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Multiple Sclerosis (MS) Care Pathway

The Saskatchewan MS Care Pathway serves to clarify medical consensus, support best practice care, and measure care against best practice standards for all providers involved in care of patients with MS.

Introduction and MS Glossary

Terminology used in the MS Care Pathway reflects the MS Phenotype Group’s 2013 descriptions of the clinical spectrum of MS, as follows:

Defining the Clinical Course of Multiple Sclerosis - NCBI - NIH see here

  • Clinically isolated syndrome (CIS): early clinical presentation characteristic of inflammatory demyelination that could be MS, but has yet to fulfill criteria of dissemination in time. CIS coupled with brain lesions carries a high risk for eventual MS diagnosis.

  • Relapsing Remitting MS (RRMS): phenotype characterized by clearly defined, acute attacks with full or partial recovery (remissions) and no disease progression between attacks.

  • Primary Progressive MS (PPMS): phenotype characterized by steady progression of disease from the beginning with no remission

  • Secondary Progressive MS (SPMS): phenotype that initially is relapsing-remitting and becomes progressive

  • Disease activity: inflammatory or neurodegenerative processes as detected by clinical relapse or imaging

  • Progression: ongoing neurodegeneration independent of relapse in patients with progressive disease phenotypes (PPMS and SPMS)

  • Worsening: persistent accumulation of disability

  • EDSS: Expanded disability status scale

Continuum of Care Suspicion of MS

While diagnosis of MS is made by a neurologist, most patients consult with their primary care physician at the time when the first clinical manifestations of MS emerge. Neurologists suggest that primary care providers maintain a high index of suspicion of MS, especially in the presence of:

• Characteristic presentation of relapsing–remitting MS -- a gradual increase in symptom number and intensity over several days, followed by a stable period with partial or full resolution.

Referral to consultant neurologist

• Within 10 days

•Neurological manifestations such as optic neuritis, transverse myelitis, signs of brainstem inflammation (vertigo, double vision, dysarthria, ataxia) that precede or accompany physical symptoms.

Consultant neurologist orders diagnostic work-up MRI brain & CT spine

•Within 30 days

Diagnosis of MS

Diagnosis of MS is made by a neurologist according to 2017 MacDonald Criteria. . 2017 revisions reflect current evidence linking early diagnosis and treatment with better long term patient outcomes. The key requirement for a diagnosis of MS is evidence of damage to the central nervous system that is disseminated in time (DIT) and space (DIS). In the past the DIT requirement led to patients waiting for a second relapse or lesion before a diagnosis could be confirmed. Under the new criteria, a diagnosis can be made using clinical symptoms, broader sources of MRI evidence, and the presence of oligoclonal bands in the spinal fluid that show disease activity in the past. For full publication of the 2017 MacDonald Criteria, see here.

2018 MRI Protocol and Clinical Guidelines for MS, see here.

Diagnosis of multiple sclerosis: 2017 revisions of the McDonald criteria    see here.

Recommendations for ancillary testing? When MS diagnosis is not confirmed but is still suspected, a neurologist will follow the patient with imaging at regular intervals for five years or until a diagnosis is confirmed.

Coordination of Care for MS Patients

Through a lifetime of symptom management and worsening disability, an MS patient can expect to see multiple care providers, try multiple prescriptions and supports, and go through multiple transitions in care. Best practice for MS care encompasses a broad multidisciplinary approach. In this environment, best practice guidelines recommend that people with MS should be offered a single point of care to help with coordination and access.

The MS Care Pathway recommends that everyone diagnosed with MS in Saskatchewan is offered the opportunity to attend the Saskatoon MS Clinic as soon as possible after diagnosis. MS specialized neurologists at the MS clinic offer....

The neurologist, family doctor and MS nurse educator are encouraged to work closely on navigating patients to multidisciplinary resources for rehabilitation and symptom management.

Other tools for coordination of care?

Initial appointment consultant neurologist

• Immediately upon diagnosis

Follow-up appointment

• Within 6 weeks
• Consultant neurologist or Saskatoon MS Clinic

Baseline data collection

• Consultant neurologist
• MS surveillance system

Multiple Sclerosis Advisory Panel Recommendations - Publications

For more info, see here.

In this setting it is very important for all care providers to collect and share patient information through the MS Registry, which can inform decisions about MS care on both individual and population levels. Patients should also have comprehensive education about when and how to interact with their care team. Dialogue about changes in health status must be proactive and ongoing.

