COMMENTARY

What We Know About Multiple Sclerosis and COVID-19

Stephen Krieger, MD

Disclosures

April 17, 2020

Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

This transcript has been edited for clarity.

Hello. I'm Dr Stephen Krieger, a neurologist at the Corinne Goldsmith Dickinson Center for Multiple Sclerosis (MS) at Mount Sinai in New York, reporting for Medscape on the care of MS patients amidst the COVID-19 pandemic.

COVID-19 has impacted every one of us. Of course, we've been counseling our patients to observe stringent precautions: sheltering in place, maintaining effective home quarantine, practicing hand hygiene, wearing masks outside the home per the Centers for Disease Control and Prevention's recommendation, and encouraging social connectedness to prevent isolation during this time of physical distancing. But what else can we do specifically for our patients with MS?

Mount Sinai and many other institutions treating patients with MS have migrated all patient care to virtual and telehealth to try to minimize their exposure to the health system during this time. We're all developing clever ways to perform neurologic exams via video visits and have patients collect and report their own data. If you have any tips on how you're doing this in your own practice, please do add them in the comments section so everyone can benefit from your experience.

Our psychologists have also been holding video support groups for our patients to try to provide remote counseling and address the anxiety that everyone's feeling. We're trying to keep patients with MS from emergency department or urgent care exposure unless it's truly necessary.

Adjusting, Delaying Therapy

In this new setting of COVID-19, we've established a higher threshold for treating MS relapses with steroids. If steroids must be used for a particularly debilitating relapse, we're trying to use oral preparations—1250 mg of prednisone a day for 3-5 days with gastrointestinal prophylaxis—so that patients can administer them at home and avoid intravenous treatment and nurse visits whenever possible.

There is yet no evidence that MS makes patients more susceptible to this infection. We're all incredibly susceptible to it. There's also no evidence that people with MS have a more severe experience of COVID-19; however, of course, disability is an important comorbidity.

Thankfully, there is also little evidence to date of increased infection susceptibility or risk for patients treated with disease-modifying therapies (DMTs). Whenever possible, our practice has been to not interrupt medication out of concern for COVID-19 and to counsel patients as such. We have to remain vigilant to the risk for disease rebound when DMTs are stopped, particularly the sphingosine 1-phosphate (S1P) modulators or natalizumab.

Sometimes we are choosing to delay infusions to minimize patients' risk of being exposed to the virus at a treatment center. Remember that natalizumab infusions can be safely delayed typically by about 1-2 weeks for extended-interval dosing. For patients with relapsing-remitting MS, we feel that ocrelizumab can probably be safely delayed by perhaps a month or 2 months without real risk for recurrent disease activity. Patients with primary progressive MS on ocrelizumab may be older, with more comorbidities and disability. Therefore, we've typically been trying to delay those infusions until the worst of the COVID-19 crisis, at least in this region, has begun to pass.

Many infusion centers may have limited resources as their nurses and other staff are redeployed for COVID-directed care. As such, trying to decrease the burden on patient centers during this time may be appropriate.

Treating Patients Positive for COVID-19

In recent months, we've really fielded two different waves of phone calls and inquiries from our patients with MS. In February and March, we had innumerable calls from people asking what they should do in advance out of concern for this disease. In April, those calls have since changed to ask what they should do now that they have COVID-19. Those are challenging conversations, because COVID-19 affects people in such a heterogeneous way, both in terms of symptoms and severity.

If one of our patients with MS develops COVID-19, we've begun counseling them that they can, for example, hold their interferon injections to avoid additional flu-like symptoms during the acute infection. We could counsel patients to hold S1P modulators like fingolimod during a prolonged episode of high fever, but hopefully not beyond the 14-day period, after which new first-dose observation would be needed again. Again, this strategy aims to prevent an extended amount of exposure in the medical system.

We are recommending that patients hold their infusion therapies at least until a week or so after their primary COVID-19 symptoms and fever have resolved. As previously noted, extended-interval dosing for natalizumab is likely both safe and effective.

And, of course, for any patient with symptoms of COVID-19, it's crucial to counsel them to seek urgent care if they develop difficulty breathing or significant shortness of breath.

Emerging Data

There is a very nice review published this April in Neurology by Brownlee and colleagues looking at the implications of using DMTs in people with COVID-19. There's also research looking at the potential for S1P modulators like fingolimod to prevent acute respiratory distress syndrome in aggressively worsening COVID-19. The hope there is that this immunomodulatory strategy might prevent the potentially devastating influx of lymphocytes into the pulmonary compartment.

Clinical data on people with MS contracting COVID-19 are also now being collected by several different research consortia around the world. In pulling together this information, they are hoping to provide crucial information that we can use to guide our treatment decisions.

Comi and colleagues presented data via the National Multiple Sclerosis Society (NMSS), I believe with a publication forthcoming, from three Italian centers at the beginning of this crisis. They looked at 150 patients with MS and COVID-19, 90% of whom remained at home. Only a small handful required intensive care unit admission and critical care. There was no trend for worse outcomes for MS patients on individual DMTs. As with the general population, however, older patients had a more severe course of COVID-19.

The International Women in Multiple Sclerosis group has been gathering the latest data on their website, listing best practices for MS patients in the era of COVID-19. And a joint effort from the NMSS and the Consortium of Multiple Sclerosis Centers, called COViMS (COVID-19 Infections in MS & Related Diseases), is going to aggregate data for MS patients with COVID that we can all learn something from in the weeks and months to come.

As we await these forthcoming data and continue to provide care for patients with neurologic disease and with MS in particular, I'd like to offer a little reminder of the two essential tools we have at our disposal: effective hand hygiene and masks to prevent transmission of this disease. We need to protect ourselves as we protect our patients. Stay safe, everyone.

Reporting from New York City for Medscape, I'm Stephen Krieger.

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