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Multiple sclerosis

About

What is covered

This pathway covers the management of multiple sclerosis in primary and secondary care.
Multiple sclerosis (MS) is an acquired chronic immune-mediated inflammatory condition of the central nervous system (CNS), affecting both the brain and spinal cord. It affects approximately 100,000 people in the UK. It is the commonest cause of serious physical disability in adults of working age.
People with MS typically develop symptoms in their late 20s, experiencing visual and sensory disturbances, limb weakness, gait problems, and bladder and bowel symptoms. They may initially have partial recovery, but over time develop progressive disability. The most common pattern of disease is relapsing–remitting MS (RRMS) where periods of stability (remission) are followed by episodes when there are exacerbations of symptoms (relapses). About 85 out of 100 people with MS have RRMS at onset. Around two-thirds of people who start with RRMS may develop secondary progressive MS: this occurs when there is a gradual accumulation of disability unrelated to relapses, which become less frequent or stop completely. Also about 10 to 15 out of 100 people with MS have primary progressive MS where symptoms gradually develop and worsen over time from the start, without ever experiencing relapses and remissions.
The cause of MS is unknown. It is believed that an abnormal immune response to environmental triggers in people who are genetically predisposed, results in immune-mediated acute, and then chronic, inflammation. The initial phase of inflammation is followed by a phase of progressive degeneration of the affected cells in the nervous system. MS is a potentially highly disabling disorder with considerable personal, social and economic consequences. People with MS live for many years after diagnosis with significant impact on their ability to work, as well as an adverse and often highly debilitating effect on their quality of life and that of their families.

Updates

Updates to this pathway

13 January 2016 Multiple sclerosis (NICE quality standard 108) added to this pathway.
15 December 2015 Link added to the NICE guideline on care of dying adults in the last days of life (NG31).
1 May 2015 Minor maintenance update.
20 March 2015 Minor maintenance update.
4 March 2015 Minor maintenance update.
29 October 2014 Minor maintenance update.

Your responsibility

Guidelines

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this interactive flowchart is not mandatory and does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the interactive flowchart to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Short Text

Multiple sclerosis: management of multiple sclerosis in primary and secondary care

What is covered

This pathway covers the management of multiple sclerosis in primary and secondary care.
Multiple sclerosis (MS) is an acquired chronic immune-mediated inflammatory condition of the central nervous system (CNS), affecting both the brain and spinal cord. It affects approximately 100,000 people in the UK. It is the commonest cause of serious physical disability in adults of working age.
People with MS typically develop symptoms in their late 20s, experiencing visual and sensory disturbances, limb weakness, gait problems, and bladder and bowel symptoms. They may initially have partial recovery, but over time develop progressive disability. The most common pattern of disease is relapsing–remitting MS (RRMS) where periods of stability (remission) are followed by episodes when there are exacerbations of symptoms (relapses). About 85 out of 100 people with MS have RRMS at onset. Around two-thirds of people who start with RRMS may develop secondary progressive MS: this occurs when there is a gradual accumulation of disability unrelated to relapses, which become less frequent or stop completely. Also about 10 to 15 out of 100 people with MS have primary progressive MS where symptoms gradually develop and worsen over time from the start, without ever experiencing relapses and remissions.
The cause of MS is unknown. It is believed that an abnormal immune response to environmental triggers in people who are genetically predisposed, results in immune-mediated acute, and then chronic, inflammation. The initial phase of inflammation is followed by a phase of progressive degeneration of the affected cells in the nervous system. MS is a potentially highly disabling disorder with considerable personal, social and economic consequences. People with MS live for many years after diagnosis with significant impact on their ability to work, as well as an adverse and often highly debilitating effect on their quality of life and that of their families.

