Secondary MS in general practice

Multiple sclerosis (MS), one of the most common diseases of the central nervous system, is on the rise in Australia, with an estimated 25,600 Australians living with the disease and an average of more than 10 people diagnosed every week.
 
GPs are often key in identifying and managing this debilitating disease, according to Director of Neurology at Austin Health in Victoria, Associate Professor Richard McDonnell.
 
‘[GPs have] an important role in identifying initial symptoms and sending the patient to a neurologist when needed, and helping monitor the patient and dealing with, not only the physical, but the psychosocial issues that come up in suffering a chronic neurological disease,’ he told newsGP.
 
Most patients present with a form of the disease known as relapsing-remitting.
 
‘They’ll come in with an attack, the symptoms have started over the last week or two. Then they’ll improve, go a variable time then have another attack,’ Professor McDonnell explained.
 
‘But after a length of time, generally about a decade, the patient’s disability just gradually worsens in six months by six months.’
 
However, a majority of patients – it is estimated up to 80% – will go on to develop a further form of the disease, secondary progressive multiple sclerosis (SPMS).
 
‘A person with secondary progressive MS will develop worsening neurological function over time, at least over six to 12 months, without any signs this is a relapse or that there’s any inflammation on their brain scan,’ Associate Professor Anneke van Der Walt, Neurologist and Principal Research Fellow at the Central Clinical School, Monash University, told newsGP.
 
There are signs GPs can look out for in patients with MS to indicate such a progression might be occurring.
 
‘Ask the patient with MS if there are any subtle changes in how far they can walk, whether they’re starting to need more mobility aids, whether they’re still feeling confident using public transport, whether they’ve had any memory or work-related problems, or bladder and bowel problems are becoming more prominent,’ Associate Professor van Der Walt said.
 
‘All of these things are red flags to suggest that something could be going on, in which case the best thing to do is to make sure that person is reviewed by their neurologist.’
 
Up until now, there have been no treatments available in Australia for this secondary form of MS – and patients who develop it are often recommended to cease their previous medications.
 
‘When patients develop signs their disease is continuing to progress, their clinician or neurologist seriously has to consider whether their medication is still useful, and in many cases it is ceased, leaving them without any treatment,’ Associate Professor van Der Walt said.
 
However, this situation may change for some patients, with the Therapeutic Goods Administration’s (TGA) approval of a drug called siponimod (brand name Mayzent) at the end of last year.
 
The medication, which is taken in a powdered form, can slow the progression of secondary progressive MS and prevent some deterioration of neurological function.
 
‘This treatment has the potential to address some unmet needs people with MS might have,’ Associate Professer van Der Walt said.
 
‘There are many people in the community living with MS who are either on no treatment, or their treatment has been stopped. This offers them a different opportunity that may actually prevent further neurological decline.’
 
But Associate Professor McDonnell is careful to emphasise that as helpful as the drug can be, it is not a cure-all.
 
‘If you look at the trial [of siponmod], yes, the patient did better on the drug compared to placebo, or did worse on it less quickly, if that makes sense,’ he said.
 
‘So both patients unfortunately, did clearly worsen, but the ones on siponomod had a rate of decline about 30% less than the patients on placebo. That translates into a slower worsening of things like mobility, which is obviously important in delaying the transition to wheelchairs, and it also delays the need for nursing home care.
 
‘So it’s not a game changer, but it certainly offers a modest benefit … it’s the only drug to date that’s been shown to slow down the natural history of what’s a pretty nasty disease.’
 
However, siponimod is also expensive – costing potentially in the tens of thousands of dollars for a year’s supply. And while the drug has been approved by the TGA, it has not been recommended for listing on the PBS.
 
‘There’s no doubt [siponimod] met its primary end point, and so that’s why the TGA approved it. But it's then that cost-benefit issue,’ Professor McDonnell said.
 
‘We’d like to be able to use it, absolutely, it certainly would be a benefit, but we’ve also got to be realistic in what we’re expecting to get out of it.’
 
In the meantime, treatment for secondary progression MS revolves around symptomatic treatment, for which Professor McDonnell recommends a team model of care, coordinated by a GP.
 
‘We try to get patients on advanced care plans, which is run for the GP to facilitate access to physio and psychology and other healthcare services,’ he said.
 
‘Sometimes patients can see a GP more easily than getting in to see the neurologist, and GPs helping with pain management, urinary tract infections and other symptoms is very useful.’
 
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MS Multiple sclerosis Neurological disease Secondary progressive multiple sclerosis SPMS