Treating multiple sclerosis and neuromyelitis optica spectrum disorder during the COVID-19 pandemic

Abstract

The emergence of novel coronavirus 2019 (COVID-19) 1 and the subsequent pandemic present a unique challenge to neurologists managing patients with multiple sclerosis (MS) and related neuroinflammatory disorders, such as neuromyelitis spectrum disorder (NMOSD). National professional bodies (e.g., Italian Society of Neurology and Association of British Neurologists) and patient organizations (e.g., National MS Society, MS International Federation, UK MS Society, and MS Australia) have responded rapidly by issuing guidelines for the COVID-19 pandemic, primarily focused on MS disease-modifying therapies (DMTs). In this commentary, we highlight the implications of COVID-19 for people with MS and related disorders, including the risk of respiratory infections, general health advice, and recommendations (from consensus-based guidelines) for immunotherapies, relapse management, and service delivery during the COVID-19 pandemic. Risk of respiratory infectionsWhether people with MS and NMOSD are at an increased risk of COVID-19 infection or at a higher risk of more severe infection is unknown. There are no data available on whether the rate of mild, self-limiting respiratory infections that do not require a medical encounter is increased in people with MS. However, there is increased infection-related health care utilization across all age groups in people with MS compared with the general population. 2 These infections include pneumonia 2,3 (particularly in people with bulbar weakness resulting in aspiration and impaired pulmonary function due to severe quadriparesis) and influenza, 3 but not upper respiratory tract infections. 2 Older age, male sex, worse physical disability, and lower socioeconomic status are associated with increased hospitalization rates in MS. 3 People with MS have a higher risk of intensive care unit admission with infections and higher 1-year mortality after admission than the general population. 4 In addition to the higher background risk of infection-related health care utilization, people with MS treated with the secondgeneration DMTs are exposed to a further increased risk of infections. 5 These factors should be considered when counseling individuals about the risks of COVID-19 infection. General health advicePeople with MS and related disorders should follow World Health Organization (WHO) and national or local health authority guidance on preventive measures to reduce transmission of COVID-19 in the general population. These include social distancing, frequent hand washing with soap and water or an alcohol-based hand rub, and respiratory hygiene. Advice from the WHO is updated regularly (who.int/emergencies/diseases/novel-coronavirus-2019).

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.…”

“…Paradoxically, it has been hypothesized that certain immunomodulatory treatments have a beneficial effect on COVID-19 infection. 1 …”

A case series and literature review of multiple sclerosis and COVID-19: Clinical characteristics, outcomes and a brief review of immunotherapies

“…Predominantly, it has an effect on B-cell lineage has minimal effects on the T-cell population mainly on a subset of T-cells and is not associated with severe viral infections [ 19 ]. Glatiramer acetate, Dimethyl fumarate and Ocrelizumab are considered to be very low risk, low risk and intermediate risk categories of disease modifying agents respectively, to attribute to the risk of novel coronavirus infection [ 3 , 20 ]. Assuming the antiviral response to SARS-CoV-2 is driven mainly by CD8+ cytotoxic T-cells, NK cells, and less so B cells, we should be aware of the risk associated with different classes of DMT in case a patient with MS develops COVID-19.…”

Neuroinvasive Potential of A Primary Respiratory Pathogen SARS-CoV2: Exploring the Underrecognized

“…Firstly, they are more predisposed than general population to acquire the virus. Secondly, treatment plan needs to be individualized for patients on long term immune suppression because evidence-based guidelines are lacking at present [52]. Therefore, a more patient-tailored approach has to be adapted by the neurologists in present circumstances.…”