How To Support People With Multiple Sclerosis During The Coronavirus Pandemics
By Pablo Villoslada, MD, PhD
People who have chronic diseases and receive drugs that affect the immune system as part of their treatment may be more at risk of exposure during coronavirus epidemics. This may be the case for people with Multiple Sclerosis (MS) and is something that is generating significant concern and anxiety between patients and their relatives. People with MS used to be young, in their 20s to 50s, which would imply by default, a good prognosis regarding the severity of coronavirus complications such as pneumonia. However, for most patients, this is not the case. First, patients with progressive MS who have a moderate to severe disability (e.g., being restricted to a wheelchair), are more likely to contract common bacterial and viral infections due to their limited mobility or sphincter and swallowing impairments. The increased frequency of infections implies they may have to take many courses of antibiotics. This may alter their microbiome and, as a result, suffer higher levels of immune senescence. For this reason, they may be predisposed to a less efficacious immune response against infection such as the coronavirus. Indeed, due to their mobility limitations, their lungs are more prone to develop secondary infections or pneumonia because of the impairment of self-cleaning. Therefore, patients with progressive MS and significant disabilities are at higher risk of developing coronavirus complications than others within their age group. For this reason, people with MS with a high disability should be considered a high-risk population and follow the most strict confinement rules for their safety.
The other group at risk, are relapsing MS cases receiving powerful immunomodulatory drugs for controlling the disease. MS drugs can impair the immune response in the cases of coronavirus. Recommendations from the National MS Society1, the MS International Federation2, or MS experts3 have provided guidelines for the use of MS drugs. Therapies such as interferon-beta, glatiramer acetate, teriflunomide, fingolimod, siponimod, dimethyl-fumarate, and natalizumab do not present a higher risk of complications for the coronavirus infection. For this reason, such therapies should be continued. However, high-efficacy therapies that deplete immune cell subpopulations such as alemtuzumab, rituximab, ocrelizumab, cladribine, or bone marrow transplantation, may significantly prevent the development of an effective immune response. For this reason, people undergoing these therapies may be at risk of serious complications. The guidelines recommend delaying the infusions of such drugs for three months, to avoid exposing such patients during the peak of the epidemics. Indeed, bone marrow transplants are currently banned due to the high levels of risk.
A theoretical risk is that people with MS may be predisposed to suffer other autoimmune diseases. Many autoimmune diseases are related to abnormal responses to common viral infections, this may suggest that some people may develop autoimmune diseases affecting the nervous system, such as Guillain-Barre syndrome or encephalitis. This risk is theoretical and probably very rare, but epidemiologic surveillance should be in place for detecting such cases.
Challenges will also occur when a vaccine for the virus becomes available. Patients receiving high-efficacy therapies and with significant immune cell depletion would be unable to develop an appropriate immune response to the vaccine. For this reason, the efficacy of the vaccine can be compromised. To develop an effective vaccination program for patients receiving such drugs, drug administration should be delayed and immune cell repopulation should be monitored, to achieve the minimum count that would make the vaccine effective. After vaccination, patients should be monitored for at least two weeks and assessed with serological tests, to see whether they have developed the appropriate IgG response to the virus. Only then should they resume their therapy for controlling MS.
In summary, people with MS should be reassured that their health is going to be protected by the health system, that will continue to advise the best strategies for protecting them against coronavirus, based on the recommendations described above. We are all fighting to solve this crisis as soon as possible to allow us to return to focusing on defeating MS and improve patients’ quality of life.
Pablo is a neurologist with more than 20 years of experience in Translational Medicine on biomarkers and new therapeutics for neurological diseases.S
2msif.org/news/2020/02/10/the-coronavirus-and-ms-what-you-need-to-know/. Updated March 24, 2020. Accessed March 24, 2020.
3Brownlee W, Bourdette D, Broadley S, Killestein J, Ciccarelli O. Treating multiple sclerosis and neuromyelitis optica spectrum disorder during the COVID-19 pandemic. Neurology. 2020 Apr 2. PMID: 32241953.