April 27, 2020

Managing Multiple Sclerosis During the COVID-19 Pandemic

What to do with what we know, and how we’re gathering more data

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Most patients with multiple sclerosis (MS) on disease-modifying therapies (DMTs) should not stop or alter their therapeutic regimen, according to Cleveland Clinic’s Mellen Center for Multiple Sclerosis Treatment and Research. That recommendation is based on the best available, most current information on the impact of COVID-19 on MS, but knowledge of this issue is evolving rapidly.

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While there still are many unknowns regarding COVID-19 and MS therapies, the Mellen Center’s Director of Experimental Therapeutics, Jeffrey Cohen, MD, says clinicians aren’t exactly walking in the dark. “We know a great deal about many of the therapies used for patients with MS and how they impact the body’s ability to fight disease,” he says. “In fact, one class of therapies, sphingosine 1-phosphate receptor modulators, is under study for treating COVID-19. Unfortunately, we simply don’t have the luxury of gathering and analyzing all data we would want before talking to our patients about this disease.”

To help fill the void, the Mellen Center has established an MS COVID-19 Registry to track the disease’s effects on patients with MS.

What we know now

The current Mellen Center recommendation, which is consistent with recent guidance from the National Multiple Sclerosis Society, is that stopping or delaying DMTs will not reduce a patient’s susceptibility to, or decrease the risk of complications from, COVID-19.

However, it’s important to note that this is only a recommendation. “We don’t yet have sufficient evidence to state this unequivocally,” says Dr. Cohen. “Preliminary data from a number of registries, which are being shared during frequent videoconferences attended by MS experts worldwide, support this general recommendation. So far, there appears to be no increase in the prevalence or severity of COVID-19 in patients with MS related to taking DMTs or related to any particular DMT. However, as in many other aspects of COVID-19, we don’t have the kind of robust, gold-standard evidence we need to make more definitive statements.”

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As more evidence emerges, he adds, recommendations might change.

COVID-19 and the MS registry

The Mellen Center has begun collecting data on patients with MS who have been tested for or diagnosed with COVID-19. These data will be combined with the Mellen Center Clinical Practice Data Registry, which tracks disease and medication history, neuroperformance testing, quantitative MRI metrics and patient-reported outcomes. The Mellen Center also operates an MS COVID-19 hotline and will use EMR data to track comorbidities and other factors outside the scope of the registries.

“We already had the infrastructure in place to acquire these data efficiently, requiring only a few modifications to adapt it for COVID-19,” notes Dr. Cohen. “We hope to offer insights on the effects of COVID-19 on MS disease activity and severity as well as on patient and clinician behaviors in response to the disease. We also hope to start identifying any associations of social determinants of health, demographics, MS disease characteristics and DMT use with COVID-19 susceptibility, manifestations, complications, severity and outcomes.”

How to counsel patients in the meantime

Physicians should emphasize the increased importance of handwashing, social distancing and other infection control measures for patients with MS, especially for those on immunomodulatory therapies. While the general recommendation is to stay the course on therapy, the Mellen Center emphasizes an individualized approach that weighs the risk of medication and visiting infusion centers against the benefits of treatment. Selected patients should also consider postponing the start of a new DMT, particularly long-acting cell-depleting agents or one requiring infusion.

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“Although in general we advise patients to continue ongoing therapy, for some patients, delaying treatment is acceptable, especially for those on longer-acting MS infusions,” says Dr. Cohen. “Extending the dosing interval can reduce exposure to healthcare facilities for older patients, those living in nursing facilities, and those with other conditions that increase the risk of COVID-19, such as cardiovascular disease or lung disease. But these decisions must be made in concert with the patient and the entire treatment team, and strictly on a case-by-case basis.” Expanded telehealth options and proactive monitoring are key aspects of facilitating these conversations during a pandemic.

“While every day seems to bring new information in the fight against COVID-19,” he continues, “we remain focused on our team-based, individualized approach to treating MS.”

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