The COVID-19 pandemic and the use of MS disease-modifying therapies

Abstract

Maria was distraught after reading about the 'potential' epidemic, yet to happen, and the horror stories on Facebook needing reassurance and certainty about what she should do. She requested an urgent appointment to review her treatment plan. Maria was a 26-year-old woman with relapsing multiple sclerosis who had recently experienced brainstem relapse with double vision and ataxia despite treatment with pegylated interferon-beta for the last 18 months. A brain MRI performed one month prior had shown 16 new T2 lesions, four of which were enhancing. One of the enhancing lesions was at the pontomedullary junction and was certainly the cause of her relapse. Treatment was to be escalated to ocrelizumab with the first dose in a week's time. In view of the emerging coronavirus pandemic, she was questioning whether or not she should go ahead with ocrelizumab. This was despite only a handful of confirmed COVID-19 cases in the country and none in her town and region.If this scenario sounds plausible what should neurologists do? Human coronaviruses are predominantly associated with respiratory tract infections and includes those that cause severe acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS) and now the COVID-19 pandemic.In an uncertain world, where we do not have a clear evidence-base, you often have to default to scientific principles, rather than using the wisdom of the crowd. Not surprising, with Italy being one of the epicentres of the COVID-19 epidemic, the Italian society of neurology or SIN (Società Italiana di Neurologia) broke cover first producing recommendations on the management of patients with MS during the COVID-19 epidemic (see Box 1). The SIN guidelines provide relatively straightforward, and one could argue arbitrary, advice on how to manage patients with MS in the short-term, but do not address supervision of these patients in the intermediate or long-term especially those with highly active MS. If the public health measures being taken flatten the peak of the epidemic, but extend its tail, the problem of community-acquired SARS-CoV2 infection and COVID-19 may be with us for many months and potentially years. Are the SIN guidelines compatible with the best interests of our patients or a knee-jerk response to an undefined problem that may not be a problem at all?

COVID-19 in multiple sclerosis: The Dutch experience

“…This is of importance as some neurologists advise dose reduction or discontinuing treatment in lymphopenic patients. 1 , 3 To date, data on lymphocytes and DMT use in MS patients are lacking.…”

COVID-19 infection in a patient with multiple sclerosis treated with fingolimod

“…Consensus statements mostly recommend cautious in the use and initiation of high-efficacy medications and deem the lower-efficacy medications safer during the pandemic. 4 Therapeutic decision-making is more challenging in patients with active COVID-19 in whom discontinuation of immunotherapies could lead to rebound disease activity (e.g., fingolimod). 5,6 In our patient, despite multiple comorbidities, the COVID-19 was resolved with good outcome, and there was no need for intensive care unit or intubation.…”

MS, pregnancy and COVID-19

“… 54 These DMTs are not directly immunosuppressive and therefore are currently not routinely being stopped in response to the COVID-19 pandemic. 55 …”

“…Induction, ‘lymphodepleting’ DMTs, which may be used some months prior to pregnancy to induce disease remission prior to trying to conceive, includes ocrelizumab, alemtuzumab, rituximab and cladribine. Caution is currently recommended when initiating these treatments; however, advice is changing as evidence increases; 55 the most recent evidence, available in preprint form only, indicates that there may be potentially increased risk of severe COVID-19 in those treated with anti-B cell monoclonal antibodies.Treatment decisions should be individualised according to disease activity and relapse risk, the number of cycles already taken and co-morbidities associated with potential complications following COVID-19 infection, such as smoking, immobility and increased age. 55 While relapses are less common during pregnancy, if they do occur, corticosteroid treatment may be considered as per below.…”