Multiple Sclerosis Podcast

COVID-19 and MS Patients: Where Do We Go From Here?

Anne H. Cross, MD; Scott Newsome, DO

Disclosures

October 05, 2022

This transcript has been edited for clarity.

Anne H. Cross, MD: Hello. I am Dr Anne Cross. Welcome to Medscape's InDiscussion series on multiple sclerosis (MS). Today we'll be discussing COVID-19 and MS. First, let me introduce my good friend and guest, Dr Scott Newsome. Dr Newsome is the director of the Johns Hopkins Neuroimmunology Clinical Fellowship Program. He's co-director of the Multiple Sclerosis Experimental Therapeutics Program there and associate professor of neurology at Johns Hopkins Medicine. He's an international expert on MS, and he's also the former president of the Consortium of Multiple Sclerosis Centers. So, welcome, all, including Dr Newsome, to this program. Before we really get into the nitty-gritty of discussion of COVID-19 and MS, I'd like to ask you, Scott, what drew you to this area of medicine — to neurology and then to MS?

Scott Newsome, DO: Thank you, Anne. I appreciate the invite to participate in this very important Medscape activity. I'll try to make this as brief as possible. For me, neuroanatomy/neuroscience always caught my attention when I was much younger. Even more importantly, as you know, my mother had MS. As a young child growing up and seeing how MS could affect an individual — the good, the bad, the ugly — that always stuck with me. As I was going through schooling, that was sort of the crux of my decision to go into not just neurology, but to become a neuroimmunologist and focus on MS care. That's the short of it. I do feel that my past experience really is what springboarded me into MS.

Cross: You must have been really rewarded as new medications came out, and you had your hand in some of it. That must've been particularly rewarding for you.

Newsome: It's a great comment because when my mother was diagnosed, there were no treatments available. And then finally, when the first clinical trials came out, she participated in one of them, and now I'm here doing a lot of clinical trials myself. Who knew that I'd be doing clinical trials when I was a young child? I saw my mother involved in a clinical trial, and that was a really good experience. As more treatments became available, some of which my mother didn't have the availability to get, it became quite exciting for me to see where the field was going and how I could play a little bit of a role in the world of new pharmaceutical therapies for our patients. Clearly, we're very lucky, now more than even just several years ago. We have over 20 FDA-approved therapies that I feel are changing people's lives for the better in MS.

Cross: Well, you've certainly played more than just a little bit of a role, but we'll move on to the topic at hand, which is MS and COVID-19 and the pandemic. What are the top things you think have changed in your care of MS patients due to the pandemic?

Newsome: There are so many. I'll try to break it into the early part of the pandemic, when we didn't really know much of anything; and then the intermediate pandemic; and then where we are now. In the early part of the pandemic, when we didn't know how COVID-19 was going to affect our patients, it was, "Geez, is my patient who has MS at risk?" Forget about the therapy the person is on; does MS in and of itself put someone at greater risk to have bad outcomes with COVID-19? And then you add on a therapy. We were holding tight on medications, not switching people to stronger therapies, even at the time where we felt that maybe they needed to be switched because we didn't know what would happen if our patient got COVID-19; would they end up having a serious outcome? And then as some of the observational studies started to churn out information, like the COViMS Registry and the Italian Registry, we started to learn a little bit more, like how MS in and of itself doesn't seem to put people at risk to contract COVID, or if they were to get COVID, to have more severe outcomes. Then I started to feel like, okay, let's get back into the pre-pandemic way of treating patients, where maybe we wouldn't hold back necessarily on escalating treatment if it was needed. Of course, we then found out, that there are certain classes of medications that may put people at risk to have more severe outcomes if they got COVID. I had to backpedal a little bit to say we have to look at the individual situation; should we look at treating people a little bit differently if we're going to escalate treatment?

Probably the biggest factor here in my clinic is that a lot of our patients have not had the opportunity to do some of the nonpharmacologic interventions, like the physical therapy, the occupational therapy — things that I feel really impact the person's quality of life. That's had a big impact in my clinic. In the latter part of the pandemic, now that we've learned as much as we have, we're trying to get people back to the physical therapist and aqua therapy if we feel that they're safe to do so.

