Harley Street at University College Hospital Leaders in clinical excellence, research & pioneering technology

A guide to an autologous stem cell transplant for Multiple Sclerosis

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Ms Kim Roberts General Manager Harley Street at University College Hospital 235 Euston Road London NW1 2BU Tel 020 3447 1500 Ms Sarah Fisher Chief Executive Officer HCA NHS Ventures 10A Shropshire House Capper Street London WC1E 6JA Tel 020 7034 8680

Other useful contacts HCA International Corporate Head Office: Mr. Michael Neeb, President & CEO 242 Marylebone Road London NW1 6JL Outpatients and day cases reception – The UCH Macmillan Cancer Centre - 020 3447 1700 (8am – 8pm) Inpatients reception – T15 020 3447 1500 (8am – 8pm) Inpatients – haematology ward - 020 3447 1595 (24 hours) Inpatients – oncology ward - 020 3447 1597 (24 hours) Business office - 020 3447 1510 (8am – 6pm) University College Hospital NHS Foundation Trust - 020 3456 7890

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A guide to an autologous stem cell transplant for Multiple Sclerosis

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Contents Section 1: Introduction  5 Section 2: Our staff 6 8 Section 3: What are bone marrow and stem cells? Section 4: Why do I need a stem cell transplant? 9 Section 5: What is involved in a stem cell collection? 10 Section 6: Tests needed before the stem cell collection and transplant 14 Section 7: Consenting to your treatment 16 Section 8: Will I need a Peripherally Inserted Central Catheter (PICC) line for my transplant?17 Section 9: The stem cell transplant 18 Section 10: Side effects of the transplant 20 Section 11: A typical day during your transplant 28 Section 12: Information about your stay at Harley Street at University College Hosptial 29 Section 13: Complementary and support services 32 Section 14: Can I do anything to help my transplant? 34 Section 15: Going home after your transplant 36 Section 16: Glossary  39 Section 17: Useful organisations 41 42 Section 18: Contact details Section 19: How to find us 43

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A guide to having an allogeneic bone marrow or stem cell transplant

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Section 1: Introduction Welcome to the Haematology and Bone Marrow Transplantation Service at Harley Street at University College Hospital. Our service provides treatment and support for individuals with various haematological diseases. The information in this booklet is designed to provide information about stem cell transplants and introduce you to our stem cell transplantation service and facilities. It also discusses the care you will receive during your stay in hospital. The HSCT (haematopoietic stem cell transplantation) service at Harley Street at University College Hospital provides a full range of transplantation services. The unit was the first private facility to attain JACIE accreditation in the United Kingdom. Our services are delivered at the following locations: Harley Street at University College Hospital, T15, University College London Hospital, 235 Euston Road, London NW1 2BU •

A 31 bed inpatient ward on the 15th floor of the UCH tower, this includes our 6 bed Young Persons’ Cancer Care unit (for 13-22 year olds).

Harley Street at University College Hospital, 5th Floor, The UCH Macmillan Cancer Centre, Huntley Street, London WC1E 6AG •

A dedicated outpatient and day care unit with 7 specially designed chemotherapy and treatment pods.

Overview of Multiple Sclerosis and Autologous Haematopoietic Stem Cell Transplantation Multiple Sclerosis (MS) is the most common non-traumatic neurological disability in young adults with 1 in 1000 people affected. Whilst the cause of MS remains unknown the overwhelming weight of evidence indicates that it is an autoimmune condition. This means that the body’s own immune system turns on its own nerve cells which results in nerve damage and neurological disability. There have been major advances in the treatment of relapsing remitting MS by modifying the immune system and reducing the inflammation in the brain and spinal cord. Two examples are the medications Gilenya and Lemtrada which result in a significant reduction in the number of relapses but the long term outcomes are unknown. In addition these therapies are associated with significant potential side effects. Autologous hematopoietic stem cell transplant (AHSCT) is another method of modifying the immune system. AHSCT has been performed in MS patients, the majority of who had failed to respond to approved treatments; case series and anecdotal reports suggest that it is potentially beneficial, particularly in relapsing remitting MS, however the long term outcomes are not known. In absence of clear-cut evidence of the benefits of AHSCT in MS and the recognised risks associated with it any decision to treat MS with AHSCT needs to be carefully considered by the patient, Neurologist and Haematologist. A guide to an autologous stem cell transplant for Multiple Sclerosis

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Section 2: Our staff

Consultants The following consultants perform peripheral blood stem cell transplants for Multiple Sclerosis at Harley Street at University College Hospital: • • • • •

Professor Stephen Mackinnon Dr Panos Kottarides Dr Chara Kyriakou Dr Chris McNamara Dr Ashutosh Wechalekar

When you come into hospital for your transplant, you will be under the care of your consultant or attending consultant. Therefore the consultant in charge of your care at this time might not be one you’ve previously met in clinic. They will always be in continuous communication with the medical team looking after you and will be involved in all the decisions made about the treatment and care you receive. We have resident specialist registrars (SpRs) and senior house officers (SHOs) who support the consultants 24 hours per day.

Clinical nurse specialists (CNSs)

A CNS is an expert nurse and a consistent point of contact for you, your family and any other healthcare professionals involved in your care. You will be assigned a transplant CNS who will also co-ordinate the preparations required for your transplant. Your CNS will offer support to you and your family throughout treatment and follow up. You can contact them with any questions or concerns you have.

Nursing staff

Clinically and managerially experienced nurses manage the inpatient ward and the outpatient and day care unit. They and their staff strive to ensure that the highest standards of care are achieved and maintained.

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Name/role

Direct dial

Switchboard on 0845 1555 000 or 020 3456 7890 then: Bleep Extension

BMT CNSs

020 3447 8899 07961 081 682 07425 017 439

5818

Out of hours urgent advice number Manager on Duty

020 3447 1595 07872 464 780

78899

71595

The inpatient ward, known as T15, is on the 15th floor of the main UCH building on Euston Road. The outpatient and day care unit is located on the 5th floor of the UCH Macmillan Cancer Centre, Huntley Street. A full list of contact numbers for both the inpatient and outpatient settings is provided at the back of this booklet.

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Section 3: What are bone marrow and stem cells? Bone marrow is the soft spongy tissue inside the central cavities of the bones. It creates the right environment for the production of stem cells (immature cells). Stem cells are blood cells at the earliest stage of development in the bone marrow. When the cells are fully mature they are released into the bloodstream. Normally, most stem cells in the body are in the bone marrow. Stem cells develop into the three different types of blood cells: • Red blood cells • White blood cells • Platelets

Red blood cells •

Carry oxygen to all cells in the body and remove waste products.