Updates

Updates to this pathway

13 January 2016 Multiple sclerosis (NICE quality standard 108) added to this pathway.
15 December 2015 Link added to the NICE guideline on care of dying adults in the last days of life (NG31).
1 May 2015 Minor maintenance update.
20 March 2015 Minor maintenance update.
4 March 2015 Minor maintenance update.
29 October 2014 Minor maintenance update.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Multiple sclerosis (2014) NICE guideline CG186
Dimethyl fumarate for treating relapsing-remitting multiple sclerosis (2014) NICE technology appraisal guidance 320
Alemtuzumab for treating relapsing–remitting multiple sclerosis (2014) NICE technology appraisal guidance 312
Teriflunomide for treating relapsing–remitting multiple sclerosis (2014) NICE technology appraisal guidance 303
Multiple sclerosis (2016) NICE quality standard 108

Quality standards

Multiple sclerosis

These quality statements are taken from the multiple sclerosis quality standard. The quality standard defines clinical best practice for multiple sclerosis and should be read in full.

Quality statements

Support at diagnosis

This quality statement is taken from the multiple sclerosis quality standard. The quality standard defines clinical best practice in multiple sclerosis and should be read in full.

Quality statement

Adults with multiple sclerosis (MS) are given support at the time of diagnosis to understand the condition, its progression and the ways it can be managed, by the consultant neurologist making the diagnosis.

Rationale

Receiving a diagnosis of a long-term condition like MS is life changing and stressful. It is important that consultant neurologists offer information, advice and support at the time of diagnosis so that the person with MS has a sense of control over their own life, is more able to make decisions about how their condition is managed, and is less anxious.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with MS are supported at the time of diagnosis to understand the condition, its progression and the ways it can be managed, by the consultant neurologist making the diagnosis.
Data source: Local data collection.
Process
Proportion of adults with MS who are given information about MS, its progression and the ways it can be managed by the consultant neurologist at the time of diagnosis.
Numerator – The number in the denominator who are given information about the condition by the consultant neurologist at the time of diagnosis.
Denominator – The number of adults receiving a new diagnosis of MS from a consultant neurologist.
Data source: Local data collection.
Outcome
Patient satisfaction with the support provided at diagnosis.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (neurology services) ensure that systems are in place for adults with MS to be supported at the time of diagnosis to understand the condition, its progression and the ways it can be managed, by the consultant neurologist making the diagnosis.
Healthcare professionals (consultant neurologists) ensure that at the time of making the diagnosis, they support adults with MS to understand the condition, its progression and the ways it can be managed.
Commissioners (NHS England local area teams and clinical commissioning groups) ensure that they commission services that support adults with MS at the time of diagnosis to understand the condition, its progression and the ways it can be managed.

What the quality statement means for patients, service users and carers

Adults with MS are given support by the consultant when first told that they have MS. This early support helps people with MS (and their families and carers) to begin to understand what MS is, what treatments are available and how the symptoms can be managed.

Source guidance

Definitions of terms used in this quality statement

Support
This should include oral and written information about:
  • what MS is
  • treatments, including disease-modifying therapies
  • symptom management
  • how support groups, local services, social services and national charities are organised and how to get in touch with them
  • legal requirements such as notifying the Driver and Vehicle Licensing Agency (DVLA), and legal rights including social care, employment rights and benefits.
[Multiple sclerosis in adults: management (NICE guideline CG186) recommendation 1.2.2]

Equality and diversity considerations

Cognitive problems are a common symptom of MS. People can experience a wide range of difficulties, including problems with attention, memory and decision making, and planning. All information should be accessible to people with cognitive problems. People receiving information about MS should have access to an interpreter or advocate if needed.

Follow-up after diagnosis

This quality statement is taken from the multiple sclerosis quality standard. The quality standard defines clinical best practice in multiple sclerosis and should be read in full.

Quality statement

Adults with multiple sclerosis (MS) are offered a face to face follow up appointment with a healthcare professional with expertise in MS, to take place within 6 weeks of diagnosis.