We've been utilizing telemedicine, and this is where I think telemedicine is quite helpful. For those patients who maybe are at higher risk to have bad outcomes with COVID, we're trying to use telemedicine to supplement some of our in-person visits. That has helped provide a higher level of care for many of our patients. As we are right now, in sort of that third stage of the pandemic, I feel like I'm getting back to how we were treating people pre-pandemic, with some caveats. I know we'll likely talk about vaccines (getting our patients vaccinated), certain therapies, and/or dose-adjusting some treatments.

Cross: That was a good point you made — well, multiple good points. But one of them was the one about nonpharmacologic treatments and the fact that a lot of our patients were reluctant for them to continue when they would be out in the public. Are you still seeing a reluctance on the part of your patients to take part in physical therapy at a center or aqua therapy?

Newsome: Yes, we still are facing that challenge. And part of the reason for some patients now is that some of the mask mandates have been lifted in different states, and there's not really a lot of physical distancing happening in some places. For good reasons, our patients are concerned. I've tried to encourage those patients who are more fearful: "Are you fully vaccinated? Boosted? It's okay to wear a mask if you're going to a place that's more densely populated." Hand hygiene is very important as well and to try to have physical distancing as much as possible. I've gone as far as reaching out to facilities where there's been concern about some of these factors not being put into place and have asked, "For our patient, can these things be implemented or is it okay for them to be a little bit apart from the next person doing physical therapy?" We certainly have people that are concerned. There are a lot of things that can be done at home. We encourage people to search for, let's say, doing Pilates or yoga for MS. So there are still a lot of things people can do at home, or walk around their neighborhood if they're able-bodied. But yes, there are many concerns.

Cross: Yes, I'm finding a lot of reluctance on the part of my patients to get out of their homes. Some people are still almost homebound after two and a half years.

Newsome: How are you approaching a patient who is very fearful and has become, essentially, agoraphobic?

Cross: I actually had one this week. She's in her seventies. Pre-pandemic, she loved to travel. She traveled to Europe and all sorts of places two or three times a year. She hasn't been anywhere since. I pointed out to her that she does have some risks of having a worse case of COVID, but she's fully vaccinated, and I encourage her to get vaccinated every time it's available to her, and I'm sure she will. I also pointed out to her that we have effective treatments. If somebody gets COVID-19 and they're at high risk, even just due to age, we have things we can do. And I encourage her to contact me and contact her primary doctor, anybody she can get, if she gets COVID. And I also keep telling people that they need to test themselves frequently if they have new symptoms just to make sure they don't have it. And if they do, then they need to let a clinician know so they can be treated.

Newsome: It's sort of trying to paint a brighter picture for the person that is very fearful. I worry about the mental health aspect of COVID and how it's impacted our patients — and obviously all of us, right? For some patients, when I'm seeing that they're really in a bad place from a mental health perspective, you have to weigh the risks and benefits. What is the risk of getting COVID vs the risk of being in a bad place for mental health or worse mental health than they already are? I've tried to talk to patients about that and say, "Well, your mental health is incredibly important. Getting out of the house occasionally is really going to be beneficial, not only for your mobility in getting out there, but also for mental health."

Cross: Totally agree with you on that, Scott. I also tell my patients to get themselves a set of good masks, usually KN95s that fit well, and I show them how you can fit it to your face and blow out, and you shouldn't have your eyeglasses fogging up or feel the breath coming out of the sides. And if they don't, they've got a good fit and then to go on with their lives. But again, many people — not just our patients — are fearful. Do you recommend all of your patients or some of your patients to get the antivirals if they should come down with COVID-19?