White blood cells • • • •

Are essential for preventing and fighting infection There are several types of white blood cells, each with a different function The white cell most active in fighting infection is called a neutrophil Lymphocytes are also important in developing antibodies to fight viral infections

Platelets •

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Help the blood to clot and prevent bleeding.

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Section 4: Why do I need a stem cell transplant?

Your transplant Your doctor has recommended you for a stem cell transplant because they consider this to be the most appropriate treatment for your condition. There are different types and different ways of preparing people for undergoing a transplant, and procedures may vary from person to person. Please do not hesitate to ask if you have any questions or require more information about transplantation. The goal of your treatment is to induce a long term remission of your underlying condition. To achieve this, you will need to receive high doses of chemotherapy. The higher doses of chemotherapy is effective because they kill the abnormal cells which are responsible for your disease. Unfortunately, this treatment suppresses your bone marrow function and affects your body’s ability to produce stem cells. This increases your risks of: • Infection – by lowering your level of white blood cells • Becoming anaemic – by lowering your level of red blood cells • Bleeding – by lowering your level of platelets By giving you back your own stem cells (referred to as an autologous stem cell transplant) following your high dose therapy, your bone marrow is effectively being ‘rescued’ from the damaging effects of treatment as these stem cells will go on to produce the cells described above. The ‘right time’ for transplant is decided between you and your consultant. Stem cell transplantation was first used in the 1960s and since then has become a valid treatment option in attempting to treat the underlying disease. There are different types of autologous transplant and different ways of preparing people for undergoing these treatments, therefore procedures may vary from person to person. Your consultant and clinical nurse specialist (CNS) will discuss with you the benefits and possible complications of your transplant, since each person’s circumstances are very different and unique. We will not give you treatment that we believe you will not benefit from.

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Section 5: What is involved in a stem cell collection?

How do you collect the stem cells? Before you begin high dose chemotherapy we firstly need to collect or “harvest” your stem cells. A small number of stem cells exist in your peripheral blood system as a result of being ‘pushed out’ by your bone marrow where they are formed. We need to increase the number of stem cells in your peripheral blood stream in order to collect enough for transplant. This is achieved by giving you an infusion of chemotherapy and G-CSF (‘growth factor’). This is known by medical professionals as ‘stem cell mobilisation’ or ‘priming’. The G-CSF injections are necessary to help over stimulate your bone marrow into producing enough stem cells for collection. G-CSF is a protein that naturally occurs in your body and helps stem cells evolve into blood cells as described previously. As we need to increase the number of stem cells available in your blood stream we have to increase the amount of G-CSF in your body. This can be achieved by you receiving daily injections of a synthetic form of this growth factor. The injections can be self-administered (you inject yourself ), given to you by your partner or be given to you by someone else e.g. District Nurse. Information on your chemotherapy for stem cell mobilisation and G-CSF will be provided to you separately from this booklet by your CNS. Your stem cells will be collected by a process called ‘apheresis’ (apheresis simply means removal or extraction) using a stem cell machine by a trained apheresis nurse.

How do you know it’s the right time to collect the stem cells? In the days leading up to your stem cell collection you may be asked to attend Harley St at UCH for a blood test. The purpose of this is to simply check how your bone marrow has responded to your ‘priming’ treatment. • For stem cells to reach adequate levels for us to collect takes approximately 10 days using chemotherapy. You will need to receive your G-CSF injections daily following your mobilisation chemotherapy until we have collected enough cells for your eventual transplant. You will be given your own timetable detailing how and when your mobilisation will take place, where you will receive it, and when we expect to collect your stem cells here at Harley St at UCH.

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If at any point during your mobilisation you become significantly unwell – especially if you develop an infection of any kind – you must seek medical help as you usually would. This can be at Harley St at UCH or your local hospital – whichever is most accessible. If you miss a dose of your growth factor injection for whatever reason, you must contact your CNS as soon as possible as both these situations might affect your stem cell collection.

What happens on the day of the stem cell collection? On the day of your stem cell collection you will be asked to attend the UCH Apheresis Unit by 08:30. First, a blood test will be taken to ensure your peripheral blood indicates that there will be enough stem cells available to collect and that this is the right time to carry out the procedure for you. Blood tests leading up to this point may give us an indication, but we need to be sure by taking a simple blood test on the day of expected stem cell collection. If your blood test indicates the level is not high enough on the expected day of collection you will have to return home and administer another G-CSF injection as usual. You should return to Harley St at UCH the next morning as planned.

What happens on a stem cell machine? If your blood test results are satisfactory we will proceed to collect your stem cells. Each time a stem cell collection is performed, a sterile single-use kit is used which is loaded onto the machine by a trained apheresis nurse. The nurse will then enter into the machine’s computer your height, weight, and the results from that morning’s blood test. Once this is done, the stem cell collection can start. Typically, the procedure is performed by putting a large needle into the crook of your non-dominant arm (the arm you don’t write with) and then another needle / cannula in the opposite arm. Your apheresis nurse will apply a local anaesthetic to the area, to make it more comfortable for you, before inserting the needle. You will then be connected to the stem cell collection machine to start collecting your cells. The procedure usually takes about 4 - 5 hours.

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Blood is taken from your arm by the larger needle to the machine. As the blood spins, it separates out the stem cells which are then collected intermittently by the machine. Your blood is then returned to you via the smaller needle / cannula in your other arm. It is a continuous ‘loop’ like process. At any one time there is only approximately 250ml of your blood outside of your body less than a small glass of water. In some cases if you don’t have very good veins it may be necessary for a special catheter to be inserted into a large vein in your groin. The catheter is known as a Vascath and will remain in place until enough stem cells have been collected. This may mean it is kept in place overnight in readiness for the second day collection. When enough stem cells have been collected for transplant, the catheter will be removed. The quality of your veins would have been assessed by your CNS before your collection so you will know whether a Vascath is required.

During the collection Your apheresis nurse will be able to tell you exactly how long your stem cell collection will take. During this time you will not be able to be disconnected or have ‘time-out’ from the procedure. You are advised to wear comfortable loose fitting clothes e.g. t-shirt and shorts / jogging bottoms. If you need the toilet during the collection you will be given assistance to use a bedpan or bottle. You are welcome to have someone stay with you during the procedure. It’s a good idea to bring a book, some magazines, a laptop, games console, etc, with you to help pass the time you’re on the machine.

