Management of Multiple Sclerosis in the Era of COVID-19 Pandemic - Episode 3
Dr Schmierer explains how the SARS-CoV-2 infection and COVID-19 pandemic have impacted treating patients with MS with DMTs.
Klaus Schmierer, MB BS, PhD, FRCP: When we’re talking about the risk associated with disease-modifying treatment in the era of SARS-CoV-2 or COVID-19, we obviously initially didn’t know to what degree the immune system in people with MS [multiple sclerosis] would be impacted. And whether the risk of contracting COVID-19 and how severe the disease is, whether that was going to be significantly more risk or in fact not as high as one would have feared. I think what was to a degree a surprise initially was that the overall risk was not massively increased. That had to do with the fact that most of what the infection actually produces, most of the body’s response, is located in the context of innate immunity. As I said earlier, these cell types are generally much less affected by the treatments that we use in order to control MS. So fortunately as it were, most COVID-19 or SARS-CoV-2 infections will be essentially dealt with by innate immunity. But of course, there are some that overcome this system, and then the adaptive immunity becomes very important.
We did realize quite early that there are risk factors, but they were pretty similar generally speaking with the normal population. Those factors include belonging to BME [Black and minority ethnic] groups, being obese, people with diabetes, with other comorbidities such as those affecting the lungs, and all of these. Additional factors, clearly the EDSS [Expanded Disability Status Scale], or the degree of disability, also played an important role. Now talking about the effect of the disease-modifying treatment, we did realize that some of the treatments appeared to increase the risk to an extent, and that particularly included the B-cell depleter medications, so ocrelizumab stood out. There was perhaps a slight risk signal for the S1P [sphingosine-1-phosphate] modulators. Interestingly, initially, the interferon-b appeared to support a slightly better outcome with the condition.
One can incorporate here that in the context of the MAGNIFY and CLARIFY-MS trials, there were a few patients who had their flu vaccinations and also had the SARS-CoV-2 vaccinations in the context or within the timelines of their treatment with Mavenclad, or cladribine. It was to an extent surprising that regardless of what their lymphocyte level was, they all produced an effective response if it wasn’t already there. There were some who simply maintained their response that was previously acquired, or they actually had a booster. So there was no relationship seen with the degree of depletion or the timing of getting the drug.
When we’re talking about guidelines for people with MS in terms of vaccination against COVID-19, it is quite clear that a general overarching rule for all of them is, get vaccinated. There’s very little evidence, in fact none that I’m aware of, that demonstrates that vaccination would lead to deterioration or trigger a relapse. Also, quite the opposite, if you develop COVID-19, there’s good evidence from a study that was done through the UK [United Kingdom] MS Register that your risk of deterioration and relapses is significantly increased. So the fundamental advice they all share is to get vaccinated. Now, there are obviously differences in terms of the vaccination response, and these have a relationship with what type of drug has been used.
This transcript has been edited for clarity.