: With regard to the question of whether people living with MS [multiple sclerosis] are at an increased risk of acquiring coronavirus—or if they get COVID-19 [coronavirus disease 2019], whether they are at an increased risk of developing complications&mdash;the bottom-line answer is that we don’t yet know. However, the good news is that we are now entering the third month of this pandemic, and there has been quite a bit of global communication among MS specialists around the world. Different countries are setting up COVID-19 and MS registries. People have blogs and websites sharing information from various clinics.  

It’s actually quite reassuring, now that we’re nearing the 3-month mark, that generally around the world, whether it’s in Europe or North America, it does not seem that there is a significant increased risk of COVID-19 in people living with MS. As you know, the majority of people living with MS are typically on a disease-modifying treatment at 1 point in their disease course. 

What’s even more reassuring is that people living with MS who have a confirmed coronavirus infection do not seem to be at a significantly higher risk of developing COVID-19—related complications. Most places are monitoring this by assessing whether patients need to be hospitalized, and if they are hospitalized, whether they need to go into the intensive care unit where they require some sort of ventilatory support.  

It’s been reassuring. Many countries around the world have established registries and are sharing information, and 3 months in, there does not seem to be any sort of signal of an increased risk of COVID-19 or COVID-19—related complications.  

They obviously are not perfect data, and we do need to do more rigorous studies to try to understand this better. But as an MS specialist, I think this is important information. I have been telling patients that we’re still not sure, but at the current time no alarming signal has emerged, and this is actually quite reassuring. 

In terms of whether there are specific risk factors for a patient with MS acquiring coronavirus, again, it’s not quite clear, but generally what we’re doing in clinical practice is applying what we know about patients who are at risk of acquiring coronavirus or COVID19—related complications. Similar to the general population, for which we know that older age and additional comorbidities are significant risk factors, we’re kind of applying the same principles in people living with MS.  

Everybody has a different cutoff of what they define as older in age, but generally for anyone above age 60 or 65, we are a little more worried about them during this time. In people who have other comorbidities, whether it’s high blood pressure, cardiac comorbidities, or other respiratory comorbidities, we are also a bit more worried. In addition, we get worried, much like the general population, if an MS patient has had close contact with someone who had a confirmed COVID-19 infection.  

The other point, and we’ll probably discuss this in a bit more detail later, is that we are a bit more concerned about individuals on certain MS disease-modifying treatments who we know have a more powerful immunosuppressant effect. Having said that, based on the data that are being reported thus far, it doesn’t really seem that these higher-efficacy medications—which we think have a more powerful suppressant effect on the immune system&mdash;dramatically increase an individual’s risk of coronavirus or COVID-19—related complications when they have MS, at least as of this point. 

Multiple Sclerosis and Risk of COVID-19

: A number of groups have published different guidelines regarding disease-modifying treatments and COVID-19. The National Multiple Sclerosis Society [NMSS] is 1 organization that has published clear and easy-to-follow guidelines. Many other organizations around the world have published guidelines that are very similar to the NMSS.  

What the NMSS does is it divides the disease-modifying treatments that we typically use in people living with MS [multiple sclerosis] into 3 categories. The first category includes immunomodulators that generally do not suppress the immune system. The medications that fall into that category are the interferon beta agents as well as glatiramer acetate and natalizumab. Natalizumab blocks trafficking of lymphocytes into the central nervous system, so technically it does not reduce peripheral immunity that is thought to be important in preventing the acquisition of coronavirus.  

The second category that the NMSS divides disease-modifying treatments into is immunomodulators that restrict the ability of the immune system to respond to an infection. Many of the MS disease-modifying treatments fall into this category. They include the oral therapies, like dimethyl fumarate, and variations of dimethyl fumarate. Fingolimod, siponimod, as well as teriflunomide are included here. These are medications that many of our patients are on, and we do know that they slightly decrease the immune system, but it’s not clear whether it dramatically changes one’s ability to respond to infections like COVID-19 [coronavirus disease 2019].  

