to not offer vitamin D solely for the purpose of treating MS.

For further details and a summary of all evidence identified in surveillance, see appendix A.


This page was last updated: 31 October 2018