Do I need to stop treatment to get vaccinated?
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Disease-modifying therapies (DMTs) treat multiple sclerosis by altering the abnormal immune response in various ways. These effects on the immune system have the potential to reduce a person’s response to COVID vaccination. This raises the question: is it better to stop my DMT so I get the full protection against COVID-19?
The short answer is No: the most important thing to do is to keep taking your DMT. The risk of leaving your MS uncontrolled trumps other potential risks, including the risk of catching COVID-19.
That said, it is important to get vaccinated against COVID-19. So negotiating your MS treatment and your vaccination may take a little juggling. That is because vaccines work by stimulating immune cells (T and B cells) to fight the virus. T cells are important to kill the virus and to induce B cells to produce long-lasting antibodies that provide more sustained protection against infection. However, these very same T and B cell populations are targeted to a greater or lesser degree by various DMTs since they promote the inflammation that is so damaging in MS. So vaccines and MS medications are working at cross-purposes. While taking some DMTs, there may be a lessening of “vaccine efficacy”, i.e. how well the vaccine protects you against getting COVID-19.
Different DMTs have differing effects on the immune system. So we have put together a quick guide to how DMT dosing should be timed to get the most out of COVID vaccination. Recommendations are based on guidelines developed by the Canadian Network of MS Clinics (https://cnmsc.ca/Covid19VaccineGuidance).
- Copaxone (and generics): Injected once a day or three times a week (depending on the formulation). Does not significantly impair the vaccine response (e.g. H1N1 flu shot) (Metze and colleagues. CNS Neurosci Ther 2019;25:245-254). So no changes to the dosing schedule are needed leading up to or after vaccination.
- Interferons (Avonex, Betaseron, Extavia, Rebif, Plegridy): Various dosing schedules from every other day to once every two weeks. A high level of vaccine protection has been reported (Metze 2019). No changes to the dosing schedule are needed leading up to or after vaccination.
- Aubagio: Taken once-daily. Aubagio does not appear to significantly impair the response to flu vaccines or new vaccines (called ‘neoantigens’ because your immune system has never encountered them before) (Bar-Or and colleagues. Neurology 2013;81:552-558. Bar-Or and colleagues. Neurol Neuroimmunol Neuroinflamm 2015;2:e70). No changes to the dosing schedule are needed leading up to or after vaccination.
- Tecfidera/Vumerity: Taken twice a day. Tecfidera does not appear to impair the immune response to various types of vaccine (von Hehn and colleagues. Neurol Neuroimmunol Neuroinflamm 2017;5:e409); the same is expected for Vumerity. No changes to the dosing schedule are needed leading up to or after vaccination.
- Tysabri: Administered once a month. Tysabri is not expected to impair the immune response to the COVID vaccine. No changes to the dosing schedule are needed leading up to or after vaccination.
- Gilenya, Mayzent, Zeposia: Taken once a day. This class of drugs reduces T cell numbers and does appear to reduce the response to vaccination (Kappos and colleagues. Neurology 2015;84:872-879). However, abruptly stopping treatment can result in worsening MS symptoms so it is best to continue the medication as directed by your doctor. The lower vaccine response means it is especially important to get the second vaccination when it becomes available. No changes to the dosing schedule are needed.
- Mavenclad and Lemtrada: Taken for 1 or 2 weeks per year for two years. Both of these medications impair the immune response for about 3-6 months after dosing so extra precautions against infection are needed during this period. There appears to be a full vaccination response to Lemtrada if the vaccine is given at least 6 months after the last dose (McCarthy and colleagues. Neurology 2013;81:872-876). The same is expected for Mavenclad although no vaccine studies have been done. To get the timing just right, your doctor may delay your next dose of Mavenclad or Lemtrada until after you have been vaccinated. It is unlikely that your MS will flare up even if your next dose is put off for a few months.
- Ocrevus: Administered once every 6 months. This medication specifically targets the immune cells that develop into antibody-producing cells so it has a significant impact on vaccine response (Bar-Or and colleagues. Neurology 2020;95:e1999-e2008). This raises a concern that people will not get full protection from vaccination. The current recommendation is to wait at least 4-6 months after the last dose of Ocrevus before getting vaccinated. Getting the second vaccine dose will be especially important to boost your immunity. If the second vaccine shot is administered a few months later, this may mean you will need to delay your next dose of Ocrevus. Your doctor will advise you on when it is best to resume treatment.
- Kesimpta: Injected once a month. This medication also targets the cells that develop into antibody-producing cells so it is likely that it will have an effect on the vaccine response (no studies have been done). However, the immune system recovers more quickly, so there is less need to stay off treatment for an extended period. The current recommendation is to skip a dose and get vaccinated that month instead. Kesimpta would be re-started about 1 month after the second vaccine dose. That would mean skipping at least 2 doses of Kesimpta (or more depending on the timing of the second vaccination). Your doctor will advise you on when it is best to resume treatment.
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