NICE vs SIGN: Management of Multiple Sclerosis (2025)
This guide provides a comparative overview of the National Institute for Health and Care Excellence (NICE) NG220 and the Scottish Intercollegiate Guidelines Network (SIGN) 159 guidelines for the management of multiple sclerosis (MS). Both guidelines aim to standardise and improve care, but they differ in structure, emphasis, and specific recommendations. This comparison is intended to aid UK clinicians in understanding the nuances of each to inform their practice, whether they are operating under the NHS in England and Wales or in Scotland.
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Diagnosis and Initial Assessment
The core principles of diagnosis, relying on the McDonald criteria (2017) to demonstrate dissemination in time and space, are consistent across both guidelines. However, their approaches to the diagnostic pathway and team structure show notable differences.
NICE NG220
- Pathway Focus: Emphasises a rapid, streamlined diagnostic pathway. Recommends referral for suspected MS to a specialist neurology service within 2 weeks of presentation with symptoms suggestive of a central nervous system demyelinating event.
- Team Structure: Advocates for diagnosis and management by a multidisciplinary team (MDT) within a specialist neurology service. The MDT should include specialists like neurologists, MS nurses, physiotherapists, and occupational therapists.
- Baseline Assessment: Stresses comprehensive baseline assessment at diagnosis, including disability (e.g., EDSS), cognition, mood, and quality of life.
SIGN 159
- Pathway Focus: Also supports the use of McDonald criteria but places a stronger emphasis on the exclusion of alternative diagnoses. It provides more detailed discussion on mimickers of MS.
- Team Structure: Similarly recommends specialist neurological services but is less prescriptive about the specific 2-week wait target. It strongly endorses the role of the MS Specialist Nurse as a central point of contact and coordination.
- Baseline Assessment: Aligns with NICE on the importance of a holistic baseline assessment.
Key Difference: NICE is more directive on the timing of referral (2-week target), while SIGN provides greater detail on differential diagnosis. Both are aligned on the critical role of specialist services and MDT care.
Disease-Modifying Therapies (DMTs)
This is the area of most significant divergence, primarily driven by differences in the health technology appraisal processes in England/Wales (NICE) and Scotland (SMC).
NICE NG220
- Classification: Uses a categorisation of DMTs as "high-efficacy" or "medium-efficacy". This is a practical, clinically oriented grouping.
- Active Relapsing-Remitting MS (RRMS): Recommends offering a choice of DMTs from a list, including high-efficacy options (e.g., cladribine, natalizumab, ocrelizumab, ofatumumab, alemtuzumab) to people with active RRMS, defined by clinical or imaging features.
- Treatment Sequencing: Suggests that for individuals with highly active disease not responding to a medium-efficacy DMT, switching to a high-efficacy DMT should be considered.
- Primary Progressive MS (PPMS): Recommends ocrelizumab for adults with PPMS who meet specific criteria (e.g., EDSS score, disease duration).
SIGN 159
- Classification: Does not use the "high/medium-efficacy" binary. Instead, it presents DMTs with their individual profiles and evidence.
- Active Relapsing-Remitting MS (RRMS): Recommendations are more tailored to specific clinical scenarios. For example, it provides distinct recommendations for "highly active" and "rapidly evolving severe" MS, often aligning with specific licensing indications.
- Treatment Sequencing: Less explicit on sequencing, focusing more on initial treatment choice based on disease activity profile.
- Primary Progressive MS (PPMS): Also recommends ocrelizumab for eligible adults with PPMS, in line with NICE.
Key Difference: The most crucial practical difference lies in DMT availability and prioritisation. The specific DMTs recommended and their place in therapy can differ due to separate approval processes by NICE and the Scottish Medicines Consortium (SMC). Clinicians must consult local formularies based on their nation. NICE's "high-efficacy" framework is a clear clinical heuristic, while SIGN's approach is more granular.
Special Situations and Holistic Management
Both guidelines comprehensively cover non-pharmacological management and special populations.