Finally, the last category is immunosuppressants that deplete lymphocytes. The medications that fall into this category are alemtuzumab, cladribine, mitoxantrone, and ocrelizumab. In some places that use it, rituximab is also included. We are a bit more worried about these medications because we consider them to be highly potent. These are ones that dramatically—or sometimes to a lesser extent&mdash;deplete lymphocytes, which we know are key to one’s ability to fight diseases such as COVID-19.  

We do get slightly more concerned when patients are on 1 of these medications. However, again, based on the data that have been accumulated thus far, even in many patients around the world who have acquired COVID-19 and have been on 1 of these lymphocyte-depleting agents, there does not seem to be a strong signal of being at extremely high risk for developing COVID-19—related complications. 

Disease-Modifying Therapies for MS During COVID-19

: Unfortunately, the in-person portion of the American Academy of Neurology meeting was canceled, but we do have access to many of the abstracts that would have been presented at the meeting.  

An example of an interesting real-world data abstract is the CLARINET-MS study, which was based on the Italian MS registry. This looked at the longer-term efficacy in the real world of 1 of the medications we commonly use in MS [multiple sclerosis], cladribine tablets.  

Overall, the results of the study were quite reassuring. Results showed that even at 3 years, the vast majority of people living with MS who were treated with cladribine tablets, the likelihood of disability significantly progressing was very low. These real-world studies are quite valuable. Obviously, when we start using a medication in a disease like MS, this medication is approved based on phase 3 clinical trials that are done in very controlled settings and are often done on a restricted patient population. But the value of real-world studies such as the CLARINET-MS study is that it gives us real-world evidence that a medication works the way we hope it will, at least based on the earlier clinical trial data. 

AAN 2020: Real-World Data on Cladribine Tablets for MS

: Because the American Academy of Neurology Annual Meeting was [canceled and abstracts were published online on AAN.com], unfortunately I wasn’t able to delve into as many abstracts and attend as many talks as I normally would have in person. But on perusal of some of the abstracts, I think there were some interesting clinical trials that were published on newer agents, including newer anti-CD20 agents. And so I think looking at these data are noteworthy.  

I also saw some additional abstracts on the concept of progression independent of relapse activity, which is a clinical outcome measure that is emerging to be very important. This is trying to get at the neurodegenerative component of MS [multiple sclerosis], which we thought was really a substrate of progression in MS. And so I think it’s very useful that some of the larger clinical trials that we have assessed these different outcome measures that are highly clinically relevant, particularly when we’re considering people living with progressive MS.  

I am also an MRI [magnetic resonance imaging] researcher. There were some interesting novel imaging measures that were reported on, including the central vein sign and the paramagnetic rim sign, and I look forward to hearing more about some of these concepts at future meetings. 

Multiple Sclerosis: Takeaways From AAN 2020

: In terms of how I think COVID-19 has changed the way we practice in the treatment of MS [multiple sclerosis], and looking toward the months ahead, it’s interesting. Again, we’re entering into the third month of this pandemic. Regardless of whether you’re a physician or not, your first reaction is always kind of sheer panic and fear. In those early days of the pandemic, many MS specialists were really reluctant to start disease-modifying treatments in patients, and even redose patients who on some of these lymphocyte-depleting agents. We were very reluctant to bring any patients into the hospital. We canceled all MRIs [magnetic resonance imaging tests] our patients were scheduled for.  

But now that we’re learning more about coronavirus as well as what COVID-19 means for our MS patients, it seems that we’re becoming more comfortable with managing immunomodulatory and immunosuppressive medications in light of this pandemic. I think we’re finding a better way to move forward with MS care. There are all these unknowns related to COVID-19, but we do know about the clear risk of neurological disability progressing when patients with MS remain untreated or are suboptimally treated. 

Another thing that’s been interesting is that many of our neurology visits have been converted to virtual visits. This is something that is actually very difficult to do in the neurology world because you can’t really examine patients accurately. But we’ve started to become much more comfortable with this and have become more creative in how we assess neurological disability in our patients using technologies like videoconferencing and other tools where we can at least partially do a neurological exam.  

