#MSCOVID19. What would you do?

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One of the difficult issues in relation to the COVID-19 vaccines is how best to dose in relation to ocrelizumab, is it best to dose ASAP when it is not optimum for a B cell response and hope that the T cell response is all that is needed or is it better to wait to get a better B cell response. It is a dilema for you and also your neurologist and health care team. We often get asked “What would you do?” So I think you may be interested in this opinion.

Seachrist EJ. Multiple sclerosis, B cell therapy, and the COVID-19 vaccine. eNeurologicalSci. 2021 Mar;22:100319. doi: 10.1016/j.ensci.2021.100319. 

Dear editor

The first COVID-19 vaccine has been approved in the United States by the FDA for emergency use. Healthcare workers will have the earliest access, so individual providers must decide quickly on receiving the vaccine. While it appears safe in healthy individuals, this decision is more complicated for healthcare providers with autoimmune diseases. This is especially true for providers with multiple sclerosis on B cell depleting therapies.

B cell depleting therapies, such as ocrelizumab and rituximab, diminish the immunization effect of vaccines, although the degree of effect varies by vaccine and timing . Recommendations are to vaccinate prior to starting B cell depleting therapy. Previously formed immune responses are not diminished by treating with B cell depleting therapy after immunization . If already on B cell depleting therapy, treating later seems to be more effective. Waiting 6 months post-infusion to get vaccinated is more effective than 2 months post-infusion based on studies with rituximab. While these early studies with rituximab in rheumatological disorders suggested that vaccination 1–2 months after rituximab infusion created very minimal response, the futility of early post-infusion vaccination has been challenged by more recent studies. In the VELOCE study in patients with relapsing remitting multiple sclerosis, significant although reduced responses to multiple vaccines were observed when given 3 months after ocrelizumab. CD19 levels are effectively depleted within 2 weeks of ocrelizumab infusion and remain depleted up to 6 months or longer in the majority of patients. It seems unlikely that vaccination 1–2 months earlier would be ineffective when compared to the modest effectiveness of 3 month post-infusion vaccination, especially considering that B cells were similarly depleted. In fact, a more systemic B cell depletion is believed to occur by 3 months post-infusion. Overall, vaccination before ocrelizumab is the most effective method, but this is not always feasible. In patients on ocrelizumab, treating at end of an infusion cycle is likely better than treating early in the cycle. If able to maintain disease control, delaying the subsequent infusion may allow for a better vaccine response. In all other patients in the midst of an infusion cycle, some vaccination response is better than none.

The vaccine timing issue in regards to B cell depletion therapy is further complicated for COVID-19 vaccines. As vaccine availability will be initially sparse, selective timing of vaccination is an unlikely luxury for healthcare workers on B cell depletion therapy. Delaying or declining a vaccine opportunity could delay access to a vaccine by many months. Again, some COVID-19 vaccine protection is better than none.

The potential for severe COVID-19 infection is higher in patients with multiple sclerosis who are older, have cardiovascular or pulmonary comorbidities, and have significant baseline disability, and B cell depleting therapies may increase the risk as well. For such high risk patients, it is prudent to consider B cell depleting therapy discontinuation. Healthcare workers are at high risk of infection given occupational exposures. While initial safety reports from the COVID-19 vaccine trials are promising, the potential adverse effects to patients with multiple sclerosis on disease modifying therapies are not known. Some patients with autoimmune diseases were included in the phase 2/3 trials of Pfizer-BioNTech COVID-19 vaccine although safety monitoring is still ongoing. Safety in immunocompromised patients is not yet defined. Expectedly, the potential risk to immunocompromised patients is low as these are not live vaccines, and patients who are immunocompromised are not contraindicated from receiving the vaccine. At this time, the benefits of preventing a COVID-19 infection outweighs the possible risks of vaccination.

This dilemma is not only a professional concern, but a personal one. I am a clinically practicing neurologist with multiple sclerosis who is taking B cell depleting therapy. COVID-19 infection and hospitalization rates are rising throughout the United States and is unlikely to improve anytime soon. Risk of infection for healthcare workers like myself continues to rise as well, and infected providers can spread the virus to their patients. Vaccination is our best chance of protecting ourselves and our patients from this terrible disease. I will be taking the first available COVID-19 vaccine, and I am recommending it for my patients in healthcare.

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MouseDoctor

13 comments

  • For many patients we don’t have the luxury of choosing when to take the Covid vaccine since there’s a lack of communication between specialist MS providers (administering our CD20 depletion therapy) and our general practitioners. Many GPs may not even understand that we’re on a treatment that decimates our immune system response or appreciate that the B-cell reduction is long-lasting. After all they have a lot of patients to care for and are particularly under stress right now with the additional burden of Covid-19. Any request to delay vaccination immediately post-infusion may be seen as a refusal and see us put to the back of the queue / kicked into the long-grass and dismissed as being unnecessarily demanding / uncooperative.

