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Telephone consultations are not used routinely for newly-presenting patients with possible epilepsy (as opposed to review patients). We used the telephone for ‘first seizure’ referrals during the Covid pandemic, as part of a neurology advanced referral management system (NARMS), and report our findings below.MethodsGP ‘first seizure’ referrals were managed by telephone by a consultant neurologist (VP) between May and November 2020. The outcome of these patients was determined by review of their electronic care record in January 2023, recording death, diagnosis change, and management change.ResultsFifty-seven patients were dealt with by either advice (5), or telephone (52). Thirteen of the telephone patients (25%) were discharged with the remaining 39 scheduled for review. Of these, seven did not attend (DNA rate 18%), diagnosis was changed in two (5%) and management in four (10%). There were no deaths.DiscussionThe changes in diagnosis and management are almost certainly within the range of conven- tional (face-to-face) practice, so telephone consultation for ‘first seizure’ seems safe. It has advantages over conventional practice – lower DNA rate, easier for patients, less expensive for the health service, and better for the environment. It should be used more widely.

Multiple Sclerosis is more common in women than men and females have more relapses than men. In a large international cohort we have evaluated the effect of gender on disability accumulation and disease progression to determine if male MS patients have a worse clinical outcome than females. Using the MSBase Registry, data from 15,826 MS patients from 25 countries was analysed. Changes in the severity of MS (EDSS) were compared between sexes using a repeated measures analysis in generalised linear mixed models. Kaplan-Meier analysis was used to test for sex difference in the time to reach EDSS milestones 3 and 6 and the secondary progressive MS. In relapse onset MS patients (n = 14,453), males progressed significantly faster in their EDSS than females (0.133 vs 0.112 per year, P<0.001,). Females had a reduced risk of secondary progressive MS (HR (95% CI) = 0.77 (0.67 to 0.90) P = 0.001). In primary progressive MS (n = 1,373), there was a significant increase in EDSS over time in males and females (P<0.001) but there was no significant sex effect on the annualized rate of EDSS change. Among registrants of MSBase, male relapse-onset patients accumulate disability faster than female patients. In contrast, the rate of disability accumulation between male and female patients with primary progressive MS is similar.

BackgroundDespite a population of just 1.9 million, healthcare in N Ireland (NI) is delivered across 5 Trusts (HSCTs). The distribution of neurologists generally and MS neurologists in particular across HSCTs is uneven, prompting real concerns about fair access to MS disease modifying therapies (DMTs).MethodsDemographic data was obtained from the monthly MS DMT Panel Meeting, operational in Belfast since January 2019. Incorporating >1000 case discussions, there is routine recording of HSCT of residence irrespective of HSCT attended for care. HSCT population sizes were established and the proportions of patients discussed from each HSCT calculated.ResultsThe proportion of NI population resident in each HSCT is Northern (25.3%), Southern (20.5%), South Eastern (19.2%), Belfast (19.0%), Western (16.0%). Between January 2019 – September 2022, there were 1001 case discussions – Northern residents (26.7%), Southern (17.5%), South Eastern (19.4%), Belfast (18.4%), Western (18.1%).ConclusionsAlthough two HSCTs have no resident neurologist with specialist interest in MS (Western, Northern) and numbers vary in others (Belfast 3, Southern 2, South Eastern 1), there is no evidence of dis- advantage by HSCT of residence regarding accessing DMTs. Ongoing vigilance is required, with robust data collection by DMT panels providing important oversight in delivering equitable services.

BackgroundTHC:CBD Nabiximols (Sativex®) oromucosal spray is used to treat moderate to severe spasticity in adults with multiple sclerosis as per NICE guidance if other pharmacological treatments e.g. baclofen, gabapentin, clonazepam, tizanidine are ineffective. Treatment is continued if there is a 20% reduction in spasticity related symptoms after 4 weeks.MethodsIn Northern Ireland, all cases for consideration of THC:CBD Nabiximols (Sativex®) have been discussed at a regional treatment panel since May 2020. The case outcomes were reviewed in January 2023.ResultsThirty-eight patients were discussed at the meeting in this timeframe; 31 patients were approved. The 7 cases were declined due to diagnosis other than MS (2), clinic review suggested (2), other treatment suggested (2) and previous trial (1).To date, 20 patients have been trialled on THC:CBD Nabiximols (Sativex®). 18 patients had a positive response and treatment continued, a negative response was reported in 2 cases. Side effects were reported in 7 cases; initial dizziness (4), fatigue (1), irritation under the tongue (1) or slight nausea (1). Three patients were able to reduce other spasticity medications.DiscussionTHC: CBD Nabiximols (Sativex®) is a well tolerated, effective treatment for spasticity when other treatments have failed.

BackgroundDisease modifying therapies (DMTs) for MS are increasing in number, efficacy and complex- ity. To facilitate a reflective approach, patient care and safety, a DMT Panel was established in Belfast in January 2019 for the NI region. It remains the only such Panel on the island of Ireland.MethodsThe Panel meets monthly and requires a quorum of three MS Neurologists and a Neuroradiolo- gist, with MS Pharmacist, MS Co-ordinator and MS Nursing representation. Imaging is reviewed together with relevant history. Applications for ocrelizumab, natalizumab, alemtuzumab, ofatumumab, cladribine, siponimod and fingolimod are considered. Consensus outcomes are recorded with reference to NICE, ABN and local guidelines.ResultsBy September 2022, there were 1001 case discussions derived from eight neurologists with spe- cialist interest in MS (including locums and now retired) with 59.7% of applications drawn from two of these. Meetings continued throughout the pandemic. Following discussion, 102 applications (10.2%) were initially entirely declined or withdrawn. Downstream variation in timing of treatment following approval was identified.ConclusionsGiven issues of MS misdiagnosis and MRI interpretation in an era of DMT opportunity and risk, the DMT Panel has brought collegiality and transparency to treatment decisions, assurance for commis- sioners, and simplified pathways to higher efficacy treatment.

