key: cord-1015578-6yki64ey
authors: Mado, Hubert; Adamczyk-Sowa, Monika
title: Multiple sclerosis patients and COVID-19
date: 2021-03-23
journal: Egypt J Neurol Psychiatr Neurosurg
DOI: 10.1186/s41983-021-00287-3
sha: 6739cdd32a65a923e54273e8d3090dd119ca8b36
doc_id: 1015578
cord_uid: 6yki64ey

Coronavirus disease 2019 (COVID-19) is now a major issue for all fields of medicine. Due to the higher mortality rate among patients with chronic diseases, it has also caused concern in patients with multiple sclerosis (MS), who in addition are often receiving immunosuppressive drugs. The aim of this article is to discuss what is currently known about the severity of COVID-19 in MS patients.

The coronavirus disease 2019 (COVID-19) pandemic is currently a major medical topic worldwide. COVID-19 is known to have the most severe course and highest mortality in patients who are elderly and with co-morbidities such as cardiovascular diseases, chronic respiratory diseases, or diabetes [1] . Therefore, the pandemic has raised concerns about the course of COVID-19 in multiple sclerosis (MS) patients, with a particular focus on the use of disease-modifying therapies (DMTs).

MS is a chronic disease presenting with progressive motor impairment, and MS patients, especially those with more severe forms of the disease, are on the whole more prone to infections [2] . In addition, many MS patients take DMTs, which are drugs that have immunomodulatory and also immunosuppressive effects. It is these effects of DMTs that are the main reason for fears that these drugs may be responsible for a potential more severe course of COVID-19, as well as a higher mortality rate. Of particular concern are those DMTs that lead to lymphopenia and also a reduction in the B lymphocyte count, for example cladribine, alemtuzumab, ocrelizumab, and rituximab [3] [4] [5] [6] [7] .

However, the prevalence of COVID-19 in MS patients based on current data appears to be similar to that in the total population [3, 4] . Furthermore, the data we know so far suggest that also DMTs do not influence the severity of COVID-19 [3] . Nevertheless, there are some concerns-firstly, it seems reasonable to suspect that MS patients with significant motor impairment are likely to have a severe COVID-19 course and increased mortality due to their commonly poor general health [4] . Second, alemtuzumab and cladribine have not been widely used in previous studies, and it is suspected that DMTs causing lymphopenia and reduced B lymphocyte counts may be responsible for the increased morbidity, severity, and mortality of COVID-19 [4] [5] [6] [7] . Noteworthy, a recently presented study in a group of 844 MS patients with suspected or confirmed COVID-19 showed that anti-CD20 therapy (rituximab or ocrelizumab) was associated with a significantly increased risk of severe COVID-19 [8] . The use of methylprednisolone in the short time before COVID-19 (less than 1 month) was further found to be a significant risk factor for severe infection [8] .

Thus, taking into account previous studies, recommendations, but also concerns, it seems that in the great majority of MS patients, treatment with previously used DMTs should be continued, and in the absolute majority of newly diagnosed MS patients, treatment with DMTs is to be started [9, 10] . However, therapy must be as personalized as possible and the selection of specific DTMs must consider any existing concerns with them-particularly for those with known lymphocyte-reducing effects, those causing B cell depletion, and those that have not been widely represented in COVID-19-related studies to date. In view of recent research, it seems reasonable to be extra vigilant about the use of rituximab and ocrelizumab. Also, it seems appropriate that MS patients for 1 month after methylprednisolone treatment should especially avoid any situation that could be associated with an increased risk of COVID-19 infection. 

Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China

Infection risks among patients with multiple sclerosis treated with fingolimod, natalizumab, rituximab, and injectable therapies

SARS-CoV-2/COVID-19 in multiple sclerosis patients receiving disease-modifying therapy

Clinical characteristics and outcomes in patients with coronavirus disease 2019 and multiple sclerosis

COVID-19 in patients with multiple sclerosis undergoing disease-modifying treatments

Treating multiple sclerosis and neuromyelitis optica spectrum disorder during the COVID-19 pandemic

SARS-CoV -2 and multiple sclerosis: not all immune depleting DMTs are equal or bad

Disease modifying therapies and COVID-19 severity in multiple sclerosis

The pressing questions in multiple sclerosis Care in the era of COVID-19

National Multiple Sclerosis Society

Not applicable

Authors' contributions HM was a major contributor in writing the manuscript (also performed literature review, analysis of results, preparation of the manuscript for the final version, making amendments at the review and post-review stage; first and correspondent author). MAS reviewed the manuscript for intellectual content and approved the final manuscript. All authors read and approved the final manuscript. In the manuscript, the authors cited information from their previous publication discussing COVID-19 and multiple sclerosis. This was to create a commentary addressing the specific issue of drugs used in multiple sclerosis patients and their impact on the course of COVID-19. 

This paper received no grant from any funding agency in the public, commercial, or not-for-profit sectors.Availability of data and materials Data available in a public repository that issues datasets with DOIs.Ethics approval and consent to participate Not applicable

The authors declare that they have no competing interest.Received: 28 January 2021 Accepted: 15 February 2021