MS Treatment Guidelines During Coronavirus

People with MS have asked for guidance on the use of disease modifying therapies (DMTs) during the COVID-19 pandemic. Representatives of the National MS Society and the National Medical Advisory Committee participated on a committee to revise the Multiple Sclerosis International Federation (MSIF) global COVID-19 advice for people living with MS, which is detailed below.

The National MS Society believes DMT decisions should be individualized and made collaboratively between the person with MS and their healthcare provider. These discussions include considering disease factors, risks and benefits of the DMT and risks associated with COVID-19.

Many disease modifying therapies (DMTs) for MS work by suppressing or modifying the immune system. Some MS medications might increase the likelihood of developing complications from a COVID-19 infection but this risk needs to be balanced with the risks of stopping or delaying treatment. We recommend that:

• People with MS currently taking DMTs continue with their treatment, unless advised to stop by their treating clinician.
• People who develop symptoms of COVID-19 or test positive for the infection discuss their MS therapies with their MS care provider or another health care professional who is familiar with their care.
• Before starting on any new DMT, people with MS discuss with their healthcare professional which therapy is the best choice for their individual circumstances. The decision should consider the following information:
  • MS disease course and activity
  • The risks and benefits normally associated with different treatment options
  • Additional risks related to COVID-19, such as:
    • The presence of other factors for a more severe case of COVID-19, such as older age, obesity, pre-existing lung or cardiovascular disease, progressive MS, higher risk race/ethnicity etc, as listed here
    • The current and anticipated future COVID-19 risk in the local area
    • Risk of exposure to COVID-19 due to lifestyle, for example whether they are able to self-isolate or are working in a high-risk environment
    • Emerging evidence on the potential interaction between some treatments

Evidence on the impact of DMTs on COVID-19 severity

• Interferons (Avonex, Betaseron, Extavia, Plegridy, Rebif) and glatiramer acetate (Copaxone) are unlikely to impact negatively on COVID-19 severity. There is some preliminary evidence that interferons may reduce the need for hospitalization due to COVID-19.
• The evidence available suggests that people with MS taking dimethyl fumarate (Tecfidera), diroximel fumarate (Vumerity), teriflunomide (Aubagio), fingolimod (Gilenya), natalizumab (Tysabri), ozanimod (Zeposia) and siponimod (Mayzent) do not have an increased risk of more severe COVID-19 symptoms.
• There is some evidence that therapies that target CD20 – ocrelizumab (Ocrevus) and rituximab (Rituxan)– may be linked to an increased chance of having a more severe form of COVID-19. However, these therapies should still be considered as an option for treating MS during the pandemic. People with MS who are taking them or ofatumumab (Kesimpta) that works in the same way, should be particularly vigilant regarding the advice here to reduce their risk of infection.
• More data on the use of alemtuzumab (Lemtrada) and cladribine (Mavenclad) during the COVID-19 pandemic are required to make any assessment of their safety. People with MS who are currently taking these therapies and are living in a community with a COVID-19 outbreak should discuss their current lymphocyte counts with their healthcare professional. (Lymphocytes are a type of white blood cell that helps protect the body from infection). If their counts are considered to be low they should isolate as much as possible to reduce their risk.
• 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 healthcare professional about the risks and benefits of postponing treatment. People are strongly encouraged not to stop treatment without the advice of their clinician.

People with MS should still seek medical advice if they experience changes in their health that may suggest a relapse or another underlying issue such as an infection. This can be done using alternatives to in-person clinic visits (such as telephone or video consultations) if the option is available. In many cases, it is possible to manage relapses at home.

The use of steroids for treating relapses should be carefully considered and only used for serious relapses. There is some evidence that receiving high-dose steroids in the month prior to contracting COVID-19 increases the risk of a more severe infection requiring a visit to hospital. Where possible, the decision should be made by a neurologist experienced in the treatment of MS. People who receive steroid treatment for a relapse should be extra vigilant and may want to consider self-isolation for at least a month to reduce their risk from COVID-19.

People with MS should continue to participate in rehabilitation activities and stay active as much as possible during the pandemic. This can be done through remote sessions where available or in clinics as long as facilities are taking safety precautions to limit the spread of COVID-19. People with concerns about their mental health should seek advice from their healthcare professional.

Flu vaccine

The flu vaccine is safe and recommended for people with MS. For countries entering flu season, we recommend people with MS receive the seasonal flu vaccine where it is available.

SARS-CoV-2 vaccine

At present there is not enough information available to comment on how the different SARS-CoV-2 vaccines in development would interact with MS or with disease-modifying therapies for MS. Advice will be included in an updated version of this statement as soon as it becomes available.

• Centers for Disease Control and Prevention
• World Health Organization