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With studies lacking, expert opinion leads guidance for DMT therapy in MS during the COVID-19 pandemic

BY FRIEDA WILEY, PHARMD

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As the COVID-19 pandemic remains steadfast, medical communities continue seeking updated guidance on how the outbreak affects their respective patient populations, and multiple sclerosis (MS) is no exception. To help address this question in the MS population, a group of researchers recently published a narrative review of national and international recommendations on disease-modifying therapies (DMT) during the COVID-19 outbreak. Their article appeared in the July/August issue of the International Journal of MS Care.


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“When the pandemic started there was limited knowledge of what to expect from infection in someone with immune modulating drugs, so patients were anxious and concerned,” said Mirla Avila, MD, assistant profession and associate program director of neurology and director of neuroimmunology of multiple sclerosis and demyelinating diseases clinic at Texas Tech University Health Science Center, Lubbock, and the study’s corresponding author. “The most important takeaway is that by summarizing the different recommendations and guidelines from different countries we can unify the care of MS patients.”

More than 2 million people have MS worldwide – a statistic that earns the condition first place as the most prevalent chronic immune-mediated disorder of the central nervous system. In addition to the stressors MS places on the immune system, DMT may affect patient susceptibility to COVID-19 by modulating and suppressing the immune system. To date, there are no clinical studies or observational studies that offer data or guidance evaluating how to treat MS during the pandemic or how MS medications affect the risk of infections. As a result, current guidances have been derived from expert opinions. MS experts have yet to reach a complete consensus offering clinicians guidance on managing DMT therapy during this pandemic.

To compile and assess available studies, researchers searched for publications using MEDLINE, Embase, and Cochrane databases from the inception of the outbreak until April 14, 2020, using keywords associated with MS and coronavirus. They also conducted a Google search on the same day.

As it stands, key recommendations regarding treating MS patients with DMTs include the following: The preferred treatment in MS patients during the COVID-19 pandemic is a DMT that does not negatively impact lymphocyte counts. All patients who have MS and are receiving DMT therapy should continue the course of treatment, regardless of whether they have active infections. Most MS organizations share the general consensus that consider delaying cell-depleting therapy DMT based on assessments of their individual risks of infection and relapse. Clinicians may choose to hold oral and injectable DMTs and delay cell-depleting DMTs in patients who have an active COVID-19 infection.

Dr. Mirla Avila

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 European Academy of Neurology guidance advises clinicians to initiate therapy of cell-depleting DMTs such as alemtuzumab, anti-CD2 monoclonal antibodies, and cladribine by evaluating the risk versus the benefit. The academy recommends delaying these therapies in MS patients until after the COVID-19 pandemic peaks within the patient’s region, reserving the initiation of such treatments only when the patient faces a greater risk of contracting a severe COVID-19 infection. The Association of British Neurologists’ recommendations discourage clinicians from alemtuzumab and cladribine induction during the pandemic altogether. Ocrelizumab may serve as an alternative in cases where high-efficacy DMT therapy is warranted and the patient is not a candidate for natalizumab.

Depending on the regional incidence of the COVID-19 pandemic, the EAN encourages patients and clinicians to consider engaging home-based infusion services instead of utilizing infusion centers. The EAN along with other organizations recommend the continuation of intermittent immunotherapies provided clinicians take appropriate preventative measures to help ward off COVID-19 infections.

Guidance regarding monitoring laboratory monitors differs. For example, the Multiple Sclerosis Society of New Zealand urges clinicians to continue blood monitoring in patients taking certain DMTs, such as teriflunomide, dimethyl fumarate, fingolimod, siponimod, and natalizumab, with more frequent monitoring in cases where lymphopenia occurs.

Despite these guidances, Dr. Avila cautioned that clinicians should bear mind the transient nature of the data upon which these recommendations were based.

“The review was done early in the pandemic, and as we know more about the virus and what to expect, recommendations may change,” she said in an interview.

Other important considerations Dr. Avila noted health care providers should observe are the data from patients who get infected during the pandemic, the outcome correlated to their morbidities and MS medications needed. She maintains this information will prove useful as the MS community prepares for a second wave.