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. 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 additional recommendations for people at risk for serious illnesses from COVID-19. • People with MS should continue 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 a 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 additional 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
Starting, Stopping or Switching Disease Modifying Therapies
Most people should start a DMT if recently diagnosed and prescribed a 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.
Based upon what is known right now, the National MS Society does not believe stopping your DMT is necessary and any decision regarding your DMT should be discussed with your MS healthcare provider. Stopping your DMT may place you at greater risk for new MS activity. We recommend that you speak with your MS provider for advice about your specific situation and weigh the risks and benefits. If you take an infused DMT, call ahead to confirm and learn of any new procedures to follow. If your infusion center is not open, contact the manufacturer of your medication to find a new infustion center.
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. Switching a DMT to one that lowers risk of getting an infection, including COVID-19, should be discussed with your provider. 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.
Steroids or ACTHAR gel are safe to administer for MS relapses.
Immunomodulators vs. 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®)