Local MS DMT practice – Time from decision to treatment Mid Yorkshire Hospitals NHS Trust Dr Bindu Yoga
Aim • To assess if all the patients are appropriately selected and treated with disease modifying treatment (DMT) as per national guidelines. • To assess the time from decision to actual commencement of DMT at Pinderfields Hospital, MYHT
Introduction • Mid Yorkshire Hospitals NHS Trust is a treatment centre covering 530,000 population (Wakefield, Pontefract, Dewsbury, North Kirklees). • MS team is based at Pinderfields Hospital – One MS consultant – No consultant March 2018-end of November 2018 – 3 part time MS nurses and 1 part time MS co-ordinator • April 2019: 351 patients on DMT, 245 patients not on DMT Leeds visiting consultants covered for the period btw march to Nov 2018. they stopped few patients DMTs as they were SPMS or did not meet the criteria. Cardiac monitoring was not done for Gilenya hence patients got transferred to LGI for those needing this treatment.
Local treatment pathway Diagnosis in MS clinic by consultant, referral to nurses, monitoring Blueteq application and Eligibility for treatment, prescription, Home care/day counselling case Final drug MDT discussion choice (patient) for second line then screening drugs tests referral from wards, GPs, other neurologists
Selection and methodology • All the patients who started or due to start new DMT between October 2018- March 2019 at PGH were selected. • Total number of patients – 21 • Diagnosis of patients – all were RRMS and met the eligibility criteria for DMT. • Method – Retrospective review of the clinic letters and local data base maintained by the MS co-ordinator
DMT choice Number Teriflunamide, 1 Copaxone, 1 Plegridy, 2 Dimethyl Fumarate, 8 Fingolimod, 2 Alemtuzumab, 3 Ocrelizumab, 4 Dimethyl Fumarate Ocrelizumab Alemtuzumab Fingolimod Plegridy Copaxone Teriflunamide
DMT choice • 5 patients were DMT naïve • Among these 5: 2 were Tecfidera, 2 Alemtuzumab, 1 Ocrelizumab • Others were switching from Plegridy, Tysabri, Tecfidera, Copaxone, Teriflunamide. • Some of these patients had already tried Rebif, Avonex as well in the past. Alemtuzumab was prescribed prior to recent EMA alert and proposal to change indication.
Duration from decision to treatment prescription Tecfidera Teriflunamide Fingolimod Ocrelizumab Alemtuzumab Copaxone Plegridy 10 days 1 week 10 weeks 9 weeks 5 weeks 9 weeks 3 weeks 1 week 17 weeks 10 weeks x2 6 weeks x2 4 weeks 2 weeks 12 weeks 4 weeks x3 7 weeks 12 month
Results (Time from decision to prescription) • <4 weeks in 43% cases (9/21), • 4-8 weeks in 19% (4/21), • 8-12 weeks in 24% (5/21), • >12 weeks in 14% (3/21). • This does not include the exact date of commencement by patient who were prescribed first line injectable or oral drugs.
Any relapses while awaiting DMT • One definite SC relapse with MRI symptomatic lesion just after starting Tecfidera. There was no database record regarding the time of start of first line DMT after prescription. It is assumed that home care delivery provided the drug in 2 weeks time after prescription.
Reasons for delay in commencing DMT • No cardiac monitoring available for Fingolimod and delay was due to organising this. • All the first line drugs are prescribed and we assume this takes approximately 2 weeks for the home care delivery to take over. • The time patient received and commenced drugs is unknown. • Some delay due to day case unit appointment and availability of staff for infusion treatment. • Screening bloods missed by phlebotomy and cervical smear processing delay in one case. • One of the patients did not engage with service so took 12 months to initiate the treatment.
Conclusions • Guidelines suggests to start DMT as soon as possible. • No national standard for treatment commencement time due to variability in service provision due different set up and vice versa. • The existing data does not specify the date of order and date of delivery/receipt by patient • There is no information about patient decision delay after offering the options. • One relapse out of 21 patients. • Should there be standard time duration to commence treatment which can drive uniformity and prevent delays? For discussion • National audit regarding this might be help understand the variability and standardise the treatment pathways.
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