NICE guideline
The full guideline, from which the NICE guideline is derived, is
produced by the National Collaborating Centre for Chronic Conditions
and will be available in January 2004 from the NCC CC website at
www.rcplondon.ac.uk or from the NICE website |
New guidelines for the management of multiple sclerosis (MS) in primary
and secondary care in England and Wales were published this week by the
National Institute for Clinical Excellence and the National Collaborating
Centre for Chronic Conditions. In addition to the recommendations identified
as priorities for implementation (see Panel),
the guideline makes recommendations about the diagnosis and treatment
of specific impairments that are likely to affect a patient with MS,
such as fatigue, bladder and bowel problems, spasticity and pain. Although
there is no specific role for pharmacists outlined in the guidance, there
are opportunities for pharmacists to support MS patients.
Priorities for NICE guideline implementation
• Specialised services Specialised rehabilitation services should
be available to every person with MS when they develop a new symptom
or other problem.
• Rapid diagnosis Patients should be referred to a specialist neurology
service and seen soon after all investigations to confirm or refute
the diagnosis.
• Protocols Each local health area should publish protocols for
the sharing and transferring of responsibility for, and information
about, people with MS.
• Responsive service Services should respond to the unique needs
of each person with MS and actively involve them in all decisions.
• Sensitivity Health service professionals should consider any “hidden” problem
contributing to a patient’s situation, such as depression
or impaired sexual function.
• Self-referral Individuals should be aware of how to make contact
with the neurological service after regular treatment has ceased,
and when such contact is appropriate. |
Disease modifying drugs such as interferon beta are usually delivered
directly to the patient’s home, so it is patients admitted to hospital
with a relapse with whom pharmacists most often have contact. In addition
to treatment with high-dose steroids, management of other symptoms associated
with the condition are assessed, and the pharmacist is able to carry
out a pharmaceutical check on these drugs as with any other inpatient.
However, there is scope for more pharmacist involvement than this. Charles
Tugwell, neurosciences directorate pharmacist at the Royal London Hospital,
is involved in the care of MS patients from the time of diagnosis in
the outpatient department. In addition to taking a drug history and performing
a pharmaceutical assessment, Mr Tugwell discusses the different treatment
options with each patient. He explains the delivery system by which the
patient will get their medicine and ensures that the administration technique
taught by the MS nurse is understood.
Mr Tugwell then acts as a point of contact with whom patients can discuss
any problems they may be having and be referred as appropriate. For example,
if there is an administration technique problem Mr Tugwell refers the
patient to the MS nurse, or if the problem is medical and he is unable
to resolve it, he would refer the patient to a neurologist.
Mr Tugwell believes more pharmacists should get involved in services
like this. He says: “Pharmacists must take opportunities that come
their way and should always be on the lookout for areas where their pharmaceutical
expertise can be usefully developed to improve clinical management of
patients.” He explains that his pharmacy department took the lead
in liaising with primary care trusts and strategic health authorities
to secure the funding required to support the provision of MS services
and the use of disease modifying drugs. “I corresponded with key
pharmaceutical companies long before beta interferon was licensed for
MS to plan from a clinical, as well as financial, perspective,” he
adds.
Patrick O’Sullivan, neurosiences directorate pharmacist at Charing
Cross Hospital, London, says that in his experience many MS patients
are motivated to find out more about their condition. The pharmacist’s
role in answering any questions a patient may have should not be overlooked.
Mr O’Sullivan says: “Some people stop taking interferon as
a result of side effects, such as ’flu-like symptoms. Advice on
how to manage these symptoms might encourage them to continue the treatment
which might prevent them from relapsing.”
Mr O’Sullivan says that many patients also ask him about alternative
remedies. The new guideline states that people with MS should be informed
that there is some evidence that complementary therapies such as fish
oils, reflexology and massage and magnetic field therapy might be of
benefit. Mr O’Sullivan adds: “Pharmacists can give practical
advice about being sceptical about some claims made on the internet,
for example. It is not appropriate to discourage patients from trying
therapies from which they may get benefit, but they may need advice on
what is really appropriate. I advise patients to seek advice from MS
charities rather than from less reputable sources.”
Claire Reed, lead pharmacist in neurosciences at Queens Medical Centre,
Nottingham, says that pharmacists have knowledge of medicines that are
not necessarily in the BNF, with which junior medical staff may not be
familiar. “Pharmacists tend to be the first port of call for these
questions,” she says.
The community pharmacist also has a role to play. Mr O’Sullivan
points out that prescribing for symptom management will usually be through
the patient’s general practitioner. “The community pharmacist
is in a position to form relationships with these patients and advise
them on the management of symptoms, or refer them back when appropriate.” He
also notes that MS patients may well end up with disabilities, which
may cause problems with opening medicine bottles, for example. On the
other hand, a carer may collect a prescription for an immobile patient
and they may be equally in need of advice or support.
David Pruce, director of practice and quality improvement, Royal Pharmaceutical
Society, was a member of the MS guideline development group. He says: “On
average, each community pharmacy will have five people with MS using
its services. For this reason alone, it is worth reading the guidance.” |
