Management of Multiple Sclerosis in the Era of COVID-19: Recommendations and Guidance from Penn Neurosciences

There is convincing evidence that the brain is susceptible to coronavirus infection.

Reports from China and elsewhere now suggest that the angiotensin-converting enzyme 2 (ACE2) receptor is expressed in the brain. A transmembrane protein, ACE2 is used by SARS-CoV-2 to initiate cell invasion and viral replication.

Suspected regions of coronavirus involvement in the brain include medullary structures closely identified with respiration and the olfactory bulb, a potential source of viral entry and dissemination. Severe neurological complications from COVID-19 appear to be infrequent in the general population. But the risks of infection are likely elevated among persons with pre-existing neurological disease, including multiple sclerosis (MS).

The treatment of MS cannot be discontinued without exacerbation of symptoms and potential progression of the disease, and this has become a concern during the COVID-19 pandemic, in part because the most effective therapies for MS now involve modification of the innate immune response.

Specialists at Penn Neurology have convened to address these concerns, and their recommendations and guidance are now available. A brief review of this report is offered herein.

Implications of MS Disease-Modifying Therapy during COVID-19 Pandemic

Coronavirus RNA and antigen (non-COVID) have been observed in the brains and demyelinating plaques of patients with MS. In the era of the COVID-19 outbreak, the disease-modifying therapies used to treat MS present a conundrum for clinicians treating patients with MS at risk for SARS-CoV-2, as well as those actively infected with the virus.

On one hand, discontinuation of these drugs will likely exacerbate the symptoms of MS. On the other, given the mechanism of action of these drugs, their continuation in a person infected with COVID-19 could lead to a more aggressive and destructive infection—or might, contrarily, limit the aggressive immune response thought to cause the severe complications of coronavirus infection.

To clarify this mystery, Amit Bar-Or, MD, FRCPC, Joseph Berger, MD, and Rachel Brandstadter, MD, of the Penn Neurosciences Division of  Multiple Sclerosis, recently produced a systematic review of the DMTs to assess their risk of magnifying COVID-19 infection: . The team also included recommendations for the management of patients with MS during the pandemic. Their report appears in Neurology, Neuroimmunology and Neuroinflammation, a journal of the American Academy of Neurology.*

COVID-19 and MS Disease-Modifying Therapies

Following a comprehensive review of these agents, and on the basis of early anecdotal reports, the authors suggest that patients with MS, including those on commonly used DMTs, are at no higher risk of contracting symptomatic SARS-CoV-2 viral infection, nor at higher risk of severe COVID-19 complications, than the population at large.

Furthermore, the authors conclude, most patients with MS should continue on their DMT, particularly those on platform therapy for whom the risk of SARS-CoV-2 infection and COVID-19 is minimal, with special consideration warranted for patients at increased risk of acquiring infection (e.g., health care workers), those with more serious COVID-19 complications, and relevant medical comorbidities.

*The authors offer the caveat that at this time, real-world experience is insufficient to define the effect of a specific MS disease-modifying therapy on COVID-19, or the effects of the disease on persons with MS treated with DMTs.

Dr. Bar-Or is the Chief of the Multiple Sclerosis Division; Dr. Berger is the Division’s Associate Chief; Dr. Brandstadter is an Assistant Professor of Neurology at the Penn Comprehensive Multiple Sclerosis Program.