Rationale

It can be difficult for people with MS to take in the information and advice they are given at the time of diagnosis. A follow-up appointment provides time for people with MS to adjust to their diagnosis. They can think about the information that they were given and any further information they want, and then can have any questions answered by a specialist. The appointment means that people with MS can meet healthcare professionals with expertise in MS, who may be involved in their future care, soon after diagnosis.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with MS have a face-to-face follow-up appointment with a healthcare professional with expertise in MS within 6 weeks of diagnosis.
Data source: Local data collection.
Process
Proportion of adults with MS who have a face-to-face follow-up appointment with a healthcare professional with expertise in MS within 6 weeks of diagnosis.
Numerator – The number in the denominator who have a face-to-face follow-up appointment with a healthcare professional with expertise in MS within 6 weeks of diagnosis.
Denominator – The number of adults receiving a new diagnosis of MS.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (neurology services) ensure that systems are in place for adults with MS to have a face-to-face follow-up appointment with a healthcare professional with expertise in MS within 6 weeks of diagnosis.
Healthcare professionals (consultant neurologists) ensure that they offer adults with MS a face-to-face follow-up appointment with themselves or another healthcare professional with expertise in MS, to take place within 6 weeks of diagnosis.
Commissioners (NHS England local area teams and clinical commissioning groups) ensure that they commission services in which adults with MS are offered a face-to-face follow-up appointment with a healthcare professional with expertise in MS, to take place within 6 weeks of diagnosis.

What the quality statement means for patients, service users and carers

Adults with MS are offered an appointment with a specialist to take place within 6 weeks of their diagnosis. This gives them time to read and think about the information they were given at the time of diagnosis and the opportunity to have any questions answered by a healthcare professional with experience in MS. They can also ask for more information and support if they need it. The appointment also gives them the opportunity to meet a healthcare professional who will be involved in their care and to find out how and when to contact them in the future.

Source guidance

Definitions of terms used in this quality statement

Healthcare professional with expertise in MS
The neurologist responsible for making the diagnosis of MS should ensure that a formal face-to-face follow-up within 6 weeks is provided by themselves or another healthcare professional with expertise in MS (such as an MS nurse), depending on the local service organisation.
[Adapted from Multiple sclerosis in adults: management (NICE full guideline CG186) section 6.6].

Equality and diversity considerations

Cognitive problems are a common symptom of MS. People can experience a wide range of difficulties, including problems with attention, memory and decision-making, and planning. This might mean that people with MS forget that they have an appointment, so they should be reminded about the appointment and contacted if they do not attend. 

Coordinated care

This quality statement is taken from the multiple sclerosis quality standard. The quality standard defines clinical best practice in multiple sclerosis and should be read in full.

Quality statement

Adults with multiple sclerosis (MS) have a single point of contact who coordinates access to care from a multidisciplinary team with expertise in MS.

Rationale

Adults with MS have different needs for information, advice and support, and this will change as their condition progresses. Support should be tailored to the individual person and responsive to changing needs, including relapses, acute deteriorating symptoms and progression. A single point of contact will ensure that adults with MS can access care and support from health and social care practitioners, which is relevant to their specific needs.

Quality measures

Structure
a) Evidence of local arrangements to provide adults with MS with a single point of contact who coordinates access to care from a multidisciplinary team with expertise in MS.
Data source: Local data collection.
b) Evidence of local arrangements for a multidisciplinary team with expertise in MS to care for adults with MS.
Data source: Local data collection.
Process
Proportion of adults with MS with a single point of contact who coordinates access to care from a multidisciplinary team with expertise in MS.
Numerator – The number in the denominator with a single point of contact who coordinates access to care from a multidisciplinary team with expertise in MS.
Denominator – The number of adults with MS.
Data source: Local data collection.
Outcome
a) Patient satisfaction with a single point of contact for coordination of access to care.
Data source: Local data collection.
b) Patient satisfaction with timeliness of access to care from the multidisciplinary team with expertise in MS.
Data source: Local data collection.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers (neurology services) ensure that adults with MS have a single point of contact who coordinates access to care from a multidisciplinary team with expertise in MS.
Health and social care practitioners (members of the multidisciplinary team) provide coordinated care for adults with MS through a single point of contact.
Commissioners (NHS England local area teams and clinical commissioning groups) ensure that, for adults with MS, they commission neurology services that have a single point of contact who coordinates access to care from a multidisciplinary team with expertise in MS.

