The Canadian Network of MS Clinics has posted a Q&A for patients with multiple sclerosis. Included are the group’s recommendations (see link below) for disease-modifying therapies (DMTs). Not immunosuppressant: Beta-interferons (Avonex, Betaseron/Extavia, Rebif, Plegridy), glatiramer acetate (Copaxone, Glatect), teriflunomide (Aubagio), and minocycline.

• No need to stop any of these agents even in patients with COVID-19 infection.

Not or mildly immunosuppressant: Dimethyl fumarate (Tecfidera) and natalizumab (Tysabri).

• Tecfidera: No need to stop even with COVID-19 infection except if lymphocytes are < 0.5; hold until lymphocytes > 0.7 Tysabri: no need to stop even with COVID-19 infection. Should not be stopped abruptly due to the risk of rebound MS disease activity.
• Immunosuppressant: Fingolimod (Gilenya): No need to stop treatment. Individual evaluation recommended in patients with COVID-19 infection. Gilenya should not be stopped abruptly due to the risk of rebound MS disease activity.

Cell-depleting immunosuppressant:

• Cladribine (Mavenclad): There is an increased risk if the treatment course was recently completed and the lymphocyte count < 0.5; patients should be instructed to limit public outings and maintain social distancing until lymphocytes recover. Consider delaying treatment initiation in new patients. In current patients, consider delaying the next course of treatment.
• Ocrelizumab (Ocrevus): Consider delaying treatment initiation in new patients. Consider delaying the next course of treatment in patients with COVID-19 or a close contact with COVID-19.
• Alemtuzumab (Lemtrada): Advise patients to take extra precautions if lymphocytes < 0.5 (limit public outings, maintain social distancing). Consider delaying treatment initiation in new patients. In current patients, consider delaying the next course of treatment.

Additional treatment recommendations have been drafted by the Association of British Neurologists (see link below):

• The ABN recommends stopping all DMTs for up to 4 weeks for patients with active COVID-19 infection.
• For patients with breakthrough disease on a first-line DMT, fingolimod has the advantage over ocrelizumab in that it can be stopped in the event of coronavirus infection.
• Natalizumab is considered the safest higher-efficacy DMT. Extended-interval dosing may be considered.
• Ocrelizumab may be considered for patients requiring a higher-efficacy DMT who are not eligible for natalizumab. However, ocrelizumab with leave patients with a persistently higher risk of infection throughout the anticipated duration of the COVID-19 pandemic.
• Consider switching treatment or delaying therapy in patients being considered for a third or fourth course of alemtuzumab or cladribine.
• Consider postponing autologous hematopoietic stem cell transplantation until after the pandemic recedes.

Click here to access the Canadian Network recommendations: https://cnmsc.ca/Announcements Click here to access the ABN recommendations: https://cdn.ymaws.com/www.theabn.org/resource/collection/6750BAE6-4CBC-4DDB-A684-116E03BFE634/ABN_Guidance_on_DMTs_for_MS_and_COVID19_APPROVED_11_March.pdf