As you are aware Northern Italy is one of the European epicentres of the coronavirus / COVID-19 pandemic. To address the concerns of MS healthcare professionals the Milan group have produced guidelines for managing DMTs in their patients. Fortunately, we have a large number of Italians in our group (‘The Blizard Little Italy’) who, with Dr Saul Reyes (ECTRIMS Fellow), helped translated the guidelines for us.
Italian recommendations on the management of MS patients during the COVID-19 epidemics
These are recommendations made by Neurologists and Infectious diseases specialists whilst we have no evidence-based data at present.
Treatment of MS patients
Given the lack of knowledge or data on the COVID-19 disease course in MS patients receiving DMTs, at present there is no recommendation to stop the different DMTs and therefore expose MS patients to the risk of MS exacerbations. We, therefore, recommend continuing the current DMT specifically with:
1. First-line DMTs (Beta-interferons, Glatiramer acetate, Teriflunomide or Dimethyl fumarate). These DMTs can be prescribed as usual.
For ‘lymphodepleting’ DMTs: Any decisions about these DMTS should be made based on individual circumstances.
Temporarily delay the start of lymphodepleting DMTs such as Ocrelizumab, Alemtuzumab, Rituximab or Cladribine.
Temporarily delay (between 6 and 12 months depending on the DMT) re-dosing of Alemtuzumab, Ocrelizumab and Cladribine. This decision should be made based on individual factors such as disease severity and disease activity.
For anti-CD2O DMTs it is recommended to delay next dose even beyond 6 months if CD19+ and CD20+ lymphocyte counts are severely decreased at the time the next dose is due.
Some special considerations: for patients who have already received the first dose of the first cycle, it is recommended to give the second dose (i.e. complete the first cycle) and ‘extra precautions’ should be taken.
Patients with confirmed COVID-19 infection: Withheld any first or second-line DMT until clinical resolution and/or approval to continue treatment by an infectious diseases specialist (given the potential antiviral activity of beta-interferons documented in the literature, for patients receiving treatment with beta-interferons the decision about continuing treatment resides on the treating neurologist).
Symptoms of potential COVID-19 infection: fever, dry cough and asthenia.
What to do in the event of COVID-19 symptoms?
Instruct your patients no to attend A&E services to avoid overcrowding them and further spreading of the virus. Instruct your patients to call the local emergency number, describe their symptoms and wait for instructions.
Evaluate the temporary withdrawal of current DMT based on the guideline provided above.
Recommendations for MS patients and healthcare professionals at MS centres:
If possible, avoid crowded places such as cinemas, theatres, schools, etc.
In high risk, areas restrict access to MS centres to MS patients only.
For patients on immunosuppressive infusion therapies, the use of protective surgical-grade masks is recommended.
If travelling long distances or using public transport is absolutely necessary, it is recommended the use of protective masks and hand sanitizing (particularly for patients on Fingolimod, Alemtuzumab, Ocrelizumab, Cladribine or Rituximab).
If possible, work from home.
Good personal hygiene is always important, specifically, it is recommended to wash your hands frequently. These recommendations are provided as a guideline only, please always refer to your local government advice.
These recommendations are likely to change depending on the evolution of the epidemics.