Are there any complications of a stem cell collection? Firstly, we have to ensure that there is a good blood flow to ensure the best collection of your stem cells. Your apheresis nurse will be constantly assessing how effective the blood flow via the needles or catheter is for this reason. When your blood is being spun and collected to harvest your stem cells, the machine needs to use a product called ACD-A. ACD-A works by attaching itself to the calcium in your blood. Calcium is needed by your blood to form a clot. Using ACD-A reduces the chances of this happening in the machine and interrupting the procedure of collecting your stem cells. Calcium is also needed for nerve functioning and so the ACD-A can cause tingling in the ends of your fingertips and toes, around your nose and lips. Sometimes it can feel as if you have funny or indescribable vibrations in your body. It may make you feel ‘light-headed’ or nauseous.

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If you feel in any way ‘unwell’ during the collection, you must tell your nurse. Such symptoms can be acted upon and controlled by your nurse to relieve these symptoms very quickly. You will be given calcium supplements in the form of chewable tablets or in some cases a ‘drip’ of calcium might be needed to complete the collection. Again, it is important to let the nurses know if you ‘don’t feel right’ in any way throughout the procedure.

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Section 6: Tests needed before the stem cell collection and transplant Once you and your Consultant have decided that this is the right treatment for you, there are several investigations that need to be done to make sure you are ready for your stem cell collection and transplant: • We will test your blood for various viruses including Hepatitis B, Hepatitis C, Syphilis, HIV and HTLV. • It is a legal requirement in the UK that these tests are done and the results known before we collect and store your stem cells. By doing these tests we are in no way implying you have these viruses. • You will have a routine blood test to check your white blood cell, red blood cell and platelet level. Another blood test taken at the same time, will also check how your liver and kidneys are working. • Those women of child bearing age, who have not undergone the menopause, will be required to take a pregnancy test. • We will need to check how well your heart and kidneys are functioning. • You will be asked to have a MUGA or Echocardiogram to test the efficiency of your heart. −− The MUGA scan requires two injections: one to prepare the blood to accept radioisotope dye, the second one an isotope dye, follows after approximately 30 minutes. The scan is done immediately following the second injection. It involves lying on a couch with a scanning camera above your chest. The whole process takes about one and half hours. There is no special preparation required except that you should have no tea or coffee for 4 hours prior to the scan. −− If you are having an Echocardiogram (or Echo), this will involve some jelly being placed on your chest and an ultrasound scan is then taken of your heart, you can eat or drink normally prior to this test. −− A G.F.R. scan looks at kidney function and requires an injection of radioisotope dye, followed by a blood sample being taken 2, 3 and 4 hours after the injection. •

You may be asked to attend for a Lung Function Test – also known as a pulmonary function test. This is a short procedure (usually lasts 20 to 30 minutes) and is done to establish how well your lungs work.

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We will try to minimise your trips to hospital for tests whenever we can. As your transplant centre, you may well be asked to attend Harley at UCH on one or two occasions for these to be achieved. Please keep the appointments you are given they are important in ensuring that this is the right time for your transplant. You must telephone your CNS if there is a problem in you attending any dates for tests that you are given.

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Section 7: Consenting to your treatment If you agree to stem cell collection, the tests described above and then transplant you will be asked to sign two separate ‘consent forms’ authorising us to proceed with each stage of your treatment. One must be signed before we collect your stem cells and the other when you are admitted to Harley Street at UCH for your stem cell transplant. When you sign the consent forms you are indicating to us that you have been given enough information to make a fully informed decision and understand what the stem cell transplant procedure involves. It is important at all stages that you continue to ask questions of your doctor and nurse if you do not understand any information given to you.

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Section 8: Will I need a Peripherally Inserted Central Catheter (PICC) line for my transplant? Patients require a PICC line to be inserted before their stem cell transplant starts. A PICC line is inserted into a vein in your upper arm. It is a semi-permanent line that ensures we can administer your medications into your blood stream via a central vein. Your CNS will help advise you about this closer to the time of your transplant work-up. The PICC line is a hollow white plastic tube designed to stay in place for the duration of your transplant process. Sometimes when your immune system is low during treatment and you are vulnerable to infection, your line can become infected through no fault of your own. If this happens we will treat you with intravenous antibiotics (antibiotics that are given into your bloodstream) or we may remove your line depending on how well your body is coping with the infection at the time. You will continue with the rest of your treatment with a cannula or ‘Venflon’. Cannulas are typically inserted into the peripheral veins of your arms or hands.. Your veins are sometimes fragile and therefore would not be able to safely withstand the volume of fluid or antibiotics that you may need during your transplant. For this reason we may need to replace your PICC line with a ‘central line’ into one of your larger veins found at the side of your neck or in your groin. The central line serves the same purpose as the PICC line and is a temporary measure. Your Doctor and Nurse will advise you about this if and when it’s needed. The PICC line will be removed when you are due to go home after your stem cell transplant.

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Section 9: The stem cell transplant When all the necessary investigations have been done and your stem cells collected, your consultant and CNS will carefully consider all the results to make sure that the procedure is right for you at this time. We will again consider all the potential benefits and risks to you when deciding to proceed with the stem cell transplant, and these will then be discussed with you in clinic before any final decision to ‘go ahead’ is made. Once this has been agreed, you will usually be admitted to Harley St at UCH within a few weeks - on a date decided upon between you, your consultant, and your CNS. You will be given a specific and individual timetable detailing your transplant process. Your stem cell transplant has several steps explained below:

Conditioning Chemotherapy Conditioning Chemotherapy suppresses your blood counts and is intended to suppress the immune reaction of your underlying disease leading to a long term remission. Your chemotherapy will be given to you over a period of six days. Information on the type of chemotherapy you will receive and how long this lasts will be detailed in information provided separately from this booklet by your CNS. On admission the ward your nurse will record your weight and height. These measurements enable the Doctors to calculate the right dose of chemotherapy for you. Your nurse and pharmacist will explain your treatment timetable and discuss any issues you may have. He or she will also discuss your previous chemotherapy experiences with you. This will help to plan for your specific care needs during your treatment. Throughout your stem cell transplant process we will give you medications to control any nausea and vomiting you may experience as a result of your chemotherapy plus any regular tablets you take at home.

