Like most neurologists, I have received several recent inquiries from patients with Multiple Sclerosis about the risks associated with MS treatments during the coronavirus pandemic.
MS Australia has produced their own statement on the issues, which is very helpful. Please check this link.
Overall, patients with Multiple Sclerosis should take similar precautions to those in the general community. Patients who are wheelchair-bound or elderly should take particular care.
Risks posed by specific treatments
With regards to specific therapies, glatiramer acetate (Copaxone) and beta-interferon (Avonex, Betaferon, Plegridy, Rebif) are immunomodulatory rather than immunosuppressive, and they make no signficiant difference to Covid risk.
Plasma exchange and intravenous gammaglobulin (IVIg) only have minimal impacts on immune resistance to viruses, but please take extra care when attending the hospital to receive these treatments (they are not commonly used to treat MS, but I have some patients receiving IVIg for other conditions).
Many of the most effective therapies used to treat Multiple Sclerosis are considered potentially immunosuppressive, including natalizumab (Tysabri), fingolimod (Gilenya), siponimod (Mayzent), dimethyl fumarate (Tecfidera), and teriflunomide (Aubagio). There is currently no evidence that these treatments increase the risk of COVID-19 infection, and there is a substantial risk of a relapse if these treatments are stopped, so please continue them, but take extra precautions with hand-washing and social distancing, particularly if your lymphocyte count is low.
The following treatments are definitely immunosuppressive: prednisolone, methotrexate (MTX), azathioprine (Imuran), mycophenolate mofetil (Cellcept), and cyclophosphamide (Cytoxan). The effects depend on the dose. If you are on any of these, please discuss the situation with your neurologist.
Pulsed immunosuppressive therapies, such as rituximab (Rituxan), ocrelizumab (Ocrevus), alemtuzumab (Lemtrada), and cladribine (Mavenclad]) should not be taken until the benefits and risk have been considered. As noted on the MS Australia website, the pulsed nature of these treatments means that they can be delayed, and this might be a reasonable option under some circumstances. Please discuss the situation with your neurologist.
Pulsed steroids for relapses
High-dose methylprednisolone is often used to get patients through an MS relapse more rapidly.This treatment has not been shown to change the long-term outcome or to minimise the risk of disability, but it can shorten the duration of symptoms. We normally avoid high-dose steroids for mild-to-moderate relapse, because steroids have a number of side effects (including osteoporosis, where the risk is associated with the lifetime exposure to steroids). In the current epidemic, high-dose methylprednisolone should generally be avoided unless the relapse is severe – particularly if the treatment requires you to attend hospital, where you might have contact with infected patients.
Flu vaccines
I have also received questions about the flu vaccine in the setting of MS and the current epidemic. In general, patients with MS should have a flu vaccine this year, even if they do not get vaccinated in other years. The aim of this is to minimise the chance of ending up in hospital, and to avoid the risk of getting both viral infections at the same time. The risk of the vaccine triggering a relapse is very low.
I hope this helps. Please make a telehealth appointment to discuss the issues if you are not sure what to do in your situation.
Best regards to all of you,
Craig McColl.
See also:
A Conversation about COVID-19 with Neurologist, Associate Professor Anneke van der Walt (https://youtu.be/cnGXV39yLPw)