MS Treatment (Disease-modifying therapy - DMT)

There is strong evidence that current DMT for MS reduces the number and severity of relapses and slows down the worsening of disability, particularly if initiated early in the course of the disease.

The MS Pathway recommends following best practice guidelines from the American Academy of Neurology. Prescribing principles for selecting therapies are outlined by the Canadian MS Working Group on Treatment Optimization and ECTRIMS/EAN Guideline on the pharmacological treatment of people with multiple sclerosis

Practice guideline recommendations summary: Disease-modifying see here

Treatment Optimization in MS: Canadian MS. Working Group ... - NCBI   see here.

There is considerable variety in DMTs available. Evaluating patient readiness for DMT and preferences in terms of route of administration, lifestyle, efficacy, common adverse effects and tolerability may improve acceptance of and adherence to therapy. In Saskatchewan, a nurse educator is provided by the MS Drugs Program to assist with patient education and counselling. Valuable resources are also available from the MS Society.

ECTRIMS/EAN Guideline on the pharmacological treatment of people with multiple sclerosis see here.

Addressing co-morbid conditions such as depression before initiating DMT may improve decision making, adherence and outcomes.

• Clinicians should prescribe DMT to people with a single clinical demyelinating event and two or more brain lesions characteristic of MS who decide they want this therapy.
• Clinicians should offer DMTs to people with relapsing forms of MS with recent clinical relapses or MRI activity.
• Clinicians should offer ocrelizumab to people with PPMS who are likely to benefit from this therapy unless there are risks of treatment that outweigh the benefits.
• Clinicians should monitor for medication adherence, tolerability, safety, and effectiveness of the therapy
• Clinicians should discuss switching from one DMT to another in people with MS who have been using a DMT long enough for the treatment to take full effect and are adherent to their therapy when they experience one or more relapses, two or more unequivocally new MRI-detected lesions, or increased disability on examination, over a one-year period of using a DMT.

In Saskatchewan, disease-modifying therapies are reviewed and approved by the MS Drugs Advisory Panel for the MS Drugs Program, and are eligible for Exceptional Drug Status. The goal of these programs is to ensure that every MS patient in Saskatchewan has access to appropriate treatment without financial barrier. Coverage requires the prescribing physician and patient to submit an application to the MS Drugs Program for approval, followed by an application for Exceptional Drug Status to the Saskatchewan Drug Plan. EDS applications for MS drugs are normally approved on the day of submission. Applications must be renewed annually.

Patient education and shared decision-making

• MS nurse educator
• Family physician
• Consultant neurologist
• Community resources

Initiation of treatment

• Consultant neurologist or Saskatoon MS Clinic

Initiation of treatment

• Consultant neurologist or Saskatoon MS Clinic

Treatment baseline MRI

• 3-6 months after initiation of treatment


• 12 months or as per drug specifications see here.

Saskatchewan Formulary MS Drugs Program see here.

Guidelines for Symptom Management

People with MS are faced with various symptoms and disabilities that may arise unpredictably and suddenly. While the consulting neurologist should be kept informed of changes in symptoms, the management of symptoms generally takes place in the community.

Common symptoms experienced by people with MS are as follows. Treatment for MS symptoms may include medication, rehabilitation, and self-management techniques. Primary care providers should treat symptoms in line with recommendations for neurological disease where guidelines are available.

Order for symptoms?

Other tools for coordination of care?

NICE Guidelines for management of patients with MS recommend all people with MS have a comprehensive review of all aspects of their care at least once a year, involving professionals with expertise in MS as well as those providing day to day care. The comprehensive review should encompass:

  • disease progress/relapses,
  • symptoms and management,
  • general health (weight, healthy behaviours, exercise, access to routine health screening, contraception, care of chronic conditions),
  • social activity and participation (including family and social circumstances, driving and access to transport, employment, access to daily activities and leisure)
  • review of care (including personal care needs, social care needs, access to adaptations and equipment at home), and
  • medication review in line with regional policies.

Caregivers should be included as part of the person's care plan. Patients and caregivers should be made aware of resources to support them in their community.

In this setting it is very important for all care providers to collect and share patient information through the MS Registry, which can inform decisions about MS care on both individual and population levels. Patients should also have comprehensive education about when and how to interact with their care team. Dialogue about changes in health status must be proactive and ongoing.

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