Stem cell infusion or return Generally one, sometimes two days, after all your chemotherapy has been completed you will be infused with your stem cells (stem cell return). This delay is so that we can make sure that the chemotherapy is ‘flushed’ out of your system before we infuse your stem cells and is dependent on how well your kidneys are working at the time of transplant. The day you receive your stem cells is referred to by medical professionals as ‘Day Zero’ (0). The process of infusing your stem cells is painless and is very much like having a blood transfusion. It usually takes between 1 to 2 hours to complete. Your stem cells will be delivered to your bedside by one of our stem cell scientists. They will then be checked by two experienced haematology nurses to ensure the correct patient details are clearly labelled on each bag and correspond to your treatment prescription.

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The cells will arrive still frozen from storage. They must be defrosted before being infused back to you. This is simply done by gently thawing them in a temperature controlled water bath next to your bed. Once thawed, they are immediately infused back to you via a drip. In each bag of frozen stem cells is a preservative called ‘DMSO’, which is used to protect the cells during storage. When the cells are defrosted, you may experience some side effects of the DMSO such as nausea, vomiting, a high temperature or a general feeling of ‘un-wellness’. This is very common and the effects usually wear off after a couple of hours. To counteract this you will be given extra anti-sickness medication in addition to your regular medicine plus an antihistamine such as ‘Piriton’ before your cells are given back to you. DMSO, once thawed, releases a significant sweetcorn-like smell. DMSO is excreted by your body through your breath, your skin and via your kidneys, so as a result of receiving the DMSO you will inevitably smell of sweetcorn for a day or two until your body has got it out of your system. There is nothing you can do to avoid this, but regular bathing and keeping up a good fluid intake does help.

Supportive Care/Therapy The infused stem cells will find their way straight back into your bone marrow. From there they begin to grow and form new blood cells, which usually takes 10-14 days. The focus of our care during this period is to offer support to patients and relatives. Whilst we encourage patients to do as much for themselves as possible, close monitoring by medical and nursing staff is required during this time. In the days following your stem cell infusion and until the new blood cells form, you will become ‘immuno-compromised’. You may hear the nurses and doctors refer to this as being ‘neutropenic’. This means that your immune system isn’t working properly and you’re at a time when you are most vulnerable to developing an infection.

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Section 10: Side effects of the transplant

Developing an infection Developing an infection is an expected complication of having a transplant. Signs of infection can vary but typically, the symptoms are: • Shivers’ or ‘hot flushes’ • Temperatures close to or above 38 degrees Celsius • Persistent episodes of vomiting and / or diarrhoea • Shortness of breath or difficulties with your breathing When you develop an infection you will be started on intravenous antibiotics and will remain on them until your symptoms clear and / or until your immune system begins to recover. Your neutropenic phase can last for several days – in some cases a week or two. During the time when you are neutropenic and develop temperatures the symptoms of your MS may transiently worsen, however they will improve as you recover from the transplant. During this time, you will also receive any intravenous fluids necessary as well as blood product support (such as blood and platelet transfusions) until your body is effectively able to cope on its own. Developing a chest infection is common when undergoing a stem cell transplant. The risk of developing a chest infection increases when you are inactive or on bed rest. It is therefore important to get up and about and take a short walks regularly. We strongly advise that if you are a smoker that you stop prior to coming in for your transplant. If you require help please contact your CNS or GP to commence a smoking cessation programme. Decreasing the risk of infection is of major importance because as a consequence of the treatment your own ability to stop infections is impaired. To reduce the risk of infections we ask you to undertake certain precautions. All the rooms on the Haematology unit are single rooms with an ensuite bathroom. We ask all visitors to wash their hands and use the alcohol gel provided when entering and leaving your room. Visitors must adhere to the hand washing routine. People with runny noses, colds, flu or any other potentially transmissible infection are not allowed to visit you. Neither should people who have been in contact with shingles, chicken pox, measles or any other viruses. If you develop a potentially transmissible infection (an example being infectious diarrhoea) you will have samples taken and sent for analysis. If you develop cold or flu like symptoms e.g. a runny nose or cough, you will have swabs taken of your nose and throat. If we identify such a transmissible infection or virus you will be transferred to a different ward (T8) in order

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to minimise the risk to other patients on the unit. Whilst on this unit you will continue to be looked after by the nursing team from T15. Your doctors will remain the same and will monitor your care as before.

Bleeding The chemotherapy not only affects your ability to produce white cells, but also your ability to produce platelets and red cells. A reduction in your platelet count means an increased risk from bleeding and bruising. There are ways you can help prevent bleeding problems: • Only use an electric shaver if you need to shave • Do not use dental floss or a hard toothbrush. Use only a baby or soft toothbrush and clean only your teeth not your gums. • A common site for bleeding is the nose. Inform nurses of any nosebleeds, never pick your nose and avoid excessive blowing as much as possible. • Watch for blood in your urine and bowel movements. Urine will appear tea coloured or red; bowel movements will appear black and tarry or bright red. Please inform your nurse of any changes. • If you cough or vomit any blood, be sure to notify your nurse and do not throw it away. • Although there are many causes for headaches, they may indicate a problem so please report them. All women, except those who are post-menopausal will need to take hormone tablets similar to the pill in order to stop menstruation. The reason for this is to prevent heavy bleeding, which may be difficult to control.

Anaemia Your red blood cell level will be low at times throughout your treatment and you may experience some of these symptoms: • Paleness • Weakness • Loss of energy • Loss of appetite • Breathlessness It is important to be aware of the signs of infection, anaemia and bleeding and to be aware of any other changes in your condition. However small or minor these changes may seem to you, you must inform your nurse or doctor. Your blood counts will be monitored daily and will be corrected by blood transfusions as needed when you haemoglobin drops below 7g/ml. Blood count regeneration in the majority of cases brings about the resolution of many symptoms endured whilst

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neutropenic. As mucositis resolves, the ability to eat and drink should become easier. Although feeling weak, you may feel able to do more for yourself. Medications that supported you through your transplant will be changed to oral tablets, in preparation for you going home. To assist your blood count recovery, you will be given an injection of G-CSF to ‘kick-start’ your bone marrow into producing new cells – approximately 5 days after your stem cell infusion. When your blood counts have recovered sufficiently and only when your medical team deem it safe, you will be discharged home.

Nausea and vomiting This is a common side effect associated with chemotherapy. It can usually be controlled or greatly reduced by using anti-sickness drugs. The chemotherapy nurses and pharmacist will discuss all of this with you before treatment starts and during your admission.