Newsome: This is a work in progress in my own mind. I'm still trying to figure out whether everyone needs Paxlovid, for example. I have recommended it. I think what's challenging for me to sort out is who are those patients that really are going to be in a bad place if they get COVID, especially now that we have Omicron which, for all intents and purposes, seems to be less lethal than maybe Delta but more contagious? So, this is a partnership. You mentioned reaching out to a clinician, reaching out to a primary care provider. In my clinic, the patient will reach out to me and then also to their primary care physician; it's a collective decision among all of us. For those patients who certainly have higher risk factors, I have been recommending it. And also the monoclonal antibody that's being used. If it's someone who is young or otherwise healthy, maybe on a less effective or less potent disease-modifying therapy and who has no other comorbidities, in that situation, maybe they don't necessarily need to go on any of the treatments, especially as we learn more about the rebound that may occur, which I'm still trying to wrap my head around. But for those that are a higher risk, absolutely I do recommend doing the antiviral. And then if they're a candidate for the monoclonal antibody, doing that.

Cross: I totally agree. Obviously, Paxlovid has its issues with drug interactions and that sort of thing. I've had a couple of patients who just could not take it. They were nauseated and vomiting and had to stop it short.

Newsome: But can I ask you a question about that patient where they're having tolerability issues? Have you told them to take half the dose or to just try to get a few days in? I mean, there's no scientific guidance, but I'm just curious.

Cross: No, I haven't, because I don't know if a half dose will work in individual cases. And usually they're so bothered by it that probably a half dose won't work for them. They'll still have to stop it. If they can only take it for a day or so, then I'll try to get them bebtelovimab, which is the current monoclonal antibody that acts against Omicron, or remdesivir. But that's a big logistical challenge because it's outpatient for 3 days, used off label, and its IV. That means a person has to get to an infusion site 3 days in a row and get an IV in and be infused. And that's typically, at least for my patients, a difficult thing. I'm pretty liberal with my use of Paxlovid these days, after looking at their other medications and making sure there aren't any big interactions. I probably have given it to some people who maybe didn't need it. But I'm trying to err on the side of caution here. So have you used any preemptive treatments in any of your patients, and which ones?

Newsome: Yes. Evusheld probably has been the number one. The typical person that I've recommended is one who is on B-cell depletion and S1P (sphingosine-1 phosphate) receptor modulators, the reason being that there is a wealth of data now showing that those patients, at least some of them, are at higher risk to have bad outcomes with COVID in general, but then there's also the vaccine response. COVID-19 vaccine response is blunted in people on those medications. And so Evusheld is a nice way to try to help mount up at least some antibodies within the body so that if someone were to be exposed to COVID or get COVID, maybe they won't be as severely affected.

Cross: I do exactly like you're doing. I'm giving it to the people on the S1P receptor modulators, as well as people on any B–cell-depleting agent, or at least offering it to them. Not everyone has accepted, but those who have are happy, I think, that they did and are now mostly coming back for their 6-month re-treatment. What do you recommend to women, since we have a lot of women with MS in the childbearing age range? What do you recommend to them regarding pregnancy and breastfeeding in this age of COVID-19?

Newsome: The only initiative that I'm aware of, the COViMS registry, shows that in our patients who are pregnant and get COVID, there seems to not be a worse outcome vs those that may not be pregnant. It's similar in the postpartum period. But I would say before that publication, we'd have conversations around "We don't really know whether, if you get pregnant and you get COVID, based on the general population data that are out there, it could affect you in a greater way than not being pregnant." I think it comes down to shared decision-making. A lot of our patients are young, otherwise healthy women in childbearing ages. We've continued to endorse getting pregnant if someone is interested in getting pregnant. I think now with the data from that recent publication, the COViMS registry, it makes me feel a little bit better that we can say to our patients, at least based on this one study and one registry, that getting pregnant, if you get COVID, may not have as dramatic an impact on you vs the general population. But I mean, all hands on deck; if someone's pregnant and they get COVID, they need to let everyone know because they could get into trouble, and we want to make sure that we do right by the future mom and baby.