Overall, as the world slowly emerges from this pandemic, I think we’re going to develop more rational ways to manage patients who are on immunomodulatory treatments. The forced virtual care aspect will actually change how we approach clinical visits, even when we emerge from the pandemic. 

MS Treatment Optimization During COVID-19

Treating Patients With MS During the COVID-19 Pandemic

AAN 2020 Data Release: Ofatumumab for Relapsing MS

: The results of studies surrounding oral cladribine, or Mavenclad, presented at AAN [American Academy of Neurology Annual Meeting] 2020 were interesting, compelling, and encouraging. I see oral cladribine representing a broad-spectrum agent that is conceivably high efficacy and well suited for a broad range of patients, both relapsing-remitting as well as secondarily progressive. I see oral cladribine being used effectively for patients with mild, moderate, and more active disease. It’s an oral therapy, short course, and easy to administer with relatively low monitoring requirements. Certainly in this COVID-19 [coronavirus disease 2019] era, I think it does play a significant role. 

The adverse-event profile or tolerability of oral cladribine, in my experience as well as the data in the pivotal trials, is favorable. The most common adverse effects, occurring at an incidence of more than 20%, are transient and fairly mild. They include headache, upper respiratory tract symptomatology, and of course transient lymphocyte depletion, which is an expected outcome given the mechanism of this drug. 

Initiating and maintaining a patient on Mavenclad has been fairly easy for me during this pandemic. There are some basic prerequisite blood tests that can be done 1 time and are fairly easy to do. The 10 days of initial-year therapy are coordinated with MS [multiple sclerosis] LifeLines. I believe the drug is mailed directly to the patient at their home. Nursing will then provide support virtually or by telephone. Beyond that, the patient is required to have a CBC [complete blood count] with differential performed at regular intervals 2 months and 6 months following administration. This has been a very easy drug for me to use before COVID and certainly during COVID. 

There were data presented at AAN 2020 centering on or involving ocrelizumab and long-term efficacy. The data confirmed that long-term ocrelizumab has significant prolonged effects in terms of slowing down disability progression in addition to reducing relapses and suppressing MRI activity. 

These data, regarding long-term use of ocrelizumab presented at AAN 2020, are certainly encouraging. They help those of us who have had patients on this drug since its launch 2 or 3 years ago. They give us confidence in continuing this drug long term. There are still some questions that I have surrounding B-cell depletion and risk of certain infections. That’s being worked on in ongoing studies. Nonetheless, these data are encouraging in that I don’t necessarily see my prescribing habits changing. I am able to provide patients with reassurance—that is, those patients who have been on ocrelizumab for several years should have continued positive results moving forward. 

Novel Oral Therapy for MS: AAN Data Updates

: This is an exciting time. This is an exciting time for multiple sclerosis. We’ve gone from having a handful of disease-modifying therapies to well over 15, 16, perhaps 17 therapies available. Looking in the near future as well as long term, there are several exciting drugs in the pipeline. Some represent perhaps updated versions of current drugs in terms of method of action. There are some new drugs being developed with new methods of action or different mechanisms of action. They may represent an option hopefully for areas of MS [multiple sclerosis] that we continue to experience challenges in treating—active secondarily progressive patients, primary progressive MS patients, etc. 

During this COVID-19 [coronavirus disease 2019] era, some have been more risk averse. Although we should all exercise judicious caution, I don’t think we are doing our patients any favors by withholding treatment. One has to weigh the relative risks of suboptimally treated multiple sclerosis against the risk of contracting COVID-19. I have settled on utilizing the best treatment for a patient while balancing that with discussion about COVID-19 safety. In other words, for the most part I’m not withholding the best treatment option for patient because of COVID-19. 

To summarize, I would say MS is a chronic disease state that requires ongoing treatment, not only disease-modifying therapy but also symptomatic therapies and lifestyle therapies. We must maintain vigilance even during this COVID-19 era and not ignore the needs of patients. 

AAN 2020: Multiple Sclerosis Treatment Considerations