Coronavirus Disease 2019

Update on Coronavirus Disease 2019 Outcomes and Vaccine Efficacy in Patients With Immune-Mediated Inflammatory Disease

Jeffrey A. Sparks; Zachary S. Wallace; Philip C. Robinson

Disclosures

Curr Opin Rheumatol. 2021;33(5):412-418. 

In This Article

Neurology

Multiple sclerosis, myasthenia gravis and other neurological diseases, such as autoimmune encephalitis are all managed with immunosuppression, so, neurology faces similar challenges to rheumatology, dermatology and gastroenterology. To add a complicating factor, it has become evident that COVID-19 infection has numerous neurological manifestations.[48]

French data in 347 multiple sclerosis patients demonstrated male gender, comorbidities and higher disability as measured by the Expanded Disability Severity Scale score (EDSS) were associated with worse COVID-19 outcome measured with a 7-point ordinal scale.[49] Of broader interest in the context of the hyper-inflammation of COVID-19, a higher proportion of multiple sclerosis patients not on disease-modifying therapy (DMT, 46%) developed severe COVID-19 compared with those taking DMT (16%).[10] In univariate analysis, DMT therapies were protective of poorer outcomes but this finding was not evident in the multivariate model, noting the limitation of small numbers in this analysis.

B-cell-depleting agents are potentially a risk for poorer outcomes based on patients with rheumatic disease. There were 51 suspected or confirmed cases of COVID-19 found in the B-cell-depleting agent ocrelizumab multiple sclerosis clinical trials up until the end of July 2020.[50] Disease severity was asymptomatic, mild or moderate in 68.6% and severe in 19.6%, with 6% dying and 6% outcome data missing. Of the total group, 31.4% were hospitalized. In the manufacturer postmarketing surveillance safety database, there were 307 postmarketing cases of COVID-19 with 86% (n = 263) confirmed and 14% suspected.[50] Of those 33% were hospitalized and 47% had asymptomatic, mild or moderate disease, with 6% dying.

As of mid-July 2020 in the OPTUM COVID-19 database there were 357 multiple sclerosis patients with confirmed COVID-19.[50] There were 48 of these patients treated with ocrelizumab and 309 not treated with ocrelizumab. The outcomes were similar between the two groups with 76% and 75% hospitalized in the non-ocrelizumab and ocrelizumab groups, respectively. There were 1.6 and 2.1% who received invasive ventilation in the non-ocrelizumab and ocrelizumab groups, respectively. Finally 3.9 and 2.1% died in the non-ocrelizumab and ocrelizumab groups, respectively.

There have been other small case series published on other neurological diseases, such as myasthenia gravis where older patients made up 75% of the deaths again supporting the premise that widely relevant risk factors remain critical in disease sub-groups we worry about.[51] In summary, the small size of the reported cohorts limits the conclusions that can be drawn but specific therapies, such as B-cell-depleting therapies remain a concern, but not to the exclusion of the broadly relevant demographic and comorbidity risk factors.

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