Patients With MS Should Not Stop DMT Because of Pandemic, Experts Say

In a commentary published in Multiple Sclerosis and Related Disorders in March, experts addressed common concerns individuals with multiple sclerosis (MS) might have when it comes to the coronavirus disease 2019 (COVID-19) pandemic and the use of disease-modifying therapies (DMTs).

Authors compared people with MS to solid-organ transplant recipients because both groups receive DMTs. Researchers point out solid-organ transplant patients are significantly more immunocompromised than individuals with MS, as most transplant patients are on triple immunotherapy. In comparison, people with MS usually receive monotherapy “and even then, the level of immunosuppression is generally low.”

June Halper, chief executive office of the Consortium of Multiple Sclerosis Centers, reiterated this point recently. “Most of the drugs that the [MS] patients are taking do not compromise their immune systems. It's called disease-modifying therapy because it's modifying the immune system. This is not the same as cancer, where a patient's immune system is severely affected because of cancer,” Halper said.

Taking this fact into consideration, researchers postulate the mortality and/or morbidity risk to an individual on a DMT and infected with COVID-19 may be quite moderate to low.

In fact, researchers note moderate immunosuppression could potentially prevent severe complications resulting from the coronavirus. COVID-19 pulmonary complications resemble those of acute respiratory distress syndrome (ARDS), which is caused by an over-exuberant immune response to the virus. Exploratory trials are currently underway to investigate whether immunosuppressants may dampen the immune response to the virus.

“Fingolimod, a S1P modulator licensed for MS, is being tested as a treatment for COVID-19 associated ARDS,” while interferon beta is being investigated based on its antiviral properties, researchers said.

Another consideration to take into account is the virology of COVID-19. Because the disease is caused by a small RNA virus with low fidelity (SARS-CoV-2), authors predict rapid mutations may occur, meaning a single vaccine will not be sufficient to address the outbreak.

Vaccines will also take months to develop and longer to distribute. Researchers warn “delaying treatment, de-escalating therapy by switching to immunomodulatory DMTs, such as interferonbeta, glatiramer acetate or teriflunomide, or interrupting dosing of DMTs to wait for a vaccine will delay the adequate treatment of MS, especially as it may take 12—18 months to develop a vaccine.”

As the nature of the pandemic changes daily, those caring for individuals with MS ought to make pragmatic descisions based on clinical evidence to ensure optimal MS management. Patients should also modify their behaviors to reduce or prevent exposure to COVID-19 (i.e. social distancing).

“Most MS centers are not seeing patients live [in person] unless it's an absolute emergency," Halper said. "Telehealth is now becoming much more valuable."

However, many factors contribute to an individual’s risk of suffering complications from COVID-19 including smoking practices, ambulatory status, age, weight, underlying respiratory illnesses, and frequency of healthcare facility visits.

“In the context of these factors the health care professionals should weigh the potential risks of SARS-CoV-1 exposure and manage their DMT accordingly,” authors said. Individualized treatment plans tailored to a patient’s risk profile will ultimately yield the best outcomes for pwMS.

Although authors do not recommend stopping different DMTs and therefore exposing MS patients to the risk of MS exacerbations, some in-person infusions of DMTs have been delayed.

“But again, this is a clinician-driven decision. It's based on the patient's history and disease course. I think that's something that's not dictated by a normal recipe, each clinician has to make their own decisions,” Halper said.

Reference

Giovannoni G, Hawkes C, Lechner-Scott J, et al. The COIVD-19 pandemic and the use of MS disease-modifying therapies [published online March 27, 2020]. Mult Scler Relat Disord. doi: 10.1016/j.msard.2020.102073.