What the quality statement means for patients, service users and carers

Adults with MS have someone they can contact to help them get the care they need from health and care services. They know when and how to contact this person. They can talk about any changes in their condition and any extra or different support they might need. Support should be available from a team with training and skills in managing MS.

Source guidance

Definitions of terms used in this quality statement

Multidisciplinary team with expertise in MS
The team should involve professionals who have expertise in managing MS, including consultant neurologists, MS nurses, physiotherapists and occupational therapists.
Other professionals should be involved, according to the needs of the individual adult with MS, such as rehabilitation physicians, speech and language therapists, psychologists, dietitians, GPs, social care and continence specialists. A multidisciplinary team approach should encompass all these perspectives as well as those of the person with MS and their family.
[Multiple sclerosis in adults: management (NICE guideline CG186) recommendation 1.3.1 and full guideline section 7.6]

Physical activity

This quality statement is taken from the multiple sclerosis quality standard. The quality standard defines clinical best practice in multiple sclerosis and should be read in full.

Quality statement

Adults with multiple sclerosis (MS) who have problems with mobility or fatigue are offered support to remain physically active.

Rationale

Remaining physically active can improve mobility and fatigue, which are common problems experienced by adults with MS. It can also help to reduce the secondary complications of inactivity, such as pressure sores, and help adults with MS to regain or maintain their strength.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with MS who have problems with mobility or fatigue are supported to remain physically active.
Data source: Local data collection.
Process
Proportion of adults with MS who are offered support to remain physically active.
Numerator – the number in the denominator who are offered support to remain physically active.
Denominator – the number of adults with MS who have problems with mobility or fatigue.
Data source: Local data collection.
Outcome
a) Adults with MS who have problems with mobility or fatigue feel supported by healthcare professionals to remain physically active.
Data source: Local data collection.
b) Levels of physical activity among adults with MS.
Data source: Local data collection

What the quality statement means for service providers, healthcare professionals, and commissioners

Service providers (GPs, community health teams and neurology services) ensure that adults with MS who have problems with mobility or fatigue are offered support to remain physically active. It may be useful to compile information about local exercise classes, groups and facilities, so that people can be given information about any that are suitable.
Healthcare professionals (members of the multidisciplinary team) ensure that they offer adults with MS who have problems with mobility or fatigue support to remain physically active.
Commissioners (NHS England local area teams and clinical commissioning groups) ensure that they commission services in which adults with MS who have problems with mobility or fatigue are offered support to remain physically active. The services commissioned should include provision of supervised exercise programmes for adults with MS who may benefit because of problems with mobility or fatigue.

What the quality statement means for patients, service users and carers

Adults with MS who have problems with movement or fatigue are helped to do some exercise because this can improve these symptoms. Healthcare professionals should explain what types of exercise are suitable, what activities are available and ask which the person prefers.

