MS Summary

MS Types

  • RRMS: Relapsing-remitting (85%)
  • SPMS: Secondary progressive
  • PPMS: Primary progressive (10-15%)
  • PRMS: Progressive relapsing (rare)

Diagnosis

  • McDonald Criteria 2017
  • MRI brain & spinal cord
  • Lumbar puncture (CSF)
  • Evoked potentials
  • DISS in space & time

DMTs UK

  • NICE-approved therapies
  • First-line: Interferons
  • Second-line: Natalizumab
  • High-efficacy: Ocrelizumab
  • Oral options available

UK Services

  • MS Specialist Nurses
  • Neuro-rehabilitation
  • MS Society support
  • NHS England pathways

Red Flags

  • Optic neuritis
  • Lhermitte's sign
  • Uhthoff's phenomenon
  • Acute relapse symptoms

Multiple Sclerosis (MS)

Comprehensive guide to diagnosis, management and UK healthcare programmes

Introduction

Multiple sclerosis is a chronic autoimmune, inflammatory neurological disease of the central nervous system (CNS) that affects approximately 130,000 people in the UK. MS is characterized by demyelination and axonal loss typically occurring in relapses followed by remissions, eventually leading to progressive neurological decline.

Epidemiology in UK

  • Prevalence: ~190 per 100,000 population
  • Incidence: ~7 per 100,000 per year
  • Female:Male ratio ≈ 3:1
  • Average age of onset: 30 years
  • Most common cause of non-traumatic disability in young adults

Types of Multiple Sclerosis

Relapsing-Remitting MS (RRMS)

85% of initial diagnoses

  • Clear relapses with full/partial recovery
  • Stable between relapses
  • Most convert to SPMS over time
  • Average 1-2 relapses per year

Secondary Progressive MS (SPMS)

Follows initial RRMS course

  • Gradual worsening with/without relapses
  • Progressive disability accumulation
  • ~65% of RRMS convert within 20 years
  • Reduced inflammatory activity

Primary Progressive MS (PPMS)

10-15% of diagnoses

  • Progressive from onset
  • No clear relapses/remissions
  • Older age at onset (~40 years)
  • Equal gender distribution

Clinical Features & Symptoms

Visual
Optic neuritis, diplopia, nystagmus

Motor
Weakness, spasticity, ataxia

Sensory
Numbness, paraesthesia, Lhermitte's

Bladder/Bowel
Urgency, retention, constipation

Cognitive
Memory, attention, processing speed

Fatigue
Overwhelming tiredness, heat sensitivity

Red Flag Symptoms Requiring Urgent Assessment

  • Acute visual loss (optic neuritis)
  • Severe ataxia or motor weakness
  • Acute bladder/bowel dysfunction
  • Significant cognitive changes
  • Brainstem symptoms (dysphagia, dysarthria)

Diagnosis - McDonald Criteria 2017

Key Diagnostic Principles

  • Dissemination in Space (DIS): Lesions in ≥2 CNS areas
  • Dissemination in Time (DIT): New lesions over time
  • No better explanation for clinical/MRI findings

Investigations in UK Practice

MRI Brain & Spinal Cord

  • Periventricular white matter lesions
  • Juxtacortical lesions
  • Infratentorial lesions
  • Spinal cord lesions (≥3mm)
  • Gadolinium enhancement (active lesions)

Lumbar Puncture & CSF

  • Oligoclonal bands (OCBs)
  • Increased IgG index
  • Mild lymphocytic pleocytosis
  • Normal glucose/protein

Evoked Potentials

  • Visual evoked potentials (VEP)
  • Somatosensory evoked potentials (SSEP)
  • Brainstem auditory evoked potentials (BAEP)

UK Treatment Pathways & DMTs

NICE Guidelines (NG220) 2022: All people with active relapsing-remitting MS should be offered disease-modifying therapy (DMT) as soon as possible after diagnosis.

First-line DMTs (NICE Approved)

Medication Type Administration Monitoring
Interferon beta Immunomodulator SC/IM injection LFTs, FBC, thyroid
Glatiramer acetate Immunomodulator SC injection None specific
Teriflunomide Oral DMT Oral daily LFTs, BP, FBC
Dimethyl fumarate Oral DMT Oral twice daily Lymphocyte count

Second-line/High-efficacy DMTs

Medication Indication Administration Key Monitoring
Natalizumab Highly active RRMS IV infusion monthly JCV antibody, MRI
Ocrelizumab Active RRMS & early PPMS IV infusion 6-monthly Immunoglobulins, infections
Cladribine Highly active RRMS Oral yearly cycles Lymphocyte count
Alemtuzumab Highly active RRMS IV infusion yearly Autoimmunity, infections

UK MS Services & Support Programmes

MS Specialist Nurses

Available in most NHS trusts for ongoing support, education, and coordination of care.

  • Relapse management
  • DMT education & monitoring
  • Symptom management
  • Care coordination

Neuro-rehabilitation

Multidisciplinary team approach to maintain function and independence.

  • Physiotherapy
  • Occupational therapy
  • Speech & language therapy
  • Neuropsychology

MS Society UK

Leading charity providing comprehensive support services nationwide.

  • Helpline: 0808 800 8000
  • Local groups & activities
  • Information resources
  • Research funding

Digital Health Services

NHS digital platforms for MS management and support.

  • MS Trust online resources
  • NHS MS decision aids
  • Telemedicine consultations
  • Remote monitoring

Symptom Management in UK Practice

Fatigue Management

  • Energy conservation techniques
  • Amantadine (unlicensed)
  • Modafinil (unlicensed)
  • Occupational therapy input
  • Cooling strategies

Spasticity

  • Baclofen (oral/intrathecal)
  • Gabapentin/Pregabalin
  • Tizanidine
  • Botulinum toxin injections
  • Physiotherapy

Bladder/Bowel

  • Anticholinergics (oxybutynin)
  • Intermittent self-catheterisation
  • Bowel management programme
  • Urology/continence referral

Pregnancy & Family Planning

UK Recommendations

  • MS does not affect fertility
  • Relapse rate decreases during pregnancy
  • Increased relapse risk postpartum (20-30%)
  • Most DMTs contraindicated in pregnancy
  • Specialist pre-conception counselling essential

DMTs in Pregnancy

  • Stop before conception: Teriflunomide, fingolimod
  • Stop during pregnancy: Most DMTs
  • May continue: Interferon-beta, glatiramer acetate
  • Postpartum: Early DMT restart recommended

Prognosis & Monitoring

Positive Prognostic Factors

  • Female gender
  • Younger age at onset
  • Relapsing-remitting course
  • Full recovery from initial relapses
  • Long interval between first and second relapse
  • Sensory or optic neuritis onset