The spread of the COVID-19 pandemic has caused us to reconsider how we treat our patients with multiple sclerosis (MS) and even the role of immunosuppression in autoimmunity. How do we decide what the best course of action is, and what does the limited research available tell us about making the right treatment decision? Those are the exact questions Dr. Amit Bar-Or explores in this interview.
Twitter @PennMDForum See Dr. Bar-Or's Profile the spread of the cove in 19 Pandemic has caused us to reconsider how we treat and manage our patients with multiple sclerosis or M s for short. Healthcare professionals have been questioning the role of immuno suppression in auto immunity, resulting in delays and even discontinuation in immunotherapy treatments. How do we decide what the best course of action is and what does limited research available? Tell us about making the right treatment decision. These are the questions will be considering today coming to you from the Reach M D Studios in Fort Washington, Pennsylvania. This is medical breakthroughs from Penn Medicine. I'm Dr Paul Graham G. And joining me on this episode is Doctor Emmett Bar or chief of the Multiple Sclerosis Division and director of the Center for Neuro Inflammation and Neuro Therapeutics at Penn Medicine. Doctor Bar or welcome to the program by Paul Great to be here. Great. So, Dr Bar, or to start us off? Can you tell us how the co vid 19 pandemic has impacted your patients with M s? So when the pandemic started, we were of course, quite concerned not knowing how the pandemic may influence people living with M s being treated with immune directed therapies that can take the edge away from the immune system. And we, like many other places, transitioned to video telemedicine as opposed to face to face visits toe enable people to remain relatively isolated and safe and tracked the hot spots of co vid so that we could learn as Mawr individuals with M s. We're living through the pandemic in other regions even prior to reaching North America. And overall, we became increasingly reassured. The first was that people with M s are at no greater risk of contracting the virus or it's complications just by virtue of having m s, we also were able toe learn that there is no particularly increased risk overall, nothing obvious in terms of increased risk for people living with M s on the different immune therapies. And in parallel to this, we were learning more and more about the virus and the serious complications because in fact, what one would be particularly concerned about is not so much whether you had some symptoms of the SARS cove to virus, but whether you develop the severe complications referred to as cove it 19 complications and it turns out that the serious complications air not actually because of the virus going rampant in the face of an incompletely functional immune system. Rather, the serious complications air now thought to be a result off the person's immune system responding to the virus. So, in fact, a vigorous response to the virus is associated with a serious complications. And in fact, some of the M S therapies have been used in the last months in clinical trials to treat and try to prevent covert 19 serious complications with some degree of success. So overall it's been reassuring. And how has the way you've treated patients with M s evolved from the beginning of the pandemic. So from the get go, we remain very vigilant to what was happening. And as I mentioned what we learned from other places, the decision had been to avoid using the particularly aggressive immune therapies such as bone marrow transplantation and for the most part, to stay the course. Recognizing that as we got more information, the risk appeared to be very low, if there at all. And the importance of maintaining people on a treatment that will control their M s was viewed as over weighing the potential risks. Associate ID with the treatment. We continue to monitor closely and really changed essentially nothing about the regimen of the different therapies, with the exception again of the particularly aggressive approaches to treatment which are used really in less than a 1 to 2% of people with M s. So looking at the treatment options available for patients with M s, how do immunotherapy agents positively affect the course of this disease? Well, we know that the immune therapies affect the course of M s in an important way and limiting new injury. There's nothing at the moment to suggest or least compellingly point to medications that improve the outcome with covert. Although, as I had mentioned, some early successes suggest that M s therapies, particularly the first line therapies, may in some ways be protected. We're certainly not recommending that as a treatment for Cove in 19, and perhaps most importantly, by virtue of being treated maintaining your treatment for your M s. You're avoiding M s disease activity, which should limit your need. Thio be exposed to the health care system and hence the benefit of the treatments is essentially keeping you away from the doctor. So for those just tuning in your listening to medical breakthroughs from Penn Medicine on reach, M. D. I'm Dr Paul Graham G. And I'm speaking with Dr Emmett Bar or chief of the multiple sclerosis division and director of the Center for a Neuro Inflammation and Neuro Therapeutics at Penn Medicine Doctor Bar. Or we spoke about earlier about the role of immunotherapy agents. So switching gears, let's talk about the topic that's been creating some controversy in the M s community. It's been suggested that