In response to the COVID-19 pandemic, neurologists around the world are sharing information regarding the use of immunosuppressive disease-modifying therapies (DMT) for patients with MS.

The Italian Society of Neurologists issued its recommendations (in Italian) last week which were then translated and shared via the UK’s BartsMS blog.

Professor Gavin Giovannoni, from Barts and The London, cautioned the recommendations were made in the context of a largely evidence-free zone.

“These are recommendations made by neurologists and Infectious diseases specialists whilst we have no evidence-based data at present.”

The recommendations were that most DMTs can be prescribed and used as usual. However other recommendations included:

• Temporarily delay the start of lymphodepleting DMTs such as ocrelizumab, alemtuzumab, rituximab or cladribine.
• Temporarily delay (between 6 and 12 months depending on the DMT) re-dosing of alemtuzumab, ocrelizumab and cladribine. This decision should be made based on individual factors such as disease severity and disease activity.
• For anti-CD2O DMTs it is recommended to delay the next dose even beyond 6 months if CD19+ and CD20+ lymphocyte counts are severely decreased at the time the next dose is due.

Australian MS experts have provided similar advice in a statement on the MS Australia website.

It reiterated that self-injected therapies such as glatiramer acetate and beta-interferon were not immunosuppressive and intermittent immunotherapies such as plasma exchange and intravenous gammaglobulin had a minimal impact on immune function.

“Because of the very real risk of relapse on discontinuing these therapies compared to the currently low risk of COVID-19 infection, the present advice is that these medications should be continued,” the statement said.

The same recommendation applied for immunosuppressive therapies such as prednisolone, methotrexate, azathioprine, mycophenolate mofetil and cyclophosphamide.

“The level of immunosuppression with these medications is variable and depends upon the dosage and combination of treatments. Because of the very real risk of relapse on discontinuing these therapies compared to the currently low risk of COVID-19 infection, the present advice is that these medications should be continued.”

It did however recommend considering delaying use of pulsed immunosuppressive therapies such as the monoclonal antibodies, as per the European and UK advice.

In addition, consideration should be given to delaying aHSCT.

“People who have recently undergone [aHSC] treatment should extend the period they remain in isolation during the COVID-19 outbreak.”