Cross: I totally agree. And you, of course, Scott, were also involved in that publication that I don't think is quite out yet but will be out in Multiple Sclerosis and Related Disorders soon. We didn't have that many people, as you know, who were pregnant or postpartum in that registry, but certainly no indication of bad outcomes. Have you noticed or are you aware of any data that MS is coming on de novo in people after having COVID-19 or that COVID-19 is causing true relapses in people with MS?

Newsome: This is a hot topic. In every clinic I have, this comes up, including: If I get vaccinated, will it cause my MS to get worse or will I have a relapse? There are case reports that are suggesting that maybe someone developed MS after COVID-19 or after getting vaccinated. If we look at the totality of the data that are out there and then if we look in our individual clinics, my view is that I don't think that either of those two things, COVID-19 itself or the vaccine, are causing MS. It's probably unmasking someone who's already predisposed, just like we've seen in years past with other infections and vaccines. More commonly what we're seeing in someone who has MS already is pseudo-relapses. We do see people's baseline MS symptoms amplify a bit, and it could last for a few days and then usually goes away. I have not seen relapses. I've heard of colleagues where they've had some patients who they think absolutely had a relapse or new spot in MRI that was enhancing post-COVID. But I think those cases are few and far between, and too few cases in my mind for me to not recommend getting vaccinated. Protect yourself and others as best as you can.

Cross: So you, Scott, wrote a first-author paper dealing with the COViMS registry and particularly focused on a couple of diseases that can mimic MS: neuromyelitis optica spectrum disorder (NMOSD) and myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD). I'm wondering if you can share with us the results of that study.

Newsome: We were very interested in looking beyond MS. There are other diseases we treat that mimic MS and we often use similar medications that suppress the immune system. There are autoimmune conditions that sometimes affect the person in even a greater way than MS. We had similar questions: Does the underlying disease itself put them at greater risk to contract COVID or to have more severe outcomes? And then further, the medication that the person may be on: Does that influence the severity of COVID-19 and are there other factors? It's sort of the Cliff Notes version of it. And, Anne, you know because you were involved in this as well, that you have to be cautious. The sample sizes were small. We had a little over 70 patients who had a NMOSD and only 20 who had MOGAD. But in those who had NMOSD, what we found was that coexisting medical comorbidities, like obesity and diabetes, for example, seemed to be what put someone at the greatest risk to have more severe COVID outcomes. Not just NMOSD, but NMOSD plus the medical comorbidity. Now, when we look at medications, the challenge is, number one, sample size. And then most of the people who had NMOSD were on rituximab, a B–cell-depleting therapy, so there it's hard to know whether the drug itself causes more severe outcomes in that patient population. I think if we leverage MS as sort of a poster child for this, I would personally feel that, yes, it probably puts someone at greater risk. If you have NMOSD, you have multiple comorbidities and you're on rituximab or another B–cell-depleting therapy. Those are the people I'm very concerned about in public health. Take preventive measures: Mask when appropriate, physical distancing, hand hygiene, get vaccinated, get Evusheld. That's sort of my process. And then in MOGAD patients, we didn't see any major factor that put them at greater risk for severe outcomes. But sample size, I think, is the reason for that.

Cross: Great. Thank you very much for doing that study so that we can have some guidance on treating those patients too. Today we've talked about COVID-19 and MS. Thank you so much for joining us. And thank you, Scott, for spending some time with me and going through this. This is Dr Anne Cross for InDiscussion.

Resources

Coronavirus Disease 2019 (COVID-19)

Multiple Sclerosis

COViMS Registry

An Italian Programme for COVID-19 Infection in Multiple Sclerosis

Paxlovid Emergency Use Authorization

Bebtelovimab Fact Sheet for Healthcare Providers

Remdesivir Prescribing Information

Evusheld Fact Sheet for Healthcare Providers

New Diagnosis of Multiple Sclerosis in the Setting of mRNA COVID-19 Vaccine Exposure

COVID-19 in Patients With Neuromyelitis Optica Spectrum Disorders and Myelin Oligodendrocyte Glycoprotein Antibody Disease in North America: From the COViMS Registry

Neuro-Ophthalmologic Manifestations of Multiple Sclerosis

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