  • I’m on Ocrelizmab in the UK. I was advised by my consultant recently to have the vaccine 12 weeks after infusion and 6 weeks before the next. This gives a window of 8 weeks to try and have the vaccine but given it’s currently being administered 12 weeks between the two jabs it’s not going to be possible. My next treatment is in March and I’m tempted to speak with my consultant about delaying this until I’ve had both doses of the vaccine.

    • in the UK too and was told 4 weeks either side of Ocrevous for covid vaccine……ask 10 different medical people the same question, get 10 different answers. Not as if it is deadly serious or anything is it?? (sarcasm)
      I now can’t have the vaccine until 1 April at the earliest as I get Ocrevous on 4 March. And I can’t see them making me an appointment for that specific date as technically I will have turned down the vaccine by then won’t I?

      I asked GP if there may be any “drop-outs/didn’t turn up” slots I could get and received generic response of “no room, you will be notified in due course”

      So looks like many more months in the house for me with my weekly outing to the carpark of the local supermarket, sitting in the car while hubby does the shopping.
      whoop de doo!

      • I’m treated in London and asked the same question of my MS Nurse rather than my GP as I am due next dose ocrevus in early March. She got me a slot at one of the vaccine hubs as the hospital neurology service has been offered vaccine slots for their own priority patients. I had the jab on Saturday.

        Can you ask via the hospital/neurology instead of your GP?

        • couldn’t get through on phone to GP so used the online form, and was told “no spaces, you will be informed in due course.”
          I seriously wish there was some joined-up thinking in the NHS!
          Spoke to a neuro secretary on Tuesday who never said a word about priority slots for neuro etc.

          I’ve sorted something myself that isn’t ideal, but hey ho

    • Hi Susie ,
      I’m at the QE in B’ham and I’m sure I was told exactly the opposite- Occ 12 weeks after second vaccine or Occ 6 weeks before first jab !!

      I really have no idea , and I’ve just been offered a vaccine this Friday!!

      Aargh !!

      • It’s a mind field isn’t it with nothing clear that I’ve seen yet. My treatment was delayed last year by almost 3 months and I personally didn’t suffer too much with that so I think if I was offered it I’d jump at the chance and delay treatment again but it all depends on your own disease progression xxx good luck xxx

  • Thank you for this post. I completely relate with this unfortunate dilemma. I am a doctor with multiple sclerosis who is taking B cell depleting therapy since February 2018 (Ocrelizumab). I had my last infusion 15th December 2020. Surprisingly and unexpectedly, we had access to Pfizer Vaccine 27th December! If only we knew! Fortunately, all my co-workers had it.
    Now the plan is to wait at least 12 weeks (VELOCE study) to get it (dealing with the uncertainty of getting it, the right timing, safety issues…).

    • Also infused on 12/15/20 and trying to time vaccine so as to have best response. Questions for you: If you had the choice of Pfizer vs. Moderna, would you opt for one over the other as an MSer using Ocrevus? If not, would you opt for one of those over the J and J assuming it gets approved? My thinking being that with two shots maybe there is a higher probability of having a response.

  • I am healthcare worker (midwife) RRMS on ocrelizumab, 4th dose received mid sept 2020 (slightly delayed from June 2020 due to delays at trust expected backlog) so I guess not a bad time to have received the Oxford astra zeneca vaccine on Saturday just gone.
    I am 4 days post vaccine and still feel like crap, hopefully that means I have some immune response…either that or something else is going on. I have aching arm, my legs are burning and weak, my tremor, usually well controlled is noticeably worse, I have developed since 24 hours post jab, conjunctivitis, myalgia, headache, fatigue, sore throat. Who wants to know? Should I report to someone or just suck it up? No idea with regards to b cell levels pre jab. Suspect was early recipient of covid March 2020 as all symptoms present and correct including anosmia but no testing available at time was very ill for 5 days, lingering symptoms 5 weeks then ok, including conjunctivitis for 2 weeks. Bit weird its come back out of blue post jab.

    • Injection site reactions are comming as is headache and fatigue etc. Read the links inthe post under blurb and it goes through them. If you have had covid you may get a very strong antibody response

  • It is nice to read of so many other healthcare professionals on B cell depleting therapies.

    I took a slightly different approach and delayed my ocrevus infusion last sept. Luckily I have now had both doses of Pfizer and am looking to restart my infusions.

    It has been quite a decision (as this paper says) whether or not to discontinue B cell depleting therapy working in the field that I do. I’m still not sure of the answer!

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