Source guidance

Definitions of terms used in this quality statement

Support to remain physically active
Healthcare professionals should discuss the potential benefits of exercise with adults with MS who have problems with mobility or fatigue. Programmes or courses of exercise therapy should be supported by a competent professional, such as a physiotherapist with expertise in MS, who can suggest the most suitable exercises and monitor the effects. Types of suitable physical activity may include the following:
  • aerobic, balance and stretching exercises, including yoga
  • a comprehensive programme of aerobic and moderate progressive resistance activity combined with cognitive behavioural techniques for fatigue in adults with MS with an Expanded Disability Status Scale score of greater than or equal to 4
  • supervised exercise programmes involving moderate progressive resistance training and aerobic exercise
  • exercise referral schemes.
People with MS should also be encouraged to keep exercising after programmes end for longer term benefits.
[Adapted from Multiple sclerosis in adults: management (NICE guideline CG186) recommendations 1.5.6, 1.5.8, 1.5.11, 1.5.13 and 1.5.14, full guideline sections 10.3.6 and 10.4.6 and expert opinion]

Managing relapses

This quality statement is taken from the multiple sclerosis quality standard. The quality standard defines clinical best practice in multiple sclerosis and should be read in full.

Quality statement

Adults with multiple sclerosis (MS) who have a relapse that would benefit from treatment are offered treatment as soon as possible and within 14 days of the onset of symptoms.

Rationale

Rapid treatment of relapse can improve recovery and long-term outcomes of people with MS and prevent unplanned hospital admissions. Local pathways for managing relapse can help to identify relapses early and improve response times. Recognition of relapses by the multidisciplinary team, based on effective assessment, is important because relapse frequency may influence which disease-modifying therapies are chosen and whether they need to be changed.

Quality measures

Structure
Evidence of local pathways to ensure that adults with MS who have a relapse that would benefit from treatment are offered treatment as soon as possible and within 14 days of the onset of symptoms.
Data source: Local data collection.
Process
a) Length of time between onset of symptoms of relapse and receiving treatment for adults with MS.
Data source: Local data collection.
b) Proportion of relapses in adults with MS that would benefit from treatment and are treated within 14 days of the onset of symptoms.
Numerator – The number in the denominator treated within 14 days of the onset of symptoms.
Denominator – The number of relapses in adults with MS that would benefit from treatment.
Data source: Local data collection.
Outcome
Unplanned hospital admissions for MS.
Data source: Hospital Episode Statistics, Admitted Patient Care, England – 2013–14, using ICD-10 code G35, from The Health and Social Care Information Centre.

What the quality statement means for service providers, health, public health and social care practitioners, and commissioners

Service providers (GPs, community health teams, and neurology services) ensure that local pathways for managing relapse are in place so that adults with MS who have a relapse that would benefit from treatment are offered treatment as soon as possible and within 14 days of the onset of symptoms.
Health and social care practitioners (those involved in the care of adults with MS) ensure that they are aware of local pathways for managing relapse so that adults with MS who have a relapse that would benefit from treatment are offered treatment as soon as possible and within 14 days of the onset of symptoms.
Commissioners (NHS England local area teams and clinical commissioning groups) ensure that they commission services that have local pathways for managing relapse for adults with MS so that treatment is offered, for relapses that would benefit, as soon as possible and within 14 days of the onset of symptoms.

What the quality statement means for patients, service users and carers

Adults with MS who have new symptoms or symptoms that suddenly get worse (a relapse) are offered treatment if this is likely to help. The treatment is offered as soon as possible and within 14 days of the symptoms starting. They can get the treatment through their single point of contact. Quicker treatment should help them get better sooner and may mean they don’t have to go to hospital.

Source guidance

Definitions of terms used in this quality statement

Relapse
A relapse should be diagnosed if the person develops new symptoms or their existing symptoms get worse and last for more than 24 hours in the absence of infection or any other cause after a stable period of at least 1 month. Relapses should be assessed and diagnosed by a healthcare professional with expertise in MS because not all relapses need treating with steroids.
[Multiple sclerosis in adults: management (NICE guideline CG186) recommendations 1.7.2 and 1.7.3]
Treatment for relapse
Treatment should be offered for relapses of MS that affect the person’s ability to perform their usual tasks. Adults with MS who have a relapse should be offered treatment with oral methylprednisolone 0.5 g daily for 5 days. Intravenous methylprednisolone should be considered if oral steroids have failed or are not tolerated or for people who need admitting to hospital for a severe relapse or monitoring of medical or psychological conditions. People should not be given a supply of steroids to self-administer at home for future relapses.
[Multiple sclerosis in adults: management (NICE guideline CG186) recommendations 1.7.5, 1.7.7, 1.7.8 and 1.7.10]

Comprehensive review

This quality statement is taken from the multiple sclerosis quality standard. The quality standard defines clinical best practice in multiple sclerosis and should be read in full.

