COVID-19: Preventive Measures in Multiple Sclerosis Patients and Others on Immuno-Modulators

April 8, 2020

Disease-modifying therapies used to treat several immune-mediated disorders in neurology may make patients more susceptible to the novel coronavirus.

Robert Fox, MD

Updated April 7,2020: As the global COVID-19 pandemic continues to roll on, with over 350,000 confirmed cases of the novel coronavirus and over 10,000 deaths in the US, risk of contraction has become especially relevant within the neuroimmunology community.

As many patients with multiple sclerosis, myasthenia gravis, and other neuroimmune disorders receive disease-modifying therapies (DMTs) that act on the immune system, they may face an increased risk of being infected with the virus and developing more severe symptoms.

With concern growing in the neurology community and beyond, NeurologyLive spoke to Robert Fox, MD, neurologist at the Mellen Center for MS and vice chair for research at the Neurological Institute at Cleveland Clinic, to learn more about what the hospital is doing to counsel patients through this time and provide guidance for staff to help prevent the spread of COVID-19.

“At this point, the Mellen Center at the Cleveland Clinic is recommending that patients not cancel, interrupt, or delay scheduled doses of their MS medication. We believe that the way the medications work, the duration of action of these medications, and the risks of MS disease activity coming back are all reasons to continue MS therapies without interruption,” Fox said. “Given what we know about the current risks of COVID-19, MS therapy interruptions appear more likely to be harmful than helpful.”

In response to the heightened concern, the National Multiple Sclerosis Society, with support from the Consortium of Multiple Sclerosis Centers and the Multiple Sclerosis Coalition, has released treatment guidelines regarding DMT use during the COVID-19 pandemic.1

Beyond strongly encouraging patients with MS to adhere to prevention guidelines from the CDC, the organization also recommends that patients continue treatment with their DMTs and discuss any specific risks directly with their MS care provider. In addition, the guidelines state that patients and their providers should strongly consider individual risk-benefit profiles before starting a cell-depleting DMT or a DMT associated with a severe increase in disability after stopping.1

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Additional global guidance from the Multiple Sclerosis International Federation (MSIF)2 suggests that “people with MS who are currently taking alemtuzumab, cladribine, ocrelizumab, rituximab, fingolimod, dimethyl fumarate, teriflunomide, or siponimod and are living in a community with a COVID-19 outbreak should isolate as much as possible to reduce their risk of infection. Recommendations on delaying second or further doses of alemtuzumab, cladribine, ocrelizumab, and rituximab due to the COVID-19 outbreak differ between countries. People who take these medications and are due for the next dose should consult their health care professional about the risks and benefits of postponing treatment.”

The organization, which encourages older patients with MS who may have comorbid lung or heart diseases to take extra care to minimize risk, also points out that no specific guidance currently exists for women with MS who are pregnant or for the pediatric population with MS. At this time, pediatric patients should follow the current guidance for adult patients.2

In addition, MSIF cautioned that patients undergoing autologous hematopoietic stem cell treatment, which includes intensive chemotherapy, may want to take special precaution.2 “People who have recently undergone treatment should extend the period they remain in isolation during the COVID-19 outbreak. People who are due to undergo treatment should consider postponing the procedure in consultation with their health care professional,” it stated.

Regarding preventive measures, Timothy Vartanian, MD, PhD, director of the Judith Jaffe Multiple Sclerosis Center at NewYork-Presbyterian Hospital/Weill Cornell Medical Center in New York, New York, advised in a posted notice3 on the hospital’s website that “there are no formal recommendations at this time for use of masks in immune suppressed patients who are in the community. We will update you on the potential benefits of a facemask if you are on a potent immune suppressing or modulating agent.”

If a patient reports symptoms associated with COVID-19, “we recommend immediate evaluation by the patient’s primary care physician or local health department. Holding MS therapy during that evaluation seems prudent, as that only takes a few days,” Fox told NeurologyLive.

Facing a growing risk for community spread, Cleveland Clinic is among many institutions encouraging patients to use telemedicine platforms to maintain their clinical management schedule with their provider.

“We recommend our patients stay home if they are sick and instead use virtual visits to check in with us regarding their MS,” Fox said. To manage the influx of inquiries, Fox added, the institution provides a standard response that reiterates the CDC recommendations “regarding handwashing, good cough etiquette, avoiding close contact with people who are sick—all the standard things that are applicable to everyone.” In addition, Fox noted that Cleveland Clinic is routinely updating information on the virus on their main website, where patients can learn more about general preventive measures and receive instructions on what to do if they feel unwell.

For the latest updates on COVID-19, visit our sister site Contagion Live.

REFERENCES

1. Disease modifying treatment guidelines for coronavirus (COVID-19). National Multiple Sclerosis Society website. nationalmssociety.org/What-you-need-to-know-about-Coronavirus-(COVID-19)/DMT-Guidelines-for-Coronavirus-(COVID-19)-and. Accessed March 24, 2020.

2. The coronavirus and MS — global advice. Multiple Sclerosis International Federation website. msif.org/news/2020/02/10/the-coronavirus-and-ms-what-you-need-to-know/. Updated March 24, 2020. Accessed March 24, 2020.

3. Recommendations about coronavirus for our patients. Weill Cornell Medicine Multiple Sclerosis Center website. mscenter.weillcornell.org/news-and-updates/recommendations-about-coronavirus-our-patients. Published March 6, 2020. Accessed March 24, 2020.