COVID-19 And MS : Dr Maria Gaughan
As the implications of SARS-Co-V-2 gradually dawned in Europe, rapid changes occurred in MS management across Europe. The degree to which pwMS, the majority of whom are on immunosuppressive or immunomodulatory medications would be impacted was initially unclear. Internationally, experts in the field attempted to categorise the risk of DMTs based on mechanism of action of the medication and pathophysiological models of COVID-19. PwMS were advised to work from home, minimise social contacts and cocoon depending on the medication that they were taking.
Clinic appointments were cancelled and switched to virtual appointments. Medications considered to have a higher risk of immunosuppression, such as Ocrelizumab and Cladribine were postponed. Patients due to commence these medications were rapidly worked up for an alternative. The goal at all times was to ensure effective control of multiple sclerosis while minimising patient risk. Global registries were hurriedly established and have provided good data, although methodological issues remain.
Large French and Italian registries have provided interesting insights.1 PwMS are not at greater risk of catching COVID-19 than the general population. 2Indeed, due to the abundance of caution taken by pwMS, infection rates are likely lower than the general population. The majority of medications taken by pwMS do not significantly increase the risk of severe infection resulting in hospitalisation, ventilation, ICU admission or death. There is a suggestion that caution should be exercised with Ocrelizumab and Rituximab, with studies suggesting slightly increased risk of more severe infection, but not of death. 3 The factors that increase risk of severe COVID-19 in MS appear to be age, disability and co-morbidities.
Current practices in Covid have evolved to ensure that patients have, as far as is possible, access to neurology OPD with virtual OPD if this remains a preference. All services, both within the public and private systems, are attempting to deal with the backlog that arose during March and April. Timely access to disease modifying treatments has remained a priority for the majority of patients.
If a person with MS develops COVID-19 we would advise them to contact their MS team. They may require laboratory investigations to ensure they are not currently immune suppressed. They may require temporary suspension of their current treatment, although more commonly treatment is continued. As with other infections, they may experience a transient worsening of their MS symptoms, although these should improve with resolution of infection. We are attempting to collect data at a national level on pwMS who experience COVID-19 infection, in order to gain further insight into the degree of impact this may have.
Key points:
- Age, disability and co-morbidities are strongly correlated with more severe COVID clinical course.
- MS itself does not increase risk of severe COVID infection, however as above, disability does.
- Certain MS treatments such as Ocrelizumab and Rituximab may possibly increase risk of more severe COVID-19 infection
- Prolonged cocooning can potentially result in deconditioning and isolation in pwMS - closure of day services, difficulty in accessing physiotherapy services, less 'incidental' mobility on a day to day basis. PwMS are encouraged to link in with online exercise classes such as those provided on the mstrust.org.uk website. We also encourage regular walks/exercise and social contact with safe practices, such as mask wearing and frequent hand washing.
References:
1. Sormani MP, Italian Study Group on C-iims, Italian Study Grp C. An Italian programme for COVID-19 infection in multiple sclerosis. Lancet neurology 2020;19:481-482.
2. Moss BP, Mahajan KR, Bermel RA, et al. Multiple sclerosis management during the COVID-19 pandemic. Multiple sclerosis 2020;26:1163-1171.
3. Louapre C, Collongues N, Stankoff B, et al. Clinical Characteristics and Outcomes in With Coronavirus Disease 2019 and Multiple Sclerosis. JAMA neurology 2020;77:1079-1088.