COVID-19 in People With Multiple Sclerosis

Dr Heather Wilson, consultant neurologist at the Royal Free London NHS Foundation Trust, explains how COVID-19 affects people with multiple sclerosis and discusses whether their treatment should be adjusted until the risk level abates.

Are people with multiple sclerosis more prone to contracting COVID-19 or at a higher risk of complications from COVID-19?

As far as we are aware, having MS doesn't make people more liable to contract the virus or at more risk from serious consequences of COVID-19 infection. However, risk may be increased in people with MS who are taking immunosuppressive disease-modifying therapies, or in people who are severely disabled from MS, with speech and swallowing difficulties who can’t protect their airways well, or those who use a wheelchair or are confined to bed.

Does COVID-19 present differently in MS patients?

No, people with MS can be expected to experience exactly the same typical symptoms of COVID-19. The only difference is that COVID-19 infection could potentially exacerbate existing neurological symptoms and fatigue, or even precipitate an acute relapse, much like other viral infections do.

Should disease-modifying therapy (DMT) regimens be modified during the COVID-19 pandemic?

This is a major area of concern for MS physicians. Because MS is characterised by overactivity of the immune system, the DMTs are all either immune-modulatory or immune-suppressive. COVID-19 risk depends on the individual therapy. These can be broadly categorised into three groups:

Moderately effective DMTs: beta interferons, glatiramer acetate, and teriflunomide

More effective DMTs: dimethyl fumarate, and fingolimod tablets

Highly effective DMTs: cladribine induction, natalizumab monthly infusions, ocrelizumab biannual infusions, and alemtuzumab induction

Moderately Effective DMTs

These treatments don’t weaken the immune system, and so do not increase risk of COVID-19 infection or complications.

Indeed beta interferon has antiviral activity and inhaled beta-interferon is being trialled as a treatment for the serious respiratory complications of COVID-19. Therefore, beta interferon is not only safe during the COVID-19 pandemic, but it is possible that it may even confer some protection.

More Effective DMTs

Dimethyl fumarate tablets do not cause immunosuppression and so are likely to be safe. Patients taking fingolimod tablets are at slightly increased risk of COVID-19 although are not in the ‘high risk’ group. Fingolimod reduces the number of circulating lymphocytes in the blood by sequestering them in the lymph nodes. Most patients will therefore have a low lymphocyte count and still be quite safe. Only those with an extremely low count might be at increased risk of infection and in that small group of patients we would recommend that the dose is reduced to alternate day fingolimod during this period of uncertainty. However, stopping the medication completely is likely to cause a rebound increase in MS activity and the consensus is that as a rule people should continue to take this medication at the usual dose.

Interestingly, fingolimod is also being trialled as an agent that may reduce the risk of serious consequences of established COVID-19 infection, which are felt to be immune-mediated.

Highly Effective DMTs

People on the highly effective DMT agents need to be aware that their immune system is weakened. This is particularly the case for people who have had alemtuzumab or cladribine induction within the past 4 to 6 months.

Induction involves giving a course of treatment which reboots the immune system in an attempt to stop it misidentifying the central nervous system and causing the inflammation and demyelination seen in MS.

Cladribine tablets are given in two 5-day courses one year apart. The beneficial effects last for at least the next 4 years. Alemtuzumab is an infusion given for 5 days, repeated after a year. More than 50% of people remain disease-free for up to 10 years after this, and some will require a third or even fourth treatment course.

The problem with induction therapy in the current climate is that the effects on the immune system are irreversible. The treatment cannot be stopped or reversed.

The immune system is particularly weakened for the 4 months following each course, so patients are at high risk of COVID-19 infection or serious complications in that period. We therefore advise these patients to shield for at least 4 months after these treatments, and to practice vigilant social distancing and ask others to do essential shopping until the COVID-19 risk is mitigated.

If patients are in the middle of a treatment course we are delaying the next treatments by 3 months in the first instance, possibly longer until the COVID-19 risk is mitigated or until we know more about the safety of these therapies with regard to COVID-19.

Ocrelizumab destroys B cells, a part of the immune system that isn’t thought to be involved in fighting viruses. Probably these patients aren’t at greatly increased risk from COVID-19. However, because there is a degree of uncertainty we are advising that subsequent treatments are delayed for 3 months in the first instance.

Natalizumab doesn’t actually suppress the immune system, it prevents autoreactive immune cells from entering the CNS. It is a highly effective MS treatment with a rapid onset of action and we think that it can be safely given during the COVID-19 epidemic. It can be given every 6 weeks rather than every 4 weeks to minimise hospital attendances.

How should an MS relapse be managed during the COVID-19 pandemic?

Most MS relapses will improve without treatment. A short course of high dose corticosteroid is occasionally given to shorten the duration of a severe, disabling relapse. However, there is a concern that corticosteroids may increase COVID-19 risk. Therefore, we are advising against using corticosteroids for all but the most severe relapses.

The risk of relapses is significantly reduced by DMTs so we advise that the moderately effective and more effective DMTs are continued. Subsequent courses of the high efficacy therapies cladribine, ocrelizumab, and alemtuzumab are being delayed because of safety concerns, but even in these situations it is likely that patients will continue to benefit from the courses they have already received for several months if not longer. If someone develops highly active disease with frequent relapses during the pandemic, natalizumab infusions can safely be given in the short- to medium-term to reduce disease activity and prevent accumulation of disability.

Should blood monitoring for MS treatments continue during the COVID-19 pandemic?

Many of the MS treatments discussed above require regular blood monitoring for safety purposes. We want to avoid people having to come to hospital if at all possible during the pandemic and as a general rule, most people who are stable on therapies can reduce the frequency of their blood tests. Guidelines for the individual drugs have been published by the ABN and others and each MS service will have its own local guidelines.

 

Medscape © 2020 WebMD, LLC

Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.

Cite this: COVID-19 in People With Multiple Sclerosis - Medscape - May 28, 2020.