Diarrhoea This is an expected side effect and is a result of your chemotherapy. It will subside and drugs can be given to help ease it when it occurs. Please inform your nurses or doctors as soon as

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possible so the symptoms can be treated quickly.

Mucositis Following chemotherapy your mouth may become tender or swollen and ulcers may form. This is known by medical professionals as mucositis. Although this is distressing, regular and thorough mouth care can greatly reduce or possibly stop this from occurring. It also helps to prevent infections in your mouth. Your nurses will educate you about mouth care and when it should be performed. Depending on the extent of your mucositis, pain relief can be prescribed if your mouth becomes painful. It is during your neutropenic phase that the side effects of your treatment are most harsh. In many cases medication is given via the PICC or Hickman line, as taking anything orally can be difficult due to mucositis - which makes eating and drinking difficult.

Alopecia (Hair Loss) Certain chemotherapy drugs cause the loss of body hair, initially to the head but also from the eyebrows, eyelashes, underarm, and pubic area. The loss is temporary and about five to eight weeks after the start of treatment re-growth will start on your head and underarms. Eyebrows and eyelashes naturally grow slowly and re-growth may take longer. The colour and texture of your hair may also differ slightly from before. Hair loss can be quite distressing and often falls out in clumps from your head when brushed, or is rubbed off on your pillow. Some people will prefer to allow it to fall out as slowly as possible, whereas others prefer to shave it all as soon as patching occurs (electric clippers only). Some patients then prefer to cover their heads, in which case turbans, scarves or hats can be worn. Although hair loss can be distressing you may well feel quite comfortable in the hospital environment with your head bare. You may experience slightly shocked responses from friends and relatives who are not prepared for the change in your appearance. If you decide not to cover your head on leaving hospital, be prepared for the extra need to protect your scalp from sunburn in the summer and heat loss as a result of the cold in winter.

Fertility High dose chemotherapy has a detrimental effect on fertility. By the time you come to transplant, you may have already discussed the subject with your consultant. In women the situation is complex and we can judge your reproduction status according to the frequency of your periods and by using simple blood tests. Depending on your underlying disease and previous treatment we may be able to offer the option of saving fertilised ova (eggs). Pre-menopausal women will need to take a hormone called norethisterone during their stay in hospital. This drug stops menstruation – if you start to menstruate while your blood counts are low (particularly the platelet count) you may lose a lot of blood. A guide to an autologous stem cell transplant for Multiple Sclerosis

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In some cases the transplant can cause women to experience menopausal symptoms earlier than would normally be expected. Further management of this will be discussed with you in your post-transplant clinic appointment. For men there is the option of sperm storage (this may have been done at the time of your original diagnosis).

Nutrition It is important to try to eat well while you are in hospital and having treatment. Eating well helps to ensure that your body has the energy and nutrients needed to rebuild damaged tissue, fight infection and cope with any treatment side effects. Your treatments are likely to increase your risk of infection and certain foods can carry germs which may be harmful to you at this time. As a precaution, we advise you to avoid the following higher risk foods during your stay in hospital: • Any uncooked meat/fish/seafood dishes • Meat/fish pâtés • Unpasteurised milk and milk products, including unpasteurised yoghurt, cream and cheese • Probiotic/live/bio yoghurts and drinks • Soft ripened cheeses, e.g. Brie, Camembert • Blue veined cheeses, e.g. Stilton, Wensleydale • Uncooked eggs and dishes containing these, e.g. homemade mayonnaise or mousse. Eggs must be cooked thoroughly until both white and yolk are solid. • Fruits or vegetables that are bruised, damaged or difficult to wash thoroughly • Food items from deli counters, mobile vans, etc Food from reputable takeaway establishments is allowed, however, it must be eaten immediately and not reheated. If you become neutropenic as a result of your treatment (i.e. your neutrophils are less than 0.5), this is when you are most at risk of picking up infections.

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We strongly advise that you also keep to the following clean diet guidelines:

Item

Not allowed

Soup

• •

Meat, fish & poultry

• • • • •

Milk & dairy produce

• •

Cheese

• • • •

Eggs

• •

Vegetables & salad

• •

Fruit/nuts/seeds

• • •

Take away food Miscellaneous

Reheated soup Cold fresh soup Raw or cold uncooked (i.e. cured) items Uncooked smoked fish Shellfish Meat/fish pâtés Any items from delicatessen counters Raw/unpasteurised milk, cream or yoghurt All probiotic drinks and products, e.g. Yakult, Actimel Any unpasteurised cheese, including Parmesan Soft ripened cheese, e.g. Brie, Camembert, Feta, unless pasteurised Blue veined cheese, e.g. Stilton, Roquefort, Gorgonzola, Blue Cheshire, Wensleydale, unless cooked Cheese with rind or mould coating, e.g. mature rind Gouda, Limburger Raw or undercooked eggs Products containing raw eggs, e.g. homemade mayonnaise, mousse All unwashed vegetables/salad All salad leaves All unwashed or damaged fruits Dried fruits All nuts and seeds unless peeled and/or cooked

•

All takeaway foods unless from a reputable establishment All items from delicatessen counters

•

Pepper, added at the table or after the cooking process

•

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Points to note: Foods sourced from outside the hospital must be cooked from fresh and rapidly refrigerated afterwards (ideally within one hour), NOT kept at room temperature. Such foods may be reheated in the unit kitchen only once – reheated cooked foods must be piping hot all the way through and have a core temperature above 70°C on serving. Shop bought frozen or chilled (sealed) microwaveable convenience meals may be brought in for patients and cooked thoroughly in the ward pantry according to the manufacturer’s instructions. All cooked food from the hospital kitchen should be served piping hot, i.e. at a core temperature of 70°C or above. All permitted foods brought in by patients or relatives should be labelled and dated before being stored in the ward fridge/freezer/cupboard. All items should be checked daily for expiry dates. Fresh fruit should not be kept in patients’ rooms. All food and drink opened should be discarded within 24 hours. Food/drinks in smaller presentations e.g. individual drink cartons/bottles or packets of biscuits/cereals/cakes are useful to minimise contamination and avoid wastage. You may drink small amounts of alcohol but this is not advisable during chemotherapy treatment or if you are taking certain antibiotics. Please ask the staff for advice.

