Management of Optic Neuritis - Episode 7
Robert C. Sergott, MD: We want to finish by talking about a concern for everyone in the world, and that is COVID-19 [coronavirus disease 2019]. We know there are high-risk populations—older adults, chronic obstructive pulmonary disease, patients on oncology treatments who are immunosuppressed. Rod, what are you doing with your MS [multiple sclerosis] patients in terms of steroids, and what advice do you have about their multiple sclerosis medications?
Rod Foroozan, MD: Yeah, this is a really challenging topic for me. We’ve seen about 5 patients with acute attacks with optic neuritis, and we’ve hospitalized a couple. We typically will give an option when we’re dealing with acute optic neuritis for home health IV [intravenous] treatment. We’ve had very good success with that. Another option is infusion centers. We have several infusion centers, including one here at Baylor College of Medicine across the street from where we are. The last is hospital admission. The fourth option that I hadn’t really considered until now is there had been some papers that suggest, we talked about the quirky findings on the Optic Neuritis Treatment Trial, where all steroids were sort of a no-no because there was an increased incidence in the current optic neuritis in the same or fellow eye.
But there have been some studies that suggest noninferiority between very high-dose oral prednisone—we’re talking around 1250 mg. If you do the calculations and you’re using 20-mg tablets, that’s 50 some-odd pills of prednisone, which is not easy to take. Nevertheless, patients have been treated with very high-dose oral and found to have similar visual outcomes to those treated with IV [intravenous]. The jury is still out on that, but I’ve had 1 patient want to go that route because they didn’t want to go into the hospital, they didn’t want to go into the infusion center, and they didn’t want someone coming into their home. I think this is a reasonable option to consider in some patients in light of the pandemic.
Robert C. Sergott, MD: The way many multiple sclerosis medications work is by limiting the activity of T cells or B cells, these 2 big populations of lymphocytes that have many subpopulations. The older MS medications, while I would call them immunomodulating, are not immunosuppressive. I think they are largely safe in the pandemic. I’ve even put people on those temporarily. They’re excellent medications, and maybe we’ll transition to 1 of the stronger medications in a year or so. The stronger medications are immunosuppressive or strongly immunomodulating. And the latest ones deplete B cells. B cells make antibodies. Antibodies can be bad, as we know in NMO [neuromyelitis optica]. But B cells and gamma globulins can be very helpful in ridding you of a viral infection or other infections.
Many of us now are postponing B-cell—depleting therapies in both MS and NMO patients until we know more about coronavirus, know more about immunity, and we have hopefully a vaccine within the next year or so. I’m now recommending to patients that they hold off, if we can, with NMO B-cell depletion and use steroids and pheresis. We’ve had to move forward on 1 patient with that and take the risks with the virus and put very strict quarantine at home measures. All our patients on all these medications are followed with lymphocyte counts, and we really want to keep those counts over 500 if possible. Our surveillance system is increased even more in the COVID-19 era.