Background: Several studies have shown that pregnancy reduces multiple sclerosis (MS) relapses, which increase in the early postpartum period. Postpartum relapse risk has been predicted by pre-pregnancy disease activity in some studies. Objective: To re-examine effect of pregnancy on relapses using the large international MSBase Registry, examining predictors of early postpartum relapse. Methods: An observational case–control study was performed including pregnancies post-MS onset. Annualised relapse rate (ARR) and median Expanded Disability Status Scale (EDSS) scores were compared for the 24 months pre-conception, pregnancy and 24 months postpartum periods. Clustered logistic regression was used to investigate predictors of early postpartum relapses. Results: The study included 893 pregnancies in 674 females with MS. ARR (standard error) pre-pregnancy was 0.32 (0.02), which fell to 0.13 (0.03) in the third trimester and rose to 0.61 (0.06) in the first three months postpartum. Median EDSS remained unchanged. Pre-conception ARR and disease-modifying treatment (DMT) predicted early postpartum relapse in a multivariable model. Conclusion: Results confirm a favourable effect on relapses as pregnancy proceeds, and an early postpartum peak. Pre-conception DMT exposure and low ARR were independently protective against postpartum relapse. This novel finding could provide clinicians with a strategy to minimise postpartum relapse risk in women with MS planning pregnancy.

Background and purpose Treatment persistence is the continuation of therapy over time. It reflects a combination of treatment efficacy and tolerability. We aimed to describe real‐world rates of persistence on disease‐modifying therapies (DMTs) for people with multiple sclerosis (pwMS) and reasons for DMT discontinuation. Methods Treatment data on 4366 consecutive people with relapse‐onset multiple sclerosis (MS) were pooled from 13 UK specialist centres during 2021. Inclusion criteria were exposure to at least one MS DMT and a complete history of DMT prescribing. PwMS in blinded clinical trials were excluded. Data collected included sex, age at MS onset, age at DMT initiation, DMT treatment dates, and reasons for stopping or switching DMT. For pwMS who had received immune reconstituting therapies (cladribine/alemtuzumab), discontinuation date was defined as starting an alternative DMT. Kaplan–Meier survival analyses were used to express DMT persistence. Results In 6997 treatment events (1.6 per person with MS), median time spent on any single maintenance DMT was 4.3 years (95% confidence interval = 4.1–4.5 years). The commonest overall reasons for DMT discontinuation were adverse events (35.0%) and lack of efficacy (30.3%). After 10 years, 20% of people treated with alemtuzumab had received another subsequent DMT, compared to 82% of people treated with interferon or glatiramer acetate. Conclusions Immune reconstituting DMTs may have the highest potential to offer a single treatment for relapsing MS. Comparative data on DMT persistence and reasons for discontinuation are valuable to inform treatment decisions and in personalizing treatment in MS.

Background: Family planning and pregnancy decisions are key considerations in the management of women with multiple sclerosis (MS), who are typically diagnosed between the ages of 20–40 years. Despite a strong evidence base that pregnancy is not harmful for women with MS, many knowledge gaps remain. These include: best management strategies through pregnancy in the era of highly effective disease-modifying therapies (DMT); foetal risks associated with DMT exposure in utero or in relation to breastfeeding; knowledge base around the use of assisted reproductive technologies; the long-term impact of pregnancy on disease outcomes, as well as the impact of long-term DMT use on women’s health and cancer risk. Methods: Here, we describe the new MSBase pregnancy, neonatal outcomes and women’s health registry. We provide the rationale for, and detailed description of, the variables collected within the registry, together with data acquisition details. Conclusion: The present paper will act as a reference document for future studies.

Background The use of non-specific immunosuppressants (NSIS) to treat multiple sclerosis (MS) remains prevalent in certain geographies despite safety concerns, likely due to resource limitations. Objective To use MSBase registry data to compare real-world outcomes in adults with relapsing-remitting MS (RRMS) treated with dimethyl fumarate (DMF) or NSIS (azathioprine, cyclosporine, cyclophosphamide, methotrexate, mitoxantrone or mycophenolate mofetil) between January 1, 2014 and April 1, 2022. Methods Treatment outcomes were compared using inverse probability of treatment weighting (IPTW) Cox regression. Outcomes were annualized relapse rates (ARRs), time to discontinuation, time to first relapse (TTFR) and time to 24-week confirmed disability progression (CDP) or 24-week confirmed disability improvement (CDI; in patients with baseline Expanded Disability Status Scale [EDSS] score ≥2). Results After IPTW, ARR was similar for DMF (0.13) and NSIS (0.16; p = 0.29). There was no difference in TTFR between cohorts (hazard ratio [HR]: 0.98; p = 0.84). The DMF cohort experienced longer times to discontinuation (HR: 0.75; p = 0.001) and CDP (HR: 0.53; p = 0.001), and shorter time to CDI (HR: 1.99; p < 0.008), versus the NSIS cohort. Conclusion This analysis supports the use of DMF to treat patients with relapsing forms of MS, and may have implications for MS practices in countries where NSIS are commonly used to treat RRMS.