Pregnancy and Family Planning
- NICE: Has a detailed section on pregnancy. Advises discussion of family planning at diagnosis and before DMT initiation. Provides specific guidance on stopping/continuing various DMTs before conception and during pregnancy/breastfeeding.
- SIGN: Similarly strong emphasis. Highlights the importance of shared decision-making and provides a useful table summarizing the safety profiles of DMTs in pregnancy.
- Alignment: Very high degree of alignment. Both stress the safety of interferon-beta and glatiramer acetate in pregnancy and the need to stop most other DMTs well in advance of conception.
Symptom Management
- Both guidelines cover spasticity, fatigue, bladder/bowel dysfunction, mobility, and cognitive issues extensively.
- SIGN includes specific recommendations for assessing and managing pain in MS, giving it more prominence than NICE.
- Both advocate for personalised, MDT-led approaches to symptom control.
Practical Clinical Flow and Monitoring
NICE Pathway
- Rapid Referral: GP refers to neurology within 2 weeks for suspected MS.
- Diagnosis & Baseline: MDT confirms diagnosis using McDonald criteria and performs holistic baseline assessment.
- DMT Discussion: Offer choice of appropriate DMTs (based on disease activity) to people with RRMS or active secondary progressive MS (SPMS).
- Monitoring: Annual review by neurologist and regular follow-up with MS nurse. MRI monitoring frequency based on DMT and clinical stability.
SIGN Pathway
- Specialist Referral: Referral to neurology for investigation.
- Diagnosis & Baseline: Confirm diagnosis, exclude mimics, holistic assessment. Emphasise MS nurse role.
- DMT Discussion: Discuss DMT options tailored to the individual's disease activity profile and preferences.
- Monitoring: Regular specialist and MS nurse review. Recommends annual MRI for the first 6 years of treatment to monitor for asymptomatic disease activity.
Practical Takeaway: The NICE pathway is more explicit about speed of initial access. SIGN places a stronger emphasis on the MS nurse and suggests a more standardised approach to early MRI monitoring.
Frequently Asked Questions (FAQs) for Clinicians
1. Which guideline should I follow if I practice in Scotland/Northern Ireland/England?
Answer: You should primarily follow the guideline relevant to your national health service. SIGN is the standard for Scotland. NICE is the standard for England and Wales. Northern Ireland typically adopts NICE guidelines. However, being familiar with both is beneficial for understanding different clinical perspectives and for when patients move between nations.
2. What is the single biggest difference in DMT recommendations?
Answer: The classification and first-line accessibility of high-efficacy DMTs. NICE formally recommends offering a choice including high-efficacy DMTs to a broader "active RRMS" population. SIGN's recommendations are more closely tied to specific licensed indications (e.g., "highly active"), which may be narrower. Always check your local health board's approved formulary.
3. How do the guidelines view the role of the MS Specialist Nurse?
Answer: Both guidelines consider the MS nurse as essential. SIGN gives the role particularly prominent emphasis as a key coordinator of care from diagnosis onwards.
4. Is there a difference in recommendations for progressive MS?
Answer: For PPMS, both recommend ocrelizumab for eligible patients. For non-active SPMS, both guidelines focus on symptomatic management and rehabilitation, as no DMTs are licensed for this stage without relapses. The evidence review is consistent.
5. How frequently should I perform routine MRI monitoring?
Answer: Neither guideline gives a rigid schedule, as it depends on the DMT and clinical course. However, SIGN suggests considering annual MRI for the first 6 years to detect subclinical activity, which is a more specific recommendation than NICE provides.
Source Links
- NICE NG220 (October 2022, last updated May 2024): Multiple sclerosis in adults: management | Guidance | NICE
- SIGN 159 (September 2024): Management of multiple sclerosis | SIGN
Summary for Clinicians: While NICE and SIGN share a common evidence base and core principles, key differences exist in the structure of DMT recommendations and practical pathways. NICE offers a streamlined, efficacy-based framework with a focus on rapid access. SIGN provides a detailed, nuanced approach with strong emphasis on differential diagnosis and the MS nurse role. The definitive choice of DMT will always be influenced by national and local commissioning decisions.