General advice Your treatments can change the way food tastes to you and dampen your appetite. If this happens there are several ways we can help you to supplement your dietary intake. The nurses looking after you will regularly assess how well you are eating, so help can be offered if you do lose your appetite and/or begin to struggle to eat. There are snacks available. These are especially useful as eating small but frequent nourishing meals and snacks (up to six times a day) can be easier to manage than three normal sized meals when your appetite is reduced and/or you are feeling unwell. There are special supplements available that contain extra energy and nutrients. These include milkshakes, juices, yoghurt drinks, and soups. They are kept on the ward and are available at any time – please ask.

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Occasionally you may not be able to manage sufficient food or drink orally to meet your needs due to treatment side effects, e.g. your mouth may be too sore to eat. If this happens, there are other feeding options that will be discussed with you. These may include feeding through your central line, or occasionally a small, narrow tube can be placed via your nose into your stomach which allows a liquid feed to be given. We have a dedicated dietician within Harley Street at University College Hospital who can offer further advice if you have ongoing difficulties with eating and drinking. If you have any special dietary requirements, are worried about any aspect of your diet or have queries about specific foods, or if you have a complaint, please tell the nursing staff.

Activity It is important to try and stay as active as possible during your treatment. At times you may feel unwell, unmotivated or bored but keeping to your normal daily activities as much as possible can help. While you are feeling unwell make sure you have some things to occupy your time such as games, books or DVDs. Having a range is advisable as you may feel that you cannot concentrate on one thing for long periods of time. As your symptoms subside, start doing some gentle exercise to increase your energy levels and stamina. The easiest way is to start with frequent short walks and gradually increase the time and distance of these. Some people find setting personal targets helpful. Our dedicated physiotherapist is based on the ward and will visit you in your room and agree a personalised exercise programme with you. The physiotherapist will monitor your progress, giving advice and adjusting the plan as needed.

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Section 11: A typical day during your transplant A ‘typical’ day is different for each patient depending on your care needs at the time. However, you can expect that: • Each day you will receive all necessary and prescribed treatment. • You will be visited on a daily basis throughout your stay by your Consultant specialist registrar and senior house officer. This is an opportunity for you to discuss how you are feeling, report any concerns to the medical team and for treatment to be tailored to your individual needs. This is an opportunity for either yourself or your friends/ family to discuss any matters with the medical team. • Your PICC line will be assessed for any signs of infection. • Your blood pressure, temperature, breathing rate, pulse as well as your oxygen level will be measured daily. This is commonly known as having your ‘obs done’. The frequency in which this will happen will increase when you are neutropenic; if you develop an infection or if you become unwell in any other way. • Your weight will be checked and your fluid intake/output will be monitored. • Daily bathing is encouraged. In normal circumstances your own skin bacteria is harmless. However, when your immune system becomes low it can be a cause of infection. Daily showering or bathing (good personal hygiene) as well as thorough hand-washing after using the toilet is therefore essential. Keeping hands clean is one of the most important things you and your partner or carer can do in helping to minimise transmission of infection. Please ensure that they are just as conscious about the importance of handwashing as you are. Alcohol gel is provided in every room and at various points around the unit.

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Section 12: Information about your stay at Harley Street at University College Hospital

Length of stay The length of stay varies from patient to patient but it is usually between three to four weeks. You are encouraged to come and go from the unit if you are medically fit to do so and no treatments or investigations need to be carried out. When your blood count falls to a point where you are neutropenic (you have a low white cell count), you will be asked to restrict your movements to the unit only, as you are at an increased risk of infection. Some people bring in their own pillows, duvets, photographs, CD players, radios or laptop computers, to help make their stay more comfortable. Please feel free to bring in small personal items to help make your stay easier.

Daily routine Numerous nursing and medical interventions are repeated on a daily basis to aid early detection of any potential problems, such as infection or bleeding. A routine blood test will be performed each day. The blood results for that day will determine your blood and platelet requirements and also if any additional treatment is needed.

Tell us how you are feeling You will be visited on a daily basis throughout your stay by the consultant, registrar, and senior house officer. This is an opportunity for you to discuss how you are feeling, report any concerns to the medical team and for treatment to be tailored to your individual needs. Friends and family are also encouraged to discuss any matters or concerns with your medical team. Good personal hygiene is encouraged. This is essential whilst your blood counts are low, as you are much more susceptible to infection during this period. Your own bacteria, which in normal circumstances are harmless, may become a source of infection, so daily showering or bathing is important. Washing your hands and using the alco gel after every visit to the toilet is also essential. You and your relatives must not mix with other patients on the ward; this will help reduce the risk of infection to you. Your skin may be drier and more sensitive than normal (as an effect of the chemotherapy). Use a mild, non-perfumed soap and mild, non-perfumed lotion for your dry skin.

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Mouth care Maintaining regular mouth care through the use of mouth washes and soft toothbrushes is very much supported and encouraged by the medical and nursing staff. It may, at times, feel a difficult task due to painful mucositis (mouth ulcers or sores which are a side effect of chemotherapy), and generally feeling unwell. Mouth care in itself will not stop mucositis but, as the lining of the mouth is damaged, you are at greater risk of infection and bleeding. Therefore, it is vitally important that the mouth is kept clean, as this will reduce the risk of infections occurring. If you are having difficulties with this, please speak with the nursing staff as this is a regular occurrence and there are many ways in which we can support you.

Other checks Your PICC line needs to be assessed daily for any signs of infection. You can monitor this with the support of the medical and nursing staff. If you have any discomfort, swelling or redness with the line you should report this immediately. Your temperature, pulse, respiratory rate and blood pressure will also be monitored daily. If you feel unwell, have a temperature or are neutropenic, these observations may be carried out more frequently. You will be weighed on a daily basis, which allows for a basic assessment. An increase in your weight indicates, among other things, that you may be retaining some of the fluid that you are having by intravenous infusions. You may require additional help through medications to remove this extra fluid. A decrease in weight over a period of days may be due to decreased appetite. This is not uncommon when undergoing a transplant. Your nurse will make daily assessments to check that you are receiving adequate nutrition.

Visiting There are no restrictions on visiting times on the unit: one family member or friend is welcome to stay in your room if you wish. However, this depends on your individual circumstances and how well you are feeling. Please feel free to discuss this option with the nurses. Children under the age of sixteen cannot be left with the patient overnight. We discourage visiting by children under the age of two. However, this is not a rigid rule and can be discussed with the medical or nursing staff.

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Please note: People who have been in recent contact with chicken pox or measles or have colds or the flu are not allowed to visit. If you think any of your visitors have had contact with, or are suffering from the above, please ask them to speak to nursing or medical staff before visiting.