M s patients might be at higher risk of contracting Severe Cove in 19 if they're being treated with anti B sell drugs. What can you tell us about this? Well, again, the question that's important is not so much whether you become symptomatic or not as much as whether you develop the severe complications and the reason that we've been paying particular attention to this treatment is a study that has come out of Italy, where people with M s followed on. Multiple different treatments, including anti CD 20 were considered in terms of the potential association of different treatments with severe covert complications, and this study suggested that there may be a small but real increase in the risk of developing Severe Cove in 19 complications on anti CD 20 now. Importantly, several other studies from other countries, including the French cohort to the Dutch cohort and the relatively early co VIMs United States Court do not replicate this observation. And they together have pretty decent numbers of individuals exposed to the different therapies, including anti C 20. What does this mean? Well, it likely means that if there is an increased risk, it is small. It depends very much on what population of patients is treated with different therapies. We do know that risk factors of developing serious complications in anyone, whether you have a mess or not, include increased Age co morbidity ease, such as high blood pressure and a variety of other conditions that can increase in frequency over age and in certain populations of M s, where anti CD 20 was reserved to people. For people with more progressive M s forms, the observation of increased risk of serious complications may in fact relate to these other features of the individuals their age and co morbidity ease rather than the actual treatment that they were on. So we do need more information. But this, at the moment, is an area that is being followed closely without us changing our approach to either the initiation or the spacing out of the anti CD 20 treatments and coming back to the pandemic. We are all eagerly awaiting a vaccine against Kobe. 19. Given that vaccination responses are predicted to be blunted until naive B cells re populate, can you talk to us about the potential risks of vaccination for patients with M s who are taking these drugs? So the question is not so much about the risk of complications from the vaccination in Pete People with M s, but whether the vaccine response will be mounted by the patient when they're on a treatment such as anti CD 20. And there's no question that there is a blunted antibody response in that context. Now it's important to note that while measuring antibodies toe mark, the response to vaccines is easy. It is actually not the only way by which the immune system mounts and effective vaccine response. In fact, the cellular limb of the immune system's response of the vaccine in many cases is just a important, if not more important than the antibodies. And it is not surprising in the context of anti CD 20 therapy, where you remove B cells as precursors to making antibodies that you would diminish the antibody response when that's used as the measurement for the vaccine. So while we still need to learn Maura about whether the SARS cov virus is effectively dealt with by the cellular immune response as by the vaccine antibody mediated response at the moment the likelihood is that vaccine responses will still be worthwhile. One of the interesting questions comes up whether there may be value and delaying infusions to allow a little bit more B cell reconstitution to have a stronger vaccine response. Uh, the good news there is that unlike some of the medicines in the world of M s, we're stopping the medicine can be associated with return of M s disease activity returned with a vengeance. This is not the case with anti CD 20 therapies, and there are studies now that are considering whether increasing the dose interval may help mount and even more vigorous and protective vaccine response. Lastly, doctor bar or based on what you've learned throughout this pandemic response so far, What are some takeaways or lessons you'd like to pass on to our listeners? Well, I think that we continue to learn there's more information that we're collecting. And now several registries and different prospective studies are being set up internationally and nationally to get mawr good quality information that will help us have a better sense of what risks there may or may not be in association with different treatments, including the question about anti CD 20. And, of course, we need to learn mawr. As the field rolls out different vaccine opportunities for individuals with and without M s, we have been overall reassured. We recognize that the immune therapies, for the most part, are not associated with increased risk and in some cases, maybe protective. Although the bottom line is that we're certainly not suggesting to people with M s on therapies to be any less vigilant than the general population, which means social distancing, masking, frequent hand washing, avoiding touching your face, and so on. So being Justus, careful as everybody else, Well, I'd like to thank my guest Dr Emmett Bar, or for sharing his insights on the role of immunotherapy agents and impacts of the Cove in 19 Pandemic on our patients with multiple sclerosis. It was a pleasure speaking with your doctor bar or the pleasure was mine, Paul. Thank you. I'm Dr Paul Graham G with Reach M d to find other episodes in this Siri's visit. Reach m d dot com slash pen Thank you for listening.