Alemtuzumab in multiple sclerosis during the COVID-19 pandemic: A mild uncomplicated infection despite intense immunosuppression

Carandini, Tiziana; Pietroboni, Anna M.; Sacchi, Luca; Riz, Milena A. De; Pozzato, Mattia; Arighi, Andrea; Fumagalli, Giorgio; Boneschi, Filippo Martinelli; Galimberti, Daniela; Scarpini, Elio

doi:10.1177/1352458520926459

Cited by 40 publications

(37 citation statements)

References 6 publications

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“…Both recovered without sequelae, stopped shedding coronavirus with PCR-negative nasopharyngeal swabs, and developed IgG antibodies against SARS-CoV-2, even with extremely low lymphocyte counts. Similar experiences, with uneventful recoveries despite lymphopenia, have been described in four people with MS who suffer a mild COVID-19 disease one week ( Carandini et al., 2020 ), two months ( Guevara et al., 2020 ) and one year ( Matías-Guiu et al., 2020 ) after their second course of Alemtuzumab.…”

Section: Discussionsupporting

confidence: 66%

COVID-19 and multiple sclerosis: A description of two cases on alemtuzumab

Fernández-Díaz

Gil

García-García

et al. 2020

Multiple Sclerosis and Related Disorders

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Background: Alemtuzumab is a treatment for highly active multiple sclerosis (MS). Immunosuppression is considered a risk factor for SARS-CoV-2 infection and there is still lack of evidence to guide MS practice. Methods/results: We describe the clinical and immunological evolution of two MS patients under alemtuzumab treatment who were affected by COVID-19, one of them only one week after receiving her last dose, and both recovered without sequelae. Conclusion: In selected patients (young, without comorbidities, and with high activity), MS itself could be more dangerous than COVID-19, so we should consider continuing MS treatment as previously planned, including alemtuzumab.

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Section: Discussionsupporting

confidence: 66%

COVID-19 and multiple sclerosis: A description of two cases on alemtuzumab

Fernández-Díaz

Gil

García-García

et al. 2020

Multiple Sclerosis and Related Disorders

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“…Two separate case reports of COVID-19 infection during the cell-depletion phase of alemtuzumab therapy have been described at the time of this writing [ 87 , 88 ]. Both patients received their second cycle of alemtuzumab therapy during the peak of the pandemic and developed the infection shortly after receiving the second cycle (1 week after treatment in one patient and 2 months after treatment in the other).…”

Section: Current Multiple Sclerosis Disease-modifying Therapiesmentioning

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 light of these profound alterations within distinct immunological compartments, anti-viral cellular immune responses are likely to be impaired. However, to date, we are aware of six case reports on patients who received alemtuzumab and experienced a mild COVID-19 disease course [154][155][156][157]. Of the published larger cohorts with a positive SARS-CoV-2 PCR, one patient received alemtuzumab treatment without reported complications [58][59][60][61][62] harmful effects cannot be excluded, however, consistent with a general view on effects of immunosuppressants in hyperinflammatory syndrome, it may be speculated that alemtuzumab has anti-inflammatory properties for this condition.…”

Section: Alemtuzumabmentioning

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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Alemtuzumab in multiple sclerosis during the COVID-19 pandemic: A mild uncomplicated infection despite intense immunosuppression

Cited by 40 publications

References 6 publications

COVID-19 and multiple sclerosis: A description of two cases on alemtuzumab

COVID-19 and multiple sclerosis: A description of two cases on alemtuzumab

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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