<p>Managing Disease-Modifying Therapies and Breakthrough Activity in Multiple Sclerosis Patients During the COVID-19 Pandemic: Toward an Optimized Approach</p>

Abstract

The emergence of the novel coronavirus disease 2019 (COVID-19) pandemic has become a major public health challenge of global concern since December 2019, when the virus was recognized in Wuhan, the capital city of Hubei province in China and epicenter of the COVID-19 epidemic. Given the novelty of COVID-19 and the lack of specific anti-virus therapies, the current management is essentially supportive. There is an absence of consensus on guidelines or treatment strategies for complex disorders such as multiple sclerosis (MS), in which the risk of infections is higher than in the general population. This is due to the overall impairment of the immune system typical of autoimmune diseases, in addition to accumulation of disabilities, and the iatrogenic effect generated by corticosteroids and the recommended disease-modifying therapies (DMTs). DMTs have different modes of action, but all modulate and interfere with the patient's immune response, thereby raising concerns about adverse effects, such as an increased susceptibility to infections. In this review, we analyze the evidence for use of DMTs during the current critical period and ratify an algorithmic approach for management to optimize care between keeping DMTs, with their infection hazards, or coming off them, with the risk of disease activation. We also provide an algorithmic approach to the management of breakthrough activity during the COVID-19 pandemic.

COVID-19 in ocrelizumab-treated people with multiple sclerosis

“…However, it should be noted that approximately one-quarter of the hospitalized cases in clinical trials had only moderate COVID-19. This suggests a potential referral bias likely driven by the general concern at the start of the pandemic and reflected in several guidelines, that patients on immunosuppressive/depleting drugs were at potential risk for severe disease and ocrelizumab infusions should be delayed ( Brownlee et al, 2020 ; Giovannoni et al, 2020 ; Hamdy et al, 2020 ).…”

The course of COVID-19 infection in patients with multiple sclerosis–The experience of one center based on the population of Upper Silesia

“…Hamdy et al suggested that DMD therapy should be discontinued in patients with active COVID-19 infection. 2 The Section of MS and Neuroimmunology of the Polish Neurological Society recommend discussing this issue with patients and consider their age, clinical condition and the type of DMD. 8 Therapy should be continued in the case of a mild course of the infection or during treatment with interferon, glatiramer, teriflunomide, dimethyl fumarate and in patients without lymphopenia (<800/ul).…”

“…3 The risk of infection differs in patients and can be increased by comorbidities and older age. 2 Infectious diseases may also lead to the deterioration of MS. The relationship between MS and COVID-19 is uncertain.…”

Transient monocular visual impairment as an initial symptom of COVID-19 infection in an individual with multiple sclerosis receiving teriflunomide

“…Fingolimod poses a moderate risk for COVID-19 infection. Alemtuzumab, rituximab, ocrelizumab, and cladribine continue to pose a significant risk [ 14 ]. Previous studies have shown that the overactivation of the innate immune response or an inadequate innate and adaptive immune response is associated with poorer outcomes [ 7 ].…”