Are immune-suppressing treatments safe during a pandemic?

The disease-modifying medications used to treat multiple sclerosis have posed something of a conundrum during the COVID pandemic. These medications suppress the abnormal immune response in MS – but this same immune response is needed to fight infections, such as the CoV-2 virus that causes COVID-19.

When the pandemic first began, various medical groups, such as the Canadian Network of MS Clinics, were quick to offer advice on treatment during the COVID era. As the pandemic has worn on, new information has become available about the safety of the immune-suppressing medications needed to control MS. The key sources of information are the MS Global Data Sharing Initiative, which has pooled information from MS patient registries from 21 countries (Simpson-Yap and colleagues. ECTRIMS 2020; abstract SS02.04); and the COViMS registry of people in North America (Salter and colleagues. ECTRIMS 2020; abstract LB1242).

Overall, having MS does not appear to increase a person’s risk of getting COVID. It may help that people with MS may see themselves as more vulnerable and may be somewhat more likely to adhere to public health advice – wearing a mask, washing hands and maintaining physical distancing. This is a prudent approach since some people with MS have known risk factors for more severe COVID: older age, disability and other medical conditions (e.g. heart, lung or kidney disease). The risk of being hospitalized is about two-fold higher in people older than age 70 and those with progressive MS; the risk is higher still for people requiring a wheelchair. So people with these risks should take extra precautions to remain safe.

Overall, MS medications do not appear to increase a person’s risk of developing severe COVID. In fact, the risk of severe COVID appears to be higher in people with untreated MS compared to those on a medication. The reasons for this aren’t immediately apparent but may be because older people and those with greater disability are less likely to be on a treatment.

For people currently on treatment, MS medications have differing effects on the immune system so the COVID risk isn’t the same with different therapies. Of the higher potency agents, Tysabri is the only one that doesn’t act as an immune suppressant and isn’t generally associated with a higher risk of infections. The general recommendation is that Tysabri can be maintained during the pandemic and can probably be continued even if you get COVID-19. Your doctor may advise you to have less frequent infusions, e.g. every 5-6 weeks rather than every 4 weeks.

Gilenya and Zeposia do lower the immune response and are associated with a higher rate of infections. Your body can probably mount a sufficient immune response if you get COVID, but your doctor may recommend that you interrupt therapy for a few weeks. If your disease is especially active, you may need an interim therapy to stop your MS from flaring up after stopping Gilenya/Zeposia.

Mavenclad is an intermittent immune suppressant. Treatment is taken for two weeks (weeks 1 and 5) a year. After the course of treatment, the period off medication allows your immune response to recover. There may be a higher-risk period of a few months after you complete your treatment weeks during which you may want to take extra precautions against COVID. From what we know thus far, people who develop COVID while taking Mavenclad appear to do well (Karan and colleagues. ECTRIMS 2020; LB1151. Oreja-Guevara and colleagues. ECTRIMS 2020; LB1165). Your doctor may advise you to delay the second course of treatment (in year 2). Your MS is unlikely to flare up even if treatment is delayed for up to 6 months.

Lemtrada is a very potent immune-suppressing agent that is associated with a risk of infections. A one-week course of treatment can suppress parts of the immune response for years, so added precautions against COVID are generally recommended. Your doctor may advise you to delay starting this treatment or taking the second course of therapy for a few months.

As for Ocrevus, the initial thinking was that this immunosuppressant could be maintained during the pandemic, but that opinion appears to have shifted. There have been a few reports that people taking Ocrevus are more likely to catch COVID (Zabalza and colleagues. ECTRIMS 2020; LB1168. Kieseier and colleagues. ECTRIMS 2020; LB1252). In addition, there appears to be a higher risk of severe COVID if infection occurs during treatment with Ocrevus (Salter 2020. Simpson-Yap 2020. Tremblay and colleagues. ECTRIMS 2020; LB1181). In part, this higher risk may be because people are started on Ocrevus because they are more ill or have progressive MS. But it is likely that the ongoing immune suppression with this agent impairs the body’s ability to fight COVID. Your doctor may advise you to skip a dose or two to allow your immune system to recover somewhat. Since Ocrevus also impairs the vaccine response, he/she may also recommend that you switch to another therapy, so you’ll be ready for the COVID vaccine when one becomes available.

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