Box 1.

Summary of recommendations

MS and COVID-19

•MS is not a risk factor per se for severe adverse COVID-19 outcomes

•Caution is needed where patients have advanced disability or a progressive phenotype

•Be aware that patients with MS may have risk factors for adverse COVID-19 outcomes (e.g. obesity, older age, some comorbid conditions)

•DMT-based therapy in the COVID-19 era

•DMT-based care appears generally safe for patients with MS who develop COVID-19 (there may be increased risk of adverse outcomes with anti-CD20 therapy, which requires confirmation)

•It is unlikely that interferon-β, teriflunomide, dimethyl fumarate, glatiramer acetate, fingolimod, natalizumab or cladribine tablets will increase the risk of COVID-19

•Existing DMT therapy may be continued (consider 6-weekly dosing interval for natalizumab if MS disease activity is well controlled)

•All currently available DMTs except alemtuzumab can be started safely at this time; initiate alemtuzumab subject to careful individual risk–benefit considerations

Vaccination against COVID-19

•All COVID-19 vaccines appear to be safe for use in people with MS

Vaccination against COVID-19 will reduce the risk of catching the disease, or will at least lessen the risk of severe disease

•Stopping or delaying DMT is unlikely to boost vaccine responses and will leave patients at risk of COVID-19 when the risk of infection is highest

•Stopping or delaying DMT also leaves patients at risk of MS disease progression, especially DMT-naïve patients and/or patients with high MS disease activity

•Increased body temperature in the setting of febrile diseases can be associated with exacerbation of MS symptoms: preventing COVID-19 infection through vaccination may in theory help here

•Vaccinate while starting/continuing treatment with interferon-β, teriflunomide, dimethyl fumarate, glatiramer acetate, fingolimod, natalizumab and cladribine tablets—there is no need to alter the regimen for these DMTs while vaccinating, subject to lymphocyte counts (see below)

•Fingolimod, alemtuzumab or anti-CD20 agents may reduce the efficacy of a vaccination; however, even a blunted vaccine response is likely to protect them against severe COVID-19

Do not withdraw fingolimod or natalizumab: this may induce reactivation MS disease activity

•Vaccinate fully up to 6 weeks before initiating DMTs that act by continuous immunosuppression (fingolimod, anti-CD20 or alemtuzumab): a longer interdose interval may be used for the OxAZ vaccine to accommodate dosing regimens for these DMTs

•Educate patients (and other healthcare professionals) on the benefits of vaccination

OxAZ Oxford University/AstraZeneca COVID-19 vaccine

See text for rationale and supporting references. Recommendations on DMT or vaccination assume no contraindications to these interventions