New COVID-19 and MS Data Available (Oct. 27, 2020)

The pandemic due to infection with the coronavirus virus SARS-CoV-2, causing the clinical syndrome called COVID-19, continues to wreak havoc. What impact it may have in MS patients remains an area of great interest and study. Our team at the RMMSC at University of Colorado continues to analyze new information from studies and registries of MS patients with COVID-19. It’s very important to note that there are many complexities to consider about this data which we detail in this update. Each individual will have a unique risk of a good or bad outcome based on a number of factors, including perhaps some disease modifying therapies (DMTs) particularly anti-CD20 therapies such as rituximab (Rituxan) and ocrelizumab (Ocrevus). Most importantly, patients should not stop or delay use of their DMT without first having a discussion of all available options with their Neurology provider. We will continue to send updates as new information becomes available.  Important new information is now available and we encourage you to read this article in full.

MS Center COVID-19 Update

 The Rocky Mountain MS Center's latest update on COVID-19 was held on October 29, 2020, and featured Dr. John Corboy, Co-Director of the RMMSC @ University of Colorado. Dr. Corboy gave an update on what we’ve learned about COVID-19 and MS, including a discussion and Q&A session with the audience. 
Watch the Update on YouTube

 

Data from multiple registries of MS patients with COVID-19 show that the main risks for MS patients exposed to SARS-CoV-2 are the same as in non-MS individuals. That is, those at highest risk of bad outcomes are older, have greater disability, and/or smoke or have other medical conditions such as obesity, diabetes, high blood pressure, cancer or others.  Some MS therapies, because of the way they work, have raised concerns if a patient is exposed to SARS-CoV-2. One small Italian study had raised a concern that anti-CD20 agents such as rituximab (Rituxan) and ocrelizumab (Ocrevus) were associated with a worse outcome (increased risk of admission to the hospital, admission to the intensive care unit, and use of a ventilator to aid) compared to dimethyl fumarate (Tecfidera). A small French study, however, did not find worse outcomes with any MS DMT. Similarly the North American registry (called (CoviMS) of 765 patients found no differences in outcomes between those on differing medications or no medication.

On September 26, 2020, however, the results of an international collection of COVID registries in MS patients was reported at the final session of the combined, virtual ACTRIMS/ECTRIMS meeting. Over 1,200 patients on any of a variety of MS disease modifying therapies (DMTs), including none, were followed to see what their outcomes were as it was related to the DMTs. The general findings were consistent with prior studies showing that age, level of disability, and other conditions or circumstances such as obesity increase the risk of having bad outcomes if MS patients are exposed to SARS-CoV-2. In this study, the anti-CD20 agents rituximab (Rituxan) and ocrelizumab (Ocrevus) were compared first, each separately, to dimethyl fumarate (Tecfidera) and then combined to natalizumab (Tysabri). In all comparisons, rituximab and ocrelizumab had about a 2-3 fold increased risk of admission to the hospital, admission to the intensive care unit, and use of a ventilator to aid breathing. There was no increased risk of death in any of the comparisons.

There are limitations in registries studies such as these, including that patients with no or minimal symptoms will not be assessed because they did not get tested. In addition, it is not possible to control for all factors such as other medical conditions. That said, it raises a concern that anti-CD20 agents may be one factor, among many, that increases risk should a MS patient be exposed to coronavirus, SARS-CoV-2. It is important to note as well, that if the overall risk of a patient is low, perhaps 3% for young, otherwise healthy patients, then doubling that risk to 6% (ie a 2 fold increase) is still an overall small increase. If the overall risk is higher, as in an older patient with many other medical conditions, the risk of the medication may not be worth the potential benefit. Each patient will be unique and all treatment decisions should be discussed with an individual’s provider who knows their entire medical history and circumstances. 

Another factor to consider is the role of vaccinations. In July, 2020 a study revealed that use of ocrelizumab is associated with a reduced response to vaccination, specifically with pneumovax, tetanus, and the flu. As there is no coronavirus vaccine yet, it is unclear if this will also be the case for a SARS-CoV-2 vaccine, but this is possible based on this study. A reduced response does not mean that the person receives no benefit from these vaccines but that their benefit may be reduced. In general, we are still recommending that patients with MS get the flu vaccine this year unless there are other medical reasons they should not.

Thus, each person will have a unique risk of good or bad outcome if exposed to the coronavirus, SARS-CoV-2, based on a number of factors, including perhaps some DMTs.  Everyone should continue to wear a mask, socially distance and wash your hands frequently to reducethe risk of exposure. In Colorado, these recommendations may be more stringent in some counties compared to others. Indeed, on October 16, 2020, Denver Mayor Michael Hancock increased mandates in Denver for use of masks even outdoors, and limited gatherings (see https://www.denverpost.com/2020/10/16/denver-covid-mask-order-group-gatherings/). 

Variations of these recommendations will likely remain in place until it can be shown that a significant proportion of the US population have developed immunity through natural infection or vaccination, and that the immunity is long-lasting. They also will likely be changing over time, at the state or county level. Most importantly, patients should not stop or delay use of their DMT without first having a discussion of all available options with their Neurology provider.