At the moment, the discussion is primarily about the COVID vaccine and the general obligation to get vaccinated, but there has also been some progress in recent weeks in the development of drugs against COVID19, or more precisely against a severe course of COVID19.
What is this all about? You will surely remember former US President Trump. In the fall of 2020 – as we now know – he was quite seriously ill with COVID19 and received an experimental drug from his doctors that probably helped prevent him from having to be treated in intensive care (and he could return to his usual antics relatively quickly). This experimental drug was so-called monoclonal antibodies, which are directed against the spike protein of SARS-CoV2 and are therefore able to neutralize the virus before a severe disease occurs. However, it is crucial that these drugs are administered within the first week after the onset of symptoms – they have no effect in later stages of the disease.
In Europe in 2021, three different antibody preparations were approved and the preparation Ronapreve® (Casirivimab/Imdevimab) has also been made widely available in Germany – but the initial enthusiasm has somewhat subsided because two of the three approved preparations (including Ronapreve®) do not work against the Omicron variant. Only the last approved antibody Sotrovimab (Xevudy®) seems to neutralize Omicron, but it is not available in Germany until the end of January. In addition, these antibody preparations have to be given as an infusion or injection in specialized facilities due to possible allergic reactions – they are therefore rather unsuitable for the family doctor’s office (but that’s where you go in the early phase of the disease when these drugs should be used).
Antiviral agents against COVID19 within 5 days
Therefore, the developments in so-called antiviral substances are of interest. Antiviral substances are agents that inhibit the virus from multiplying because they inhibit important virus proteins (polymerases, proteinases). These are the polymerase inhibitor Molnupiravir and the protease inhibitor Paxlovid®. Both substances showed a statistically significant reduction of hospital admissions or death when used ≤5 days after symptom onset in adult patients at risk for severe COVID-19 disease (by 30% with Molnupiravir or 86 % with Paxlovid®). According to guidelines of the Federal Ministry of Health (BMG), Molnupiravir can be used in outpatient patients without additional oxygen needs and at risk for severe disease progression. Care must be taken with women of childbearing age – pregnancy with Molnupiravir is absolutely contraindicated and men should not father a child for at least three months after taking it.
The study data for Paxlovid® have been submitted to the authorities, but there is still no official approval here – the Federal Minister of Health wants to advocate for an emergency approval, according to the news. But this drug is also not without problems due to various side effects.
Use in Multiple Sclerosis: individual decision
Nevertheless, the current developments represent a glimmer of hope for people at risk for severe COVID19 courses. This brings me to the special situation with MS: MS per se is not a risk for severe COVID19 courses. But there are of course also older people with MS who have an increased risk for a severe COVID19 course due to their age, severe disability or additional diseases (cardiovascular, diabetes, etc.). Yes, and then there is the group of patients who have immunotherapies with substances that can impair the vaccine response (S1P modulators and B cell depletion) and are very worried. The legitimate question arises here too, whether an early use of the above-mentioned drugs is advisable.
In the end, it is always an individual decision, but the German MS experts have thought about these questions in the last week and have given a recommendation for the use of COVID19 therapies in MS (https://www.dmsg.de/news/detailansicht/stellungnahme-zur-therapie-der-fruehen-sars-cov2-infektion-bei-personen-mit-ms-pwms). In short, an early therapeutic measure in case of COVID19 infection can be considered if patients are treated with substances that restrict the vaccine response (the S1P1 modulators Fingolimod, Siponimod, Ozanimod and Ponesimod and the B cell depleting therapies Ocrelizumab, Ofatumumab, Rituximab) or if there is another reason for a missing vaccine response and additional risk factors for a severe course such as age > 50 years, severe disability, diseases of the cardiovascular system are present. However, it should be ensured that the chosen therapy also has an effect against the currently predominant Omicron variant.
And one thing must be clear: The most effective protection against COVID19 is the complete (3-fold) vaccination against SARS-CoV2 – the availability of drugs against SARS-CoV2 should not lead to the belief that vaccination can be dispensed with.
