Managing Multiple Sclerosis During the COVID-19 Pandemic

Dr. Wilner:
COVID-19 has been associated with a myriad of neurologic symptoms and conditions, including delirium, stroke, and Guillain-Barre Syndrome, but there are also patients who already have neurologic disorders who may be at special risk of complications, such as those with multiple sclerosis.  While often relatively young and healthy, these patients are usually treated with immunosuppressive therapy which can put them at risk for infections.  Whether and how to modify their treatment during the COVID-19 pandemic are questions of great concern and the questions that we’ll be exploring today. 

For ReachMD, this is COVID-19: On the Frontlines.  I’m Dr. Andrew Wilner, and here to help us answer some of those questions is Dr. Stephen Krieger.  Dr. Krieger is an Associate Professor of Neurology at the Corinne Goldsmith Dickinson Center for Multiple Sclerosis at Mount Sinai Hospital in New York City. 

Dr. Krieger, welcome to the program.

Dr. Krieger:
Thanks, Dr. Wilner, for having me.

Dr. Wilner:
Before we get too deep into the details regarding multiple sclerosis management, Dr. Krieger, could you tell us a bit about your experience treating MS during the pandemic?  Are you still seeing your patients in person, for example, or are you using telemedicine?

Dr. Krieger:
Well, I think for many outpatient practices, including our own, the first challenge of the COVID pandemic was just finding ways to ensure continuity of care while minimizing the amount of time that patients or providers needed to spend in the office setting and in the healthcare environment.  So, we rapidly transitioned at Mount Sinai to seeing all of our MS patients and all of our neurology outpatients to virtual health and telehealth as quickly as possible.

Dr. Wilner:
Have you treated any MS patients who have COVID-19?

Dr. Krieger:
I would say I’ve taken care of at least a dozen patients with MS who have had COVID-19 during this period of time.  In our MS center, I think that number altogether is probably close to 100 MS patients with symptoms of COVID-19 at this point.  So, we’ve really seen a broad range of experiences, and I think it rather closely mirrors that in the general population.  Younger, healthier people have had a milder experience with COVID-19, but some of our patients who have more advanced multiple sclerosis who have a significant amount of physical disability and other comorbidities have had a much more serious time with COVID-19 infection.

Dr. Wilner:
Let me follow up on that.  Is there any evidence that getting infected with COVID-19 triggers an MS relapse?

Dr. Krieger:
Well, that’s a great question.  We do consider viral infections, in general, to be a risk factor for MS relapse,and so it’s one of the reasons we, for instance, encourage people with MS to get their flu shot every year, which is not a live virus vaccine, and therefore, it’s safe for MS patients, because that’s at least one way of trying to avoid a viral infection for someone with MS which could trigger MS disease activity.  So, in theory, COVID-19 infection could certainly also trigger MS relapse.  I have not seen that happen in any of my patients, and I have not heard that that has occurred in any of our patients at the Mount Sinai MS Center as of yet, but COVID-19 is such a diverse viral infection in terms of its own severity that I think the focus, when someone develops symptoms, is just to make sure that they get through that and don’t end up having the severe pneumonia or the severe inflammatory reaction, the so-called cytokine storm, that has had such incredible morbidity and mortality across the world.

Dr. Wilner:
Dr. Krieger, I’m going to take advantage of having you on the line, because I saw a patient last week with MS who comes to my clinic.  My instinct was to tell her, “Make sure you practice social distancing and wear your mask because you’re on immunosuppressive therapy and you might be more susceptible to the virus, or if you get it, you might get even more sick,” but as I was saying this, I didn’t really know if there was an evidence base to support what I was saying.  Can you comment on immunosuppressive therapy and COVID-19?

Dr. Krieger:
Sure.  I think your instincts in general there were correct to think that these immune-modulating medicines might put people with MS at greater risk, but a few things worth saying about that. So, in Italy, where they had a few weeks of experience with COVID-19 before it came to America, the Italian MS Society Group had put together 300 or 400 MS patients in a cohort who had COVID-19, and they did not find that their MS patients were more susceptible to the disease or had worse outcomes than the general population of people getting COVID-19 were experiencing, so, so far, there isn’t evidence that our immune modulators in multiple sclerosis specifically increase that risk. 

Interestingly, we often tell people that many of our medicines could increase the risk of viral infections, but the reason that we tell people with MS that they may be at risk for viral infections is because some of our medicines stop our immune system’s ability to harness the immune repertoire that people develop over their adult lives to fight viral infections.  This is why people on those medicines may have an increased risk of herpes outbreaks or shingles outbreaks, because our ability to keep those viruses in check have been a little bit compromised.  But, with COVID-19, this is a novel infection.  None of us have an immune repertoire to fight it, and so in essence, it’s not really that our MS patients are more susceptible than the rest of us; it’s really that we are all as susceptible to this as people who are immune-compromised, because none of us have the repertoire to fight it off, and that’s why it has been so highly infectious across the board.

Dr. Wilner:
Just to follow up on the immunosuppressive therapy, you are not withholding or changing dosage regimens for natalizumab or ocrelizumab.  You’re proceeding as you normally would.  Is that correct?