Washing and laundry There are currently no laundry facilities available on the inpatient unit; however, there is a launderette nearby, on Cleveland Street.

Parking There are no parking facilities provided. Parking is free on Sundays and from Monday to Friday after 18:30 and before 08:30. The roads around the hospital are within the congestion charge zone so you will have to pay in the usual way

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Section 13: Complementary and support services A range of complementary therapies are available:

Aromatherapy Uses blends of essential oils extracted from plants, often mixed with a base oil.

Reflexology A specialised form of foot or hand massage, where gentle pressure is applied to specific points on the feet or hand with the thumbs. Sessions can help promote the patient’s physical and emotional wellbeing, and are used to bring about a feeling of deep relaxation.

Reiki A soothing and relaxing therapy, where the therapist uses ‘natural energy’ through light touch either on, or just above, the body. Relaxation may help patients cope better with stress and anxiety. You may also come into contact with the following supportive members of staff:

Psychological and emotional care team Our psychologists and counsellors are here to help you deal with the emotional side effects of your treatment and will offer you information, support and practical help.

Spiritual and pastoral care Pastoral and spiritual support is available for all individuals and their families and friends. If you would like to speak to one of our spiritual care providers regarding your religious or spiritual needs, please ask your nurse to arrange this.

Dietician The unit dietician can arrange supplement drinks and snacks to be delivered if you are having difficulty eating. The ward has a constant supply of high calorie drinks that you can access at any time. If you are losing weight and supplement drinks are not enough to help maintain it, then the dietician will be consulted regarding the use of alternative methods of giving you nutritional support.

Physiotherapist

We have a dedicated unit physiotherapist who works from 09:00 to 17:00, Monday to Friday. Your nurse can give you advice and refer you to the physiotherapist if required.

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Ward pharmacist We have four qualified pharmacists in total: a clinical manager, lead haematology pharmacist, senior pharmacist and clinical pharmacist. Two of these pharmacists will carry out twice daily ward rounds where they will check all drug charts. They are responsible for the monitoring of all drugs which are prescribed, dispensed and given on the unit, including chemotherapy.

Symptom control and palliative care team Palliative care is available and appropriate for all patients, at all stages of their disease and treatment. It involves caring for you in a holistic or ‘whole’ way and meeting your physical, emotional, spiritual, and social needs. The palliative care team is available to give specialist advice and support to the nursing and medical staff in charge of your care. This team of doctors and nurses will be able to offer practical advice and guidance that address the problems facing you, your family, and those closest to you.

Occupational therapy service This can be arranged when necessary.

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Section 14: Can I do anything to help my transplant? There are no set rules as to ‘what not to do’ before coming to Harley St at UCH for your transplant. We respect your right as an individual and your ability to recognise the importance of this treatment for you at this time. However, we do expect you to take on board our advice and direction of your care throughout the duration of your treatment with us. Some basic ‘pointers’ are: • We ask that you keep the hospital appointments you’re given and keep yourself as ‘well’ as possible until the time you come to Harley ST at UCH for your transplant. • This means avoiding people (including children) with coughs, colds and contagious illnesses such as chickenpox etc. If you do develop any signs of infection or signs of a cold such as sore throat, runny nose, bringing up green or brown coloured phlegm etc, you must inform your CNS as soon as possible. We need to ensure that you are as 34 A guide to an autologous stem cell transplant for Multiple Sclerosis

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•

•

•

well as can be before you start your transplant. If you suspect you might have had problems with your teeth recently, it’s recommended that you see your dentist before you come into hospital. We need to make sure you don’t have any cavities or dental infections before you start your treatment. Your dentist can contact us on the numbers given at the back of this booklet if needed. Eat a healthy diet and get yourself into the habit of drinking at least two litres of fluid a day in addition to your usual cups of teas and coffees. Extra fluid can be water, squash or juices, etc. When you come to the hospital your nurse can advise you on what foods you can eat and those which to avoid whilst undergoing your transplant. The booklet ‘What can I eat when I am neutropenic’ is provided for your information.

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Section 15: Going home after your transplant The most common question patients ask is “will I be different after my transplant?” The following information is a guide as to what is ‘normal’ to expect once you are discharged from the hospital.

‘Follow up’ hospital appointments On discharge you will be given an outpatient appointment with your transplant consultant 1-2 weeks post discharge. You will have a clinical review and blood tests at this visit. If your PICC line has not been removed prior to discharge you will need to have it redressed weekly until it is removed. At approximately 4 weeks post discharge you will receive another appointment with your transplant consultant and if you have recovered well from your transplant you can return home and receive any further follow up appointments you may need there. We will make you an appointment with your agreement at either 3 or 6 months post your stem cell transplant with one of the Neurologists that you saw at the initial time of your referral for a stem cell transplant. The purpose of all of these appointments is to check your continued recovery and to support you through this process.

Vulnerability to infection and viruses For several weeks after transplant your immune system is still recovering and returning to normal. You will therefore still be prone to picking up infections and ‘getting temperatures’ etc. For the first few weeks it’s wise to avoid crowded or public places; people with coughs and colds etc. If you do become unwell, you must seek medical advice straight away. Examples of situations in which to seek advice are the same as before / during your transplant and could be: • Temperatures of 38°C or near to this • Vomiting and/or diarrhoea that doesn’t settle within 24 hours • Being unusually short of breath whilst at rest or upon exertion • Developing ‘flu’ like symptoms such as sore throat, runny nose, etc You must telephone your nurses at Harley St at UCH or contact your local hospital if this happens. Your local hospital should contact Harley St at UCH for advice or direction of your care in this instance. Remember, there is never a wrong time to seek help or advice and feeling ‘unwell’ takes many forms. Always seek guidance if you are in any way concerned.

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Fatigue or tiredness In the first few months following your transplant you can expect to feel very fatigued or tired. Fatigue is a really common side effect of treatment and you should regain near normal strength within a few months after you go home. A transplant is a very exhausting experience physically, emotionally and mentally. You can expect it to take between three and six months to get your energy levels back to ‘normal’ and before you can go back to work etc. For some, it takes longer. This isn’t however an excuse to ‘wrap yourself in cotton wool’ – you must continue to make a daily effort to getting back to your usual routine. Don’t set yourself impossible targets or compare yourself to healthy friends. You’ve just undergone a stem cell transplant. Try to do a task (however simple it seems), for the day. If it’s too much, rest and try again the following day. Gradually you will get stronger.

