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MS groups weigh how DMT may influence COVID-19 risks

By Jake Remaly

credit: Courtesy NIAID-RML

Disease-modifying therapies for multiple sclerosis may affect the risk of COVID-19 infection, but much information about this subject remains uncertain. Several groups have provided guidance based on scientific principles. Treatment decisions should consider individual patient factors and the risk of stopping therapy, organizations suggest.


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Many disease-modifying therapies (DMTs) suppress or modify the immune system, but neurologists currently lack evidence about how COVID-19 affects patients with multiple sclerosis, according to the Multiple Sclerosis International Federation (MSIF). The federation published guidance on DMTs and COVID-19 based on advice from MS neurologists and research experts from its member organizations. “Some MS medications might increase the likelihood of developing complications from a COVID-19 infection,” according to the MSIF, “but this risk needs to be balanced with the risks of stopping treatment.”

credit: Courtesy NIAID-RML

Recommendations may vary

“There are numerous recommendations circulating that attempt to provide clarity and guidance, however, differences among the recommendations have created confusion,” according to the National MS Society. “DMT decision making varies significantly from country to country, ranging from highly provider directed to a collaborative decision-making model. … DMT decisions should be individualized and made collaboratively between the person with MS and his/her health care provider.”

Patients with MS and their physicians should weigh risks and benefits before starting cell-depleting DMTs such as alemtuzumab, cladribine, ocrelizumab, or rituximab, according the National MS Society. They also should consider the risks and benefits of DMTs that carry warnings of a potentially severe increase in disability after stopping therapy, including fingolimod and natalizumab. “We endorse the global advice provided by the [MSIF] – but emphasize that DMT decision making must be individualized and based upon multiple factors,” such as MS disease course, other medical conditions, other medications, and patient values and risk tolerance, the National MS Society said.

The Consortium of MS Centers and the MS Coalition have endorsed the National MS Society DMT guidance and the MSIF global advice.

“Some MS medications might increase the likelihood of developing complications from a COVID-19 infection,” according to the MSIF, “but this risk needs to be balanced with the risks of stopping treatment.”

Recommendation to continue therapy

Patients currently taking DMTs should continue treatment, according to the MSIF. Those who develop symptoms of COVID-19 or test positive for the infection should discuss their DMT with a health care professional who is familiar with their care. Decisions about starting a DMT should take into account a patient’s disease course, disease activity, and regional COVID-19 risks, the MSIF suggests. For patients due to start DMT, treatments that do not reduce lymphocytes, such as interferons, glatiramer acetate, or natalizumab, should be considered. “Medications that reduce lymphocytes over longer intervals include alemtuzumab, cladribine, ocrelizumab and rituximab,” the MSIF said.

Fingolimod, dimethyl fumarate, teriflunomide, and siponimod “may reduce the ability of the immune system to respond to an infection,” and “people should carefully consider the risks and benefits of initiating these treatments during the COVID-19 pandemic,” according to the MSIF. “People with MS who are currently taking alemtuzumab, cladribine, ocrelizumab, rituximab, fingolimod, dimethyl fumarate, teriflunomide, or siponimod and are living in a community with a COVID-19 outbreak should isolate as much as possible to reduce their risk of infection.”

Recommendations vary by country regarding the possibility of delaying doses of alemtuzumab, cladribine, ocrelizumab, and rituximab. “People who take these medications and are due for the next dose should consult their health care professional about the risks and benefits of postponing treatment,” the MSIF said.

Patients with MS who recently have undergone autologous hematopoietic stem cell treatment “should extend the period they remain in isolation during the COVID-19 outbreak,” according to the MSIF. In some cases, postponing this procedure may be warranted.

Dr. Gavin Giovannoni

People with MS who are currently taking alemtuzumab, cladribine, ocrelizumab, rituximab, fingolimod, dimethyl fumarate, teriflunomide, or siponimod and are living in a community with a COVID-19 outbreak should isolate as much as possible to reduce their risk of infection.

Accelerated dissemination of information

Gavin Giovannoni, MBBCh, PhD, of Blizard Institute at Queen Mary University of London, has answered questions about MS and COVID-19 and described case reports on his website, MS-Selfie. In addition, Dr. Giovannoni and coauthors wrote a commentary, “The COVID-19 pandemic and the use of MS disease-modifying therapies,” which was published in Multiple Sclerosis and Related Disorders.

“The potential hazards posed by each DMT differ and, rather than imposing a blanket rule, decisions regarding treatment should be individualized and discussed with patients,” Dr. Giovannoni and colleagues wrote. “For some patients having their MS treated and controlled may be more important than the potential danger of being exposed to and acquiring a more severe COVID-19 infection.”

Dr. Giovannoni also coauthored the Association of British Neurologists’ guidance on the use of MS DMTs during the COVID-19 pandemic [https://www.theabn.org/page/covid19_guidelines]. Amid the pandemic, neurologists are gathering and sharing information at an accelerated pace. For example, the commentary was written and published online in a week, Dr. Giovannoni said on Twitter.

“The need for up-to-date and reliable information in relation to [MS and COVID-19], which changes on a daily basis, is turbocharging the traditional processes that underpin medical and scientific publishing,” he said.