Update on drug therapies for MS – Part 2
In Part 1 of this article we looked at some of the questions that were addressed by new research presented at this year’s meeting of the Americas and European Committee for Treatment and Research in MS (ACTRIMS/ECTRIMS). The meeting was held on September 11-13, 2020, with a special session on COVID-19 on September 26, 2020. For Part 2, we’ll look at what was learned about the more potent MS therapies, and what has been learned during the COVID-19 pandemic.
The standard approach to treating MS is to start with an injectable (e.g. Copaxone or an interferon) or oral (e.g. Aubagio, Tecfidera) disease-modifying therapy (DMT), then step up to a more potent medication (e.g. Mavenclad, Tysabri, Ocrevus or Lemtrada) if the person continues to have relapses or experiences worsening disability. A more potent medication can be used upfront, but they’re generally reserved for people with severe MS or who are rapidly getting worse.
An Italian study of over 700 people with MS looked at these two approaches – using an oral or injectable for a median of five years before escalating versus starting with a high-potency medication right away (Iaffaldano and colleagues. ACTRIMS/ECTRIMS 2020; abstract PS01.04). Over a 10-year period, the amount of disability was slightly worse in people who delayed getting treatment with a higher-potency drug.
People taking Tysabri are often switched to another treatment if they acquire a JC virus infection due to the risk of PML, but those who remain free of the virus can stay on treatment indefinitely. A Swedish study looked at 171 people who had been taking Tysabri for at least 10 years (Kagstrom and colleagues. ACTRIMS/ECTRIMS 2020; abstract P0331). People experienced no relapses in the first year of starting Tysabri. MS symptoms and cognitive function significantly improved during treatment and disability levels stabilized. About 20% had to stop Tysabri at some point. Most did so because they’d acquired the JC virus or they became pregnant (Berglund and colleagues. ACTRIMS/ECTRIMS 2020; abstract P0350). Few people (6.5%) stopped because the drug had stopped working.
A separate study looked at the 5-year outcomes of people who had taken Mavenclad (Giovannoni and colleagues. ACTRIMS/ECTRIMS 2020; abstract P0202). People took the standard course of Mavenclad (2 weeks of treatment per year for two years), then remained off medication for the next few years. In the follow-up to the Mavenclad clinical studies, researchers found that relapses were reduced during treatment – but relapses didn’t become more frequent in the four years after the drug was stopped, suggesting that the drug was still working.
The rate of worsening disability among people with relapsing MS treated with Ocrevus remained low for 6.5 years (Giovannoni and colleagues. ACTRIMS/ECTRIMS 2020; abstract P0216). Overall, about 16% experienced worsening disability, with 5% progressing to needing a walking aid. For people with primary-progressive MS, 54% experienced worsening disability over seven years of treatment with Ocrevus, with 12% progressing to needing a wheelchair (Wolinsky and colleagues. ACTRIMS/ECTRIMS 2020; abstract P0237). Among those who delayed starting treatment for two years, the proportion of people needing a wheelchair after five years of Ocrevus was 22%.
There have been concerns since the start of the COVID-19 pandemic about whether people with MS have a higher risk of becoming ill, and if it’s safe to be taking MS medications that suppress the immune response. Patient registries around the world have tried to answer these questions by pooling data for all of the known people with MS who developed COVID-19. Here is what they’ve found thus far.
Do people with MS have a higher risk of contracting the CoV-2 virus that causes COVID-19?
People with MS appear to have a similar risk overall of catching the virus as people without MS (Meca-Lallana and colleagues. ACTRIMS/ECTRIMS 2020; abstract LB1156). An emerging concern, however, is that some studies have suggested that people taking Ocrevus are more likely to get COVID-19, especially if they have been on treatment for a while (Kieseier et al. ACTRIMS/ECTRIMS 2020; Zabalza and colleagues. ACTRIMS/ECTRIMS 2020; abstract LB1168). So it may be especially important for people taking Ocrevus (or Rituxan) to rigorously adhere to the current public health recommendations: wash your hands, wear a mask and avoid large gatherings of people.
Do people with MS get sicker from COVID-19?
It doesn’t appear that MS increases the risk of having a severe case of COVID-19. However, older people, those with progressive MS and people with other medical illnesses (such as kidney disease or respiratory problems) do appear to have a higher risk of more severe COVID-19 (Zabalza and colleagues. ACTRIMS/ECTRIMS 2020; abstract LB1168). While people often worry about taking a DMT, there is some evidence to suggest that people with untreated MS are more at risk from COVID-19 than those taking a DMT.
Is it safe to take my MS medication?
As mentioned above, people with untreated MS appear to have a worse course of COVID-19 than people on a DMT. Moreover, no DMT appears to be associated with a higher risk of dying from COVID-19. So guarding against the known risks of MS by taking a medication is probably a better approach than worrying about what happens if you catch COVID-19.
That said, not all medications are the same. The largest database, the MS Global Data Sharing Initiative, found that two medications – Rituxan and Ocrevus – are associated with a higher risk of poorer COVID-19 outcomes (Simpson-Yap and colleagues. ACTRIMS/ECTRIMS 2020; abstract SS02.04). People taking Rituxan were more likely to be admitted to hospital or ICU than people taking other DMTs. Similarly, people taking Ocrevus were more likely to require ICU admission if they contracted COVID-19. Both of these medications profoundly suppress the immune response, which may impair how your body responds to the virus. If you’re taking one of these medications, you may want to talk to your neurologist about what would be best for your situation – continue with the usual regimen, delay the next dose or switch to another medication.
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