Physical appearance During your transplant you will lose your hair but this will grow back after several weeks of being discharged home from hospital. The colour and / or texture of your hair may be slightly different when it grows back. Expect your hair to be ‘baby fine’ in the first couple of weeks. Use baby shampoo (it’s less astringent than commercial shampoo brands) and massage your scalp when you bathe to help stimulate your hair follicles. Your skin might be slightly drier than normal and again this is due to your treatment. You may find it more comfortable to use mild, un-perfumed (sensitive) body washes and moisturisers.

Weight loss It’s usual for you to experience taste changes and for your appetite to change when you undergo a stem cell transplant. Whilst we will try to keep any weight loss to a minimum in hospital, you can expect to put any lost weight back on once you get home - over a period of weeks. Your Nurse can refer you to the hospital dietician at any point if you need help or advice in regard to your diet or if you’re worried about your food intake.

Sex drive and sexual activity Generally it’s ok to have sex or resume your usual sexual activity as long as you maintain good hygiene and you do not put yourself at risk of STI’s (sexually transmitted infections). Throughout your stem cell transplant process your blood counts and your immune system are low. You and your partner are advised against oral – genital and / or anal sex during this time and also during your early recovery time post-transplant. If you have sex it’s recommend that you use condoms (in addition to any birth control medicines you may be taking); dental dams or other protective measures. Your sex life can be affected by changes

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in your body image, physical appearance and general tiredness post-transplant. Despite how distressing it seems, this is entirely normal. Some women may experience the signs of early menopause – including symptoms such as hot flushes, vaginal dryness, vaginal tightness and mood swings. Men may experience erectile dysfunction, ejaculation problems and mood swings as well. If these become significant issues for you and your partner, you can discuss them with your doctor and nurse when you come to the hospital for your ‘Post – Transplant’ follow up appointment.

Returning to work This will depend on the speed of your recovery / how quickly you ‘get your strength back’. Post-transplant fatigue is therefore a significant factor in deciding when you return to your job. Most patients take at least an extra one to two months after going home before they contemplate going back to work – especially if your job is one which is particularly stressful or physically demanding. It might be an idea that you start back on a part time basis and see how you cope from there. We can provide you / help with any medical certificates, etc, you might need to cover this time off.

Going on holiday Until your immune system is fully recovered and you feel your general strength is returning, we advise that you wait a while before planning any trips away. Some patients plan for a short break or holiday after about four to six weeks after going home. ‘Long-haul’ trips are generally more tiring and might be better planned for or achieved some time after this. Again there is no set rule, but we advise you to be cautious about travelling abroad especially in the early weeks of your recovery.

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Section 16: Glossary A Alopecia

Hair loss

Anaemia

A condition where there is a decreased number of red blood cells

Autologous transplant

Transplant using your own bone marrow or stem cells

B Blood count

Numbers of cells in the blood

Bone marrow

Soft spongy material in bones which produces blood cells

C Chemotherapy

Drugs used in the treatment of cancer. They work by killing the cancer cells or slowing their growth

E Engraftment

Process whereby new bone marrow begins to grow and produce new cells; indicated by rise in blood counts

H Haemoglobin

Amount of iron carried by red blood cells. Lack of haemoglobin is called anaemia

Haemopoietic

Relating to the formation of blood or blood cells, such as ‘haemopoietic stem cells in bone marrow’

Lymphocytes

Type of white blood cell

L M Mucositis

Mucositis is a condition characterised by pain and inflammation of the surface of the mucous membrane. The mucous membrane is the soft layer of tissue that lines the digestive system from the mouth to the anus Mucositis is often divided into two main types, including: • oral mucositis, which occurs inside the mouth and can cause painful mouth ulcers (sores) to develop • gastrointestinal mucositis, which occurs inside the digestive system and often causes diarrhoea

N Neutropenia

Low white cell count

Northisterone

A hormone similar to the contraceptive pill, to prevent periods

Platelets

Cells which help blood to clot

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Section 17: Useful organisations Cruse Bereavement Care Helpline: 0844 477 9400 Website: www.cruse.org.uk Email: [email protected] Multiple Sclerosis Society Helpline: 0808 800 8000 Website: www.mssociety.org.uk Email: [email protected] The Macmillan Support and Information Centre The Macmillan Support and Information Centre welcomes all people with cancer and red cell haematological conditions, and their families and friends. It offers one to one support and a range of information resources. The Centre operates a drop in service (09:00 to 17:00, Monday to Friday) and is located on the ground floor of the UCH Macmillan Cancer Centre, Huntley Street, London, WC1E 6AG. Telephone: 020 3447 8663 Email: [email protected] RD4U (Support for young people following the death of someone close) Freephone helpline: 0808 808 1677 Website: www.rd4u.org.uk Email: [email protected]

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Section 18: Contact details Location

Direct dial

Extension*

Harley Street at University College Hospital inpatients, nurses’ station: South North

020 3447 1595 020 3447 1545

71595 71545

Harley Street at University College Hospital outpatients and day care, reception area

020 3447 1700 020 3447 1701

71700 71701

Haematology Apheresis Unit, 4th floor, The UCH Macmillan Cancer Centre

020 3447 1803

71803 78955

Apheresis unit nurses’ station

020 3447 8955

71804

For Professor Mackinnon or Dr Chris McNamara please contact their practice manager: Yasmina Adhihetty T: 020 3447 1728 E: [email protected] For Dr Panos Kottaridis or Dr Chara Kyriakou please contact their secretary: Tenzin Seldon T: 020 3447 1528 E: [email protected] For Ashutosh Wechalekar please contact his secretary: Jean Berkeley T: 020 7433 2816 E: [email protected] *Dial the UCLH switchboard on 0845 1555 000 or 020 3456 7890 then ask for the extension number

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Section 19: How to find us Inpatients T15, UCLH 235 Euston Road London NW1 2BU T: 020 3447 1500

Outpatients and day care 5th Floor, The UCH Macmillan Cancer Centre, Huntley Street London WC1E 6AG T: 020 3447 1700

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Harley Street at University College Hospital Inpatients and Correspondence 15th floor, 235 Euston Road London NW1 2BU Tel 020 3447 1500 Fax 020 3447 1590 Harley Street at University College Hospital Outpatients and Day Cases 5th floor, The UCH Macmillan Cancer Centre Huntley Street London WC1E 6AG Tel 020 3447 1700 www.harleystreetatuch.co.uk *This version checked on 04/01/2016

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