Guidance for the use of disease modifying therapies during the COVID-19 pandemic
People with MS have asked for guidance on the use of Disease Modifying Therapies (DMTs) during the COVID-19 pandemic. There are numerous recommendations circulating that attempt to provide clarity and guidance, however, differences among the recommendations have created confusion. DMT decision making varies significantly from country to country, ranging from highly provider-directed to a collaborative decision-making model.
The National MS Society's National Medical Advisory Committee believes DMT decisions should be individualized and made collaboratively between the person with MS and his/her healthcare provider. Based on their expert advice, the Society recommends:
- People with MS should follow CDC guidelines and these additional recommendations for people at risk for serious illnesses from COVID-19.
- People with MS should continue disease modifying therapies (DMTs) and discuss specific risks with their MS healthcare provider prior to stopping a DMT.
- Before starting a cell depleting DMT* or a DMT that carries warnings of potentially severe increase in disability after stopping**, people with MS and their MS healthcare providers should consider specific risks (e.g. age, comorbid health conditions, location) and benefits.
These recommendations have been endorsed by the Consortium of Multiple Sclerosis Centers (CMSC) and all other members of the MS Coalition***.
In addition to the above guidance, the MS International Federation (MSIF) provides global advice on DMT use during the COVID-19 pandemic. Their recommendations provide more detailed guidance for the initiation and continuation of DMTs and are endorsed by the National MS Society and the MS Coalition. With both the MSIF and the Society’s recommendations, decisions regarding DMT use should be individualized and made by the person with MS and his/her healthcare provider.
We are continuing to monitor this quickly evolving situation and these recommendations may be modified as data becomes available.
* Cell depleting therapies include: Lemtrada, Mavenclad, Ocrevus and Rituxan (used off-label in MS)
** DMTs with a warning of potentially severe increase in disability after stopping include: Gilenya and Tysabri
*** Members of the MS Coalition include: Accelerated Cure Project for Multiple Sclerosis, Can Do MS, Consortium of Multiple Sclerosis Centers, International Organization of Multiple Sclerosis Nurses, MS Views and News, Multiple Sclerosis Association of America, Multiple Sclerosis Foundation, National Multiple Sclerosis Society and United Spinal Association
Frequently Asked Questions about DMTs and COVID-19
Should I stop my DMT due to the COVID-19 pandemic?
No, you should not stop your DMT. Some websites and other MS organizations suggest that you postpone dosing of certain DMTs or switch DMTs. Based upon what is known right now, the National MS Society does not believe stopping your DMT is necessary. Stopping your DMT may place you at greater risk for new MS activity. We do recommend that you speak with your MS provider for advice about your specific situation and weigh the risks and benefits.
Which DMTs are immunomodulators and which are immunosuppressants?
DMTs that are immunomodulators generally do not suppress the immune system and do not place you at greater risk for infections – including COVID-19. These include:
- glatiramer acetate (COPAXONE®, Glatopa®,Glatiramer Acetate Injection®)
- interferons (Betaseron®, Rebif®, Avonex®, Extavia®, Plegridy®)
- natalizumab (Tysabri®)
Some DMTs are immunomodulators but also restrict the ability of the immune system to respond to infection and therefore may increase your risk of infections, including COVID-19. These include:
- dimethyl fumarate (Tecfidera®)
- diroximel fumarate (Vumerity)
- fingolimod (Gilenya®)
- siponimod (Mayzent®)
- teriflunomide (Aubagio®)
Some DMTs deplete certain types of immune system cells known as lymphocytes and are considered immunosuppressants – and therefore may increase your risk of infections, including COVID-19. These include:
- alemtuzumab (Lemtrada®)
- cladribine (Mavenclad®)
- mitoxantrone (Novantrone®)
- ocrelizumab (Ocrevus®)
- rituximab (Rituxan®)
I was recently diagnosed with MS and was prescribed a DMT. Should I start my DMT or should I postpone starting until after the COVID-19 crisis?
Yes, you should start your DMT. Some DMTs may increase your risk of infections, including COVID-19. This must be weighed against other factors including your MS activity, your age, other medical conditions and other potential factors that could impact your DMT. This is a difficult decision and needs a thorough discussion with your MS provider.
Should I switch my DMT to one that has lower risk of my getting an infection, including COVID-19?
The guidance from the National MS Society is to discuss the risks and benefits of your DMT with your MS provider. Stopping an effective DMT may increase your risk of more MS activity – including relapses. Some DMTs may increase your risk of COVID-19 infection, but this is not a certainty. The risks and benefits need to be weighed for each individual situation.
Should I stay home and “quarantined” because I have MS and I am on a DMT?
People with underlying lung and heart conditions and those aged over 60 years are more likely to experience complications and become severely ill with the COVID-19 virus. This group will include many people living with MS, especially those with additional health complications, mobility issues and those taking some MS treatments.
All people with MS are advised to pay attention to guidelines for reducing the risk of infection with COVID-19. Older people with MS, especially those who also have lung or heart diseases should take extra care to minimize their exposure to the virus. The World Health Organization recommendations include:
- Wash your hands frequently with soap and water or an alcohol-based hand rub
- Avoid touching your eyes, nose and mouth unless your hands are clean
- Try to keep at least 6 feet of distance between yourself and others, particularly those who are coughing and sneezing
- When coughing and sneezing, cover your mouth and nose with a flexed elbow or tissue
- Practice food safety by using different chopping boards for raw meat and cooked foods and wash your hands between handling them.
In addition, people with MS should:
- Avoid public gatherings and crowds – of greater than 10 people
- Avoid using public transport where possible
- Where possible, use alternatives to face-to-face routine medical appointments (for example, telephone appointments).
Is it ok for my family members or other close contacts to go to work or other types of social gatherings?
Care partners and family members who live with, or regularly visit, a person with MS should also follow the same recommendations to reduce the chance of bringing COVID-19 infection into the home.
There is a lot still unknown about COVID-19 and risks for people living with MS. As we learn more, we will update our information and provide more detailed guidance.