A fine balance: Immunosuppression and immunotherapy in a patient with multiple sclerosis and COVID-19

Valencia‐Sánchez, Cristina; Wingerchuk, Dean M.

doi:10.1016/j.msard.2020.102182

Cited by 39 publications

(33 citation statements)

References 12 publications

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“…Moreover, using immunosuppressant drugs during the COVID-19 pandemic remains a challenge (9). Immunosuppressed patients could be at a higher risk for a more severe COVID-19 course.…”

Section: Discussionmentioning

confidence: 99%

Myasthenia Gravis and COVID-19: Clinical Characteristics and Outcomes

et al. 2020

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Myasthenia gravis (MG), an autoimmune neuromuscular disorder, may be a risk factor for severe COVID-19. We conducted an observational retrospective study with 15 consecutive adult MG patients admitted with COVID-19 at four hospitals in São Paulo, Brazil. Most patients with MG hospitalized for COVID-19 had severe courses of the disease: 87% were admitted in the intensive care unit, 73% needed mechanical ventilation, and 30% died. Immunoglobulin use and the plasma exchange procedure were safe. Immunosuppressive therapy seems to be associated with better outcomes, as it might play a protective role.

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“…Moreover, using immunosuppressant drugs during the COVID-19 pandemic remains a challenge (9). Immunosuppressed patients could be at a higher risk for a more severe COVID-19 course.…”

Section: Discussionmentioning

confidence: 99%

Myasthenia Gravis and COVID-19: Clinical Characteristics and Outcomes

et al. 2020

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“…It is likely safe to continue ongoing treatment during the pandemic provided the ALC is higher than 200/mm 3 and is likely safe (and potentially beneficial) to even do so in patients infected with COVID-19. Two cases of COVID-19 worsening after stopping fingolimod have been reported [56,57]. Treatment interruption may be considered if ALC goes below 200/mm 3 although the impact of this low level of circulating lymphocytes on infection risk is not well defined [58].…”

Section: Potential Relevance To the Covid-19 Pandemic And Possible Rimentioning

confidence: 99%

Multiple Sclerosis Disease-Modifying Therapy and the COVID-19 Pandemic: Implications on the Risk of Infection and Future Vaccination

et al. 2020

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The coronavirus 2019 (COVID-19) pandemic is expected to linger. Decisions regarding initiation or continuation of diseasemodifying therapy for multiple sclerosis have to consider the potential relevance to the pandemic. Understanding the mechanism of action and the possible idiosyncratic effects of each therapeutic agent on the immune system is imperative during this special time. The infectious side-effect profile as well as the route and frequency of administration of each therapeutic agent should be carefully considered when selecting a new treatment or deciding on risk mitigation strategies for existing therapy. More importantly, the impact of each agent on the future severe acute respiratory syndrome coronavirus type-2 (SARS-CoV-2) vaccine should be carefully considered in treatment decisions. Moreover, some multiple sclerosis therapies may have beneficial antiviral effects against SARS-CoV-2 while others may have beneficial immune-modulating effects against the cytokine storm and hyperinflammatory phase of the disease. Conventional injectables have a favorable immune profile without an increased exposure risk and therefore may be suitable for mild multiple sclerosis during the pandemic. However, moderate and highly active multiple sclerosis will continue to require treatment with oral or intravenous high-potency agents but a number of risk mitigation strategies may have to be implemented. Immune-modulating therapies such as the fumerates, sphinogosine-1P modulators, and natalizumab may be anecdotally preferred over cell-depleting immunosuppressants during the pandemic from the immune profile standpoint. Within the cell-depleting agents, selective (ocrelizumab) or preferential (cladribine) depletion of B cells may be relatively safer than non-selective depletion of lymphocytes and innate immune cells (alemtuzumab). Patients who develop severe iatrogenic or idiosyncratic lymphopenia should be advised to maintain social distancing even in areas where lockdown has been removed or ameliorated. Patients with iatrogenic hypogammaglobulinemia may require prophylactic intravenous immunoglobulin therapy in certain situations. When the future SARS-CoV-2 vaccine becomes available, patients with multiple sclerosis should be advised that certain therapies may interfere with mounting a protective immune response to the vaccine and that serological confirmation of a response may be required after vaccination. They should also be aware that most multiple sclerosis therapies are incompatible with live vaccines if a live SARS-CoV-2 vaccine is developed. In this article, we review and compare disease-modifying therapies in terms of their effect on the immune system, published infection rates, potential impact on SARS-CoV-2 susceptibility, and vaccine-related implications. We propose risk mitigation strategies and practical approaches to disease-modifying therapy during the COVID-19 pandemic.

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“…In the most severe case, high levels of IL-6 were reported and intubation was necessary. If discontinuation of fingolimod increased the risk of acute respiratory distress syndrome, or if fingolimod effect per se is attributable to this course, remains unknown [81][82][83][84][85]. Notably, two patients remained completely asymptomatic during COVID-19 infection [86].…”

Section: Glatiramer Acetatementioning

confidence: 99%

Immunology of COVID‐19 and disease‐modifying therapies: The good, the bad and the unknown

Zrzavy

Wimmer

Rommer

et al. 2020

Euro J of Neurology

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The outbreak of the SARS‐CoV‐2 pandemic, caused by a previously unknown infectious agent, posed unprecedented challenges to healthcare systems and unmasked their vulnerability and limitations worldwide. Patients with long‐term immunomodulatory/suppressive therapies, as well as their physicians, were and are concerned about balancing the risk of infection and effects of disease‐modifying therapy. Over the last few months, knowledge regarding SARS‐CoV‐2 has been growing tremendously, and the first experiences of infections in patients with multiple sclerosis (MS) have been reported. This review summarizes the currently still limited knowledge about SARS‐CoV‐2 immunology and the commonly agreed modes of action of approved drugs in immune‐mediated diseases of the central nervous system (MS and neuromyelitis optica spectrum disorder). Specifically, we discuss whether immunosuppressive/immunomodulatory drugs may increase the risk of SARS‐CoV‐2 infection and, conversely, may decrease the severity of a COVID‐19 disease course. At present, it can be recommended in general that none of those therapies with a definite indication needs to be stopped per se . A possibly increased risk of infection for most medications is accompanied by the possibility to reduce the severity of COVID‐19. Despite the knowledge gain over the last few months, current evidence remains limited, and, thus, further clinical vigilance and systematic documentation is essential.

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A fine balance: Immunosuppression and immunotherapy in a patient with multiple sclerosis and COVID-19

Cited by 39 publications

References 12 publications

Myasthenia Gravis and COVID-19: Clinical Characteristics and Outcomes

Myasthenia Gravis and COVID-19: Clinical Characteristics and Outcomes

Multiple Sclerosis Disease-Modifying Therapy and the COVID-19 Pandemic: Implications on the Risk of Infection and Future Vaccination

Immunology of COVID‐19 and disease‐modifying therapies: The good, the bad and the unknown

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