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. DMT decision making varies significantly from country to country, ranging from highly provider-directed to a collaborative decision-making model.

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

Representatives of the National MS Society and the chair of 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.

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.
• 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 disease course and disease activity in light of COVID-19 risk in the region. The following information should be considered during decision-making:
  • 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 limited evidence available suggests that people with MS taking dimethyl fumarate (Tecfidera), diroximel fumarate (Vumerity), teriflunomide (Aubagio), fingolimod (Gilenya), ozanimod (Zeposia) and siponimod (Mayzent) do not have an increased risk of more severe COVID-19 symptoms or death.
  • Therapies that target CD20 – ocrelizumab (Ocrevus) and rituximab (Rituxan)– may be linked to an increased chance of being admitted to hospital or requiring intensive care treatment due to COVID-19. This preliminary finding requires further investigation.
  • More data on the use of natalizumab (Tysabri), 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 ocrelizumab (Ocrevus) or rituximab (Rituxan) and are living in a community with a COVID-19 outbreak should be extra vigilant and may want to consider self-isolation to reduce their risk of infection.
• People with MS who are currently taking alemtuzumab (Lemtrada) or cladribine (Mavenclad) and are living in a community with a COVID-19 outbreak should discuss their current lymphocyte counts with their healthcare professional. If their counts are considered to be low they should isolate as much as possible to reduce their risk.

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. 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 an appropriate amount of time 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.

The following data sources were reviewed during the development of this advice:

• Data of the Italian MuSC-19 project - Sormani MP et al. Disease modifying therapies and COVID-19 severity in Multiple Sclerosis. (submitted)
• Exploratory data of the COVID-19 and MS Global data sharing initiative, as of June 10, 2020

• Centers for Disease Control and Prevention
• World Health Organization