Dr. Krieger:
In general, we are.  I mean,one of the downsides, in a sense, of the infused monoclonal antibodies is that they require in-person healthcare contact with a nurse or an infusion center, and so in some cases we are delaying a little bit or we have spaced out the infusions a little bit more over time during the worst of the COVID crisis in New York, not really because the medicine itself confers an increased risk but really because we’re just trying to decrease the amount of time that our patients have to spend in an infusion suite or in an infusion chair and contacting healthcare resources.  Also, by spacing them out a little bit we’re allowing our patients to delay their next infusion by a month or two.  By doing that, we also allow the infusion centers to decrease their patient volume, which allows them to do better social distancing in the infusion suite. 

Dr. Wilner:
That’s really helpful information, and it also leads into my next question.  Standard therapy for an MS relapse is a few days of high-dose, intravenous solumedrol, but that requires a trip to the hospital.  Have you considered giving high-dose oral steroids for a patient that has a relapse so they can stay at home and not enter the potentially dangerous environment of the hospital?

Dr. Krieger:
Yes, I think you’re exactly right.  I mean, one way that we have adjusted our MS practice in the setting of COVID-19 has been to have a slightly higher threshold to use steroids at all because steroids really are a rather potent immune modulator, and I think someone getting the kind of high doses of steroids that we use for an MS relapse, that may put a person at increased risk for COVID susceptibility for a period of time, so we have had a slightly higher threshold to treat a potential relapse.  And secondly, to your point exactly, trying to keep people out of infusion suites or spare people from having nurses come to their home and spare the nurses having to go into people’s homes unnecessarily I think is warranted. 

Dr. Wilner:
Well, for those just joining us, you’re listening to COVID-19: On the Frontlines.  I’m Dr. Andrew Wilner, and today I’m speaking with Dr. Stephen Krieger about the management of multiple sclerosis patients during the COVID-19 pandemic. 

So, Dr. Krieger, you’ve given us a great understanding of where things currently stand, but now I’d like to look to the future and discuss what’s on the horizon.  To start, if there ever is a vaccine for COVID-19, will it be safe for MS patients?

Dr Krieger:
That’s a really important question moving forward.  We are all eagerly anticipating the development and availability of a vaccine for COVID-19, but for people with multiple sclerosis and other autoimmune diseases, vaccines are a little bit complicated.  The general guidance for people with MS is that they should not take live virus vaccines if it can be avoided because live virus vaccines, like exposure to other live viruses, potentially can trigger MS relapse.  There is actually very little data to support this, but it is common in our field to avoid such vaccines when possible.  I don’t think we know what the novel coronavirus vaccine is going to look like, whether that’s going to be a live virus attenuated, if it’s going to be protein-based, how it’s going to be delivered or administered, and so I think we’re going to have to take a wait-and-see approach to that.  If it’s not a live virus vaccine, that’ll be an easier decision, but if it is a live virus vaccine, we are going to have to really think through the risk-benefit ratio of that for our MS patients, and that will be a new thing for us to consider.

Dr. Wilner:
Another effect of the pandemic has been its effect on ongoing research.  Patients can’t come in.  Coordinators aren’t available.  Has that affected any work that you’re doing in New York?

Dr. Krieger:
It has to a degree.  At Mount Sinai, all clinical research activities were paused  to try to redirect resources to COVID-intensive work, both clinical and research, and also just to spare people and patients and research participants having to come into a healthcare system during the worst of the crisis.  Mount Sinai has very nicely, I think, staged the reopening of clinical research, including for multiple sclerosis, where people who are participating in clinical trials could stand to benefit themselves from the investigational product or therapy.  That has been reopened so that those potential benefits for research participants can be realized.  Research that doesn’t offer a potential benefit to the participant has still remained on pause. 

Dr. Wilner:
Finally, Dr. Krieger, we’ve talked about changes in the increased use in telemedicine, some changes in dosing intervals, switching from intravenous to oral steroids.  What do you think the treatment of MS will be like when we get back to normal or whatever the new normal is?  Are we going to continue doing any of these things, or are we just going to go back to the way it was?

Dr. Krieger:
There is a lot of debate in the field of multiple sclerosis right now as to the extent to which COVID-19 will change MS care.  There are people arguing that MS care will change forever, and there is a counterargument that MS care won’t change at all.  I think a lot of the fundamentals of MS care, the decisions that we make regarding our disease-modifying therapies, won’t change dramatically, but the way we deliver that care is probably going to look different in the post-COVID world where we are not crowding people into waiting rooms and we’re not doing as much hands-on work, and I think as neurologists we need to get comfortable not doing a hands-on neuro exam for a lot of people, which is a change for us, but I do think that there are still good ways of delivering quality MS care and safe treatment decisions even in this new normal.

Dr. Wilner:
Well, this has been a very informative look into the management of MS patients during the COVID-19 pandemic, and I want to thank you, Dr. Krieger, for sharing your extensive clinical experience.  It was a pleasure speaking with you today. 

Dr. Krieger:
Thanks so much again for having me.

Dr. Wilner:
I’m Dr. Andrew Wilner.  For continuing access to this and other episodes from COVID-19: On the Frontlines, and to add your perspectives toward the fight against this global pandemic, visit ReachMD.com where you can Be Part of The Knowledge.  Thanks for joining us.