Quality statement

Adults with multiple sclerosis (MS) are offered a comprehensive review at least once a year by healthcare professionals with expertise in MS.

Rationale

A comprehensive review for people with MS ensures that they have the opportunity to hear from healthcare professionals about any new treatments, to be kept informed of their options, and for any issues or changes that might need referral to different services or other healthcare professionals to be identified. A planned review will also pick up people who have not been in contact with services, whose condition is not being monitored and who are not receiving support. These people may have more unmet needs than those in regular contact.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with MS are offered a comprehensive review at least once a year by healthcare professionals with expertise in MS.
Data source: Local data collection.
Process
Proportion of adults with MS who have a comprehensive review by healthcare professionals with expertise in MS within 12 months of the previous review or diagnosis.
Numerator – The number in the denominator who have a comprehensive review by healthcare professionals with expertise in MS within 12 months of the previous review or diagnosis.
Denominator – The number of adults with MS.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (GPs, community health teams and neurology services) ensure that adults with MS are offered a comprehensive review at least once a year by healthcare professionals with expertise in MS.
Healthcare professionals (members of the multidisciplinary team with expertise in MS) ensure that they offer adults with MS a comprehensive review at least once a year.
Commissioners (NHS England local area teams and clinical commissioning groups) ensure that they commission services that offer adults with MS a comprehensive review at least once a year by healthcare professionals with expertise in MS.

What the quality statement means for patients, service users and carers

Adults with MS are offered an appointment at least once a year to discuss their condition with healthcare professionals with experience in MS. At this appointment they are asked about their symptoms, their medicines, their overall health and wellbeing, and how their condition affects their day-to-day life (family life, work and other activities). They can raise any problems and mention any extra support they need. A planned yearly appointment will also pick up people who have not been in contact with services over the past year but need some support.

Source guidance

Definitions of terms used in this quality statement

Comprehensive review
A comprehensive review involves reviewing all aspects of care for a person with MS. The review should be carried out by healthcare professionals with expertise in MS and its complications, be tailored to the needs of the person with MS, and assess the following:
  • MS symptoms
  • the course of the disease and number of relapses in the past year
  • general health, including mental health
  • social activity and participation
  • care and carers
  • palliative care, when needed.
Other health and social care practitioners with expertise in specific areas of the review should be involved if needed. It is likely that the emphasis in the review may change over time and that different healthcare professionals may carry out the review. Any issues identified during the comprehensive review should be referred to other members of the MS multidisciplinary team and to other appropriate teams so that they can be managed. People with MS should also be offered a medication review.
[Multiple sclerosis in adults: management (NICE guideline CG186) recommendations 1.6.1, 1.6.2, 1.6.3, 1.6.4 and 1.6.5, full guideline section 11.6 and expert opinion]

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Pathway information

Your responsibility

Guidelines

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this interactive flowchart is not mandatory and does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the interactive flowchart to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Supporting information

Glossary

A contracture is a shortening in the soft tissues (that is, tendons, muscles or ligaments) around a joint that limits the passive (and active) range of movement at that joint.
Expanded Disability Status Scale
Involuntary laughing and crying related to a frontal lobe lesion.
The subjective sensation of horizontal and/or vertical movement of the visual field that is unexplained by movement of the observer or environment.

Paths in this pathway

Pathway created: October 2014 Last updated: January 2016

© NICE 2017

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