Large patient registries aid in complex disease management, vaccine guidance

COVID-19 and MSThe novel coronavirus and the disease it causes (COVID-19) have raised many scientific questions. Adding to the complexity are questions about how COVID-19 affects people with underlying health conditions. 

Neurologists and neuroscience researchers at The Ohio State University Wexner Medical Center are especially interested in COVID-19 and multiple sclerosis (MS).

Benjamin Segal, MD, co-director of the Neurological Institute at the Ohio State Wexner Medical Center, says concern about COVID-19 and MS stems from many unknowns, but also from the parallels between these conditions. 

“Serious complications of COVID-19 can be caused by an overexuberant immune response to the virus,” Dr. Segal says. “Some people with COVID-19 infections experience neurological symptoms that may be secondary to this response. MS is caused by an abnormal immune response targeting the central nervous system. This raised concerns that COVID-19 could exacerbate MS.” 

With similar systems affected, doctors and researchers are focused on understanding the interplay between COVID-19 and MS. 

“There are a lot of issues regarding the potential impact of COVID-19 on MS,” Dr. Segal says. “One question at the top of doctors’ and patients’ minds is, ‘Are patients with MS, particularly those being treated with drugs that quell the immune system, more vulnerable to contracting COVID-19?’” 

This and other questions were the topics of an encore session during September’s MSVirtual2020, the largest global academic MS meeting. Dr. Segal, who served as chair of the MSVirtual2020 scientific program, moderated the COVID-19 session. 

Presenters highlighted COVID-19 data from studies of large MS patient registries. These data — along with available vaccine study data — are guiding current care for patients with MS.

COVID-19 contraction risk: What we know so far

When it comes to the risk of people with MS contracting COVID-19 at higher rates, Dr. Segal says early data aren’t raising red flags. 

“In the studies done thus far, the incidence of COVID-19 in MS patients is reflective of the general population,” Dr. Segal says. “People with MS don’t seem to be more vulnerable to getting infected — and that includes even those with MS who are on disease-modifying therapy.”

Dr. Segal says many factors could be at play, but there is some indication that MS patients may have a natural inclination to be more cautious, keeping COVID-19 rates from spiking. 

“In one of the studies, patients who were on disease-modifying therapies actually had a lower incidence of COVID-19 than the general population, which appeared to be a result of these individuals social distancing.”

COVID-19 outcome differences 

In terms of factors that predict the severity of COVID-19 infection, researchers aren’t seeing a big difference between the general population and those with MS. 

“The same factors that seem to be predictive of a worse outcome from COVID19 infection in the general population also apply to those with MS. They include older age, sex, race and comorbidities like cardiovascular disease, obesity and chronic pulmonary disease,” Dr. Segal says. “The factors that influence outcomes, however, can be highly impactful.”

For example, in a study of one American registry, African American MS patients who contracted COVID-19 had a three-fold higher risk for ICU admission or death compared with non-Hispanic, white MS patients. 

Disease-modifying therapies and COVID-19 outcomes

Despite what we know so far about COVID-19 in people with MS, questions loom about how MS disease-modifying therapies, which are designed to suppress the immune system, may increase the risk of serious complications once a patient is infected.

Dr. Segal says many studies are looking at specific disease-modifying therapies and their connection to COVID-19 severity and rates of hospitalization, ICU admission and mechanical ventilation. Within these studies, results have been mixed, reinforcing the need for more data.

“In a large study of a French MS patient registry, there was no significant connection between MS disease-modifying therapies and more severe complications of COVID-19,” Dr. Segal says. “In contrast, in a global study that included over 1,500 subjects, patients treated with a certain class of disease-modifying therapy that depletes B cells had higher rates of hospitalization and ICU admission, but not death.  

“Patients with MS should be cautious, of course. But so far, in the majority of cases, MS patients on treatment who contracted COVID-19 recovered and were ultimately discharged from the hospital. 

“Though each case needs to be considered individually, I generally wouldn’t encourage MS patients to stop taking their disease-modifying therapy without discussing that decision with their neurologist first.” 

COVID-19 vaccine recommendations

With a COVID-19 vaccine imminent, questions are emerging about how MS patients will fare.

Will those on disease-modifying therapies be less able to mount a strong response to the vaccine? And will this limit protection against future infection?

Dr. Segal says more data is needed. He adds that some early results have raised more questions than answers. 

“There was a reported case of spinal cord inflammation in a patient who received one of the experimental vaccines,” Dr. Segal says. “Fortunately, that patient recovered. This leads to concerns about whether or not the vaccine itself could trigger an MS-like episode. I think we’ll need to examine the trial data in detail — which may be different for different vaccines — before we draw any definitive conclusions.”

On the horizon

While large-scale studies and registry data will continue to inform clinical decisions, researchers at the Ohio State Wexner Medical Center are beginning to collect biological samples to look into the effects of COVID-19 on patients with MS and other neurological disorders.

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Ohio State scientists have identified a unique immune cell that promotes neuronal survival, says Benjamin Segal, MD, co-director of The Ohio State University Wexner Medical Center’s Neurological Institute.

“We are hopeful that as we understand more about these cells, it will lead to novel treatments to reverse neurological damage and injury across many types of neurological disease — traumatic brain injury, stroke, MS and more,” he says.

"For my patients, the idea of being able to restore neurological function is really amazing.”

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