The disadvantage of previous recommendations on MS and COVID 19 is that while these recommendations were made by experts to the best of their knowledge and belief, ultimately there was a lack of data to support these recommendations. I too have always emphasized this problem in my previous posts on COVID 19 and MS, promising to revisit the topic as soon as there is news. This is now the case, even if we cannot yet speak of a solid data basis. Nevertheless, it is worth taking a look at the data collected so far by Italian colleagues on MS and COVID 19, which were published online in Lancet Neurology at the end of April (Sormani MP; Italian Study Group on COVID-19 infection in multiple sclerosis. An Italian programme for COVID-19 infection in multiple sclerosis. Lancet Neurol. 2020 Apr 30 pii: S1474-4422(20)30147-2).
In total, the Italian study group was able to gather data from 232 MS patients. A positive PCR test for SARS CoV2 was found in 57 patients, and there was a high clinical suspicion of a SARS CoV2 infection in 175 patients (this high number of unconfirmed suspected cases is due to the lower testing capacity in Italy). The average age of the sample was 44 years, the vast majority of patients (88%) were classified as relapsing MS, the average EDSS value was 2.6. Of the 232 patients, 21 were untreated, all others received immunotherapeutic treatment for MS. All currently used MS therapies were represented in the sample, including highly effective and/or cell-depleting drugs such as Fingolimod (13.4%), Natalizumab (10.8%) or Ocrelizumab (11.2%).
For 223 of the 232 patients (96% of the cases) the course of COVID-19 was mild, only 4 patients (2% of the cases) had a severe course of the disease (i.e. with shortness of breath, drop in saturation, pneumonia). Unfortunately, six MS patients (3% of the cases) had a critical course (respiratory failure, septic shock and multi-organ failure), five of whom died.
It is of particular interest to look closely at these patients with severe or critical courses: The five fatalities had an average age of 67 years, had received their MS diagnosis on average more than 20 years ago and therefore already suffered from a chronic progressive course (average EDSS 6.7). Interestingly, three patients no longer had any MS therapy at all and four patients had cardiovascular risk factors (diabetes, severe obesity or arteriosclerosis) – i.e. the already generally known risk factors for a severe COVID-19 course. In contrast, the other five MS patients with a severe but not fatal course had an average age of 47 years and had without exception a relapsing MS with an average EDSS of 4.6. All patients were treated (2x Ocrelizumab, 1x Natalizumab, 1x Copaxone, 1x Fingolimod), but 4 of the 5 survivors had no additional diseases, i.e. were healthy apart from the MS.
These first data therefore support the assumption that probably not the MS or the immunotherapeutic treatment of the MS is significant for the course of a SARS CoV2 infection, but that – as in other population groups – especially advanced age and cardiovascular risk factors are essential factors for a severe COVID-19 course.
Even though these are preliminary data, it is reassuring that in hard-hit Italy, 96% of all COVID-19 cases in MS patients were mild and there is no evidence that MS therapies have a negative impact on the course of a COVID-19 illness.
Thus, the work of the Italian colleagues also supports the current view that it is not useful to suspend or delay MS therapy because of the pandemic – this is now also stated in the updated recommendations of the DMSG. Also in view of the Italian data, the most important task is to treat MS efficiently and prevent the development of neurological deficits.
While it remains important to consider each case individually and advise MS patients individually, if there are no serious internal diseases or cardiovascular risk factors, it is increasingly assumed that the same risk assessment applies to MS patients, whether treated or untreated, as for the general population.
