Please note that all session and slide content are the views of the Speakers, not the MS Academy. The content of the recording is the speaker’s personal opinion at the time of recording. Due to the everchanging situation, advice given at the time of recording is subject to change.

Chairs

Prof Jeremy Hobart, Consultant Neurologist, University Hospitals Plymouth

Rachel Dorsey-Campbell

Rachel Dorsey-Campbell, Senior Lead Pharmacist – Neurosciences, Imperial College Healthcare NHS Trust

Sarah White

Sarah White, MS Clinical Nurse Specialist, St George’s Hospital

Summary

Jeremy, Rachel, and Sarah answered a host of questions related to care delivery, medication management, and more.

They pointed out that COVID-19 was a rapidly evolving situation, and that the information shared during the webinar was based on the best available evidence at the time.

Before moving onto questions, they outlined the April 2 update to the ABN guidance on the use of disease modifying therapies (DMTs) in MS during the pandemic.

Rachel said the key change was around blood monitoring (2.13):

“We are trying to avoid people coming into hospital as much as possible, so we felt we needed to try to give some guidance on relaxing blood monitoring… Broadly speaking, the guidelines double the interval for most blood tests… but there are some exceptions.”

  • Cladribine: bloods stay the same
  • Teriflunomide: monthly bloods for the first six months, four monthly thereafter
  • Alemtuzumab: three monthly bloods

Wherever possible, the recommended monitoring should continue, said Rachel.

The Alemtuzumab guidance was “the most contentious” she added, before going on to explain the reasoning behind it:

  • Most cases of renal failure and immune thrombocytopenic purpura (ITP) present between monthly blood monitoring
  • The most powerful weapon against ITP is patient awareness of the signs and symptoms

“Relaxation of blood monitoring must go hand-in-hand with a strong reinforcement to patients about the things they should look out for,” said Rachel.

Questions and answers

“We already had a list of all the patients on treatment, so it really helps if you have up to date spreadsheets or databases,” said Sarah.

Rachel said the guidance states that patients who have had alemtuzumab or cladribine in the previous three months were the most vulnerable.

Sarah said: “We decided that it would be very difficult to identify everyone with a respiratory issue or who was being PEG fed, because it would be so time consuming. We took the decision that anyone with an EDSS of seven or above would fall into the shielding category.”

Jeremy said his service had identified anyone with a lymphocyte count of <800 or an EDSS of more than seven as being in the extremely vulnerable group.

He went on to say that there was growing evidence to suggest that COVID-19 does not appear to be more common in people with MS on DMTs, versus those not on DMTs.

“We would not be advising high-dose steroids unless absolutely necessary… We are trying to reassure patients that the point of steroids is to speed up recovery, they won’t change the outcome,” said Rachel.

There may be a case for escalating treatment, she added, but there are challenges with the recommended high-potency DMT, natalizumab – currently, many centres currently lack the capacity to administer it safely.

The panel said:

  • There is limited evidence around the efficacy of EID, and work is ongoing in this area
  • There is some suggestion that PML risk is reduced with EID
  • EID is stated as an option on the SPC
  • Most teams have no option but to move to EID at the moment

“The evidence is probably not strong enough to recommend it for everybody under normal circumstances, but these are not normal circumstances. I think everyone should be moving to EID to keep people out of hospital,” she added.

Rachel said that Imperial had found B-cell counts to be consistently low in people on ocrelizumab prior to their six- and 12-month infusions. This corresponds with data from rituximab-treated patients.

“I think we can reassure people that the drug is still acting, even if we haven’t given it to them. Our recommendation to patients is not to come in for a third or fourth infusion, but to wait.”

She added that decisions should be taken on a case-by-case basis, and Jeremy said that it was an evolving field of understanding.

Said Sarah: “I think it’s important to support our patients as best we can because many of them are feeling very anxious. But we must be mindful that some centres are really struggling.”

If the patient fell into the isolation category, Sarah’s team will send a letter or email to their employer.

ABN guidance appears to be aimed at patients in hospital with COVID-19. It states that medications should be stopped in people with “active COVID-19 infection” until they have had two negative tests, one week apart.

If the patient was at home with mild symptoms, stopping their treatment is not necessary, and may actually be riskier than continuing it, the panel agreed.

Unless the last dose was in the previous three months, the risk is moderate and comparable to those seen in the other DMTs, Rachel said.

The panel agreed that there was not enough evidence to support this claim, and they would be reluctant to conclude that it was helpful.

“There may be a benefit of teriflunomide, but it is far from clear,” said Jeremy.

Again, the panel agreed that there was not enough evidence to support this.

“No. I think you have to balance the risk of someone who requires a PEG aspirating or not getting enough food or fluids against the risk of having the PEG inserted,” said Sarah.

“There is no way around it. If a patient needs care they need care, and it is more about using the right techniques,” said Sarah, adding most care agencies had advised their staff on safety.

Rachel said her team would advise anyone who had started that year’s course to finish it, though if someone was between year one and year two, they would delay the treatment.

Rachel said Imperial had been allowing people to continue their treatment if they wanted to, but no longer had the capacity to do so.

Unless the patient has other COVID-19 risk factors, self-isolating and social distancing is adequate, though Jeremy said he explained to people that the more they avoided contact, the safer they would be.

“We know it does put you at risk of viral infection but if you are eligible for fingolimod it’s because you have failed first-line treatment and need something else… However, getting someone in to do that first observation at the moment… might not be feasible,” said Rachel.

The panel said:

  • Different trusts will have differing levels of radiology access at the moment
  • High JCV-positive patients should still be scanned, though that may need to be less frequently
  • Thorough screening at infusions becomes even more important when access to MRI is limited

“How long is a piece of string? We just don’t know… It will be a couple of months at least,” said Rachel.

“I’m not aware of any. I think the number of patients on MS treatments being treated for COVID-19 is very small and we won’t get the information on that for some time. The MS Register is collecting information, so if you have anybody who is COVID-positive they would like to know about it,” said Rachel.

“Make sure everyone is also looking after their own health and taking breaks. I know lots of us are working long hours, going above and beyond. But this is going to go on for quite a long time so we need to be mindful of looking after ourselves as well,” said Sarah.

“Think outside the box. If you’re struggling and you need help, there are a lot of people being redeployed and there are a lot of non-clinical staff who could be helpful. Speak to your business managers,” said Rachel.

Useful links

02.04.20_ABN_Guidance_on_DMTs_for_MS_and_COVID19_VERSION_4_April_2nd

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This meeting has been sponsored by Roche Products Limited. Roche Products Limited has had no control over the educational content of this activity.

  

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