Covid has changed the way Neurologists look at disease modifying therapy for multiple sclerosis, MS. The basic principles of MS therapy remain the same: 1) Be picky about the diagnosis of MS; 2) Choose the right therapy to control the disease for the particular patient; and 3) Don’t blame all symptoms on MS. But the impact of the Covid-19 pandemic has been profound, on the population at large, and on patients with MS.
1. Be picky about the MS diagnosis.
This is still extremely important because there are many other diseases that cause symptoms common in MS, and these diseases are not MS. The pre-pandemic criteria for the diagnosis of MS, the Macdonald -17 Criteria, with the ability to use spinal fluid abnormalities in the diagnosis, has replaced the older Macdonald-10 criteria. Comparison of these criteria in the pre-pandemic era suggests the newer criteria were a little more sensitive, but a little less specific, than the older criteria. However, how the new criteria will fare in the pandemic and post-pandemic era is an open question. Whether the criteria must be updated, given the potential effects of Covid and so-called “Long Covid” on the nervous system, is still an open question. Still, the best criteria we have at the moment are the Macdonald-17 criteria. Again, the correct diagnosis is absolutely essential before any MS treatment is considered.
2. Choosing the right therapy
Controlling the disease has become much more of an open question after Covid. Early during the pandemic, the best advice was to continue the therapy a patient was on, isolate, and wait for the vaccines. Now, it has become clear that some MS therapies, particularly those which sequester or deplete lymphocytes, by the way some of the most popular therapies, blunt the body’s immune response to the vaccines for Covid. This introduces a conundrum for therapy—Must we trade a potentially lethal disease (Covid) which vaccines can definitely help, for a non-lethal disease (MS), in which many patients don’t have another clinical attack or evidence of progression for many years after their first attack?
3. Don’t blame all symptoms on MS.
The caution not to blame all symptoms in an MS, even in a patient appropriately diagnosed and treated for MS, is still a crucial principle. However it is confounded by the potential long term effects of Covid on the nervous system. Sleep disorders, fatigue, nerve root compression and other neuropathies, and the myriad of non-MS related problems patients with MS can have, all must be even more carefully considered in MS patients. They must be diagnosed and treated appropriately in order to provide the best quality of life for MS patients. And the fact that patients who don’t have typical Covid symptoms can have asymptomatic Covid doesn’t clarify the situation.
Managing Multiple Sclerosis
So, the basic tenets of caring for patients with MS, and involving them in that care, remain the same. But carrying out those tenets in the Covid and post-Covid era will become increasingly difficult, until the “data are in.” In the meantime, some of the more traditional “platform” therapies have regained some of their appeal, as opposed to the more aggressive ones, in the era of Covid. And the need to do research into new therapies to enhance recovery and prevent disability in MS patients is even more critical today than it was in the pre-Covid era. Covid changed everything. But with that change come new challenges, and if we’re lucky new insight.
In the meanwhile, it is important to continue with lifestyle efforts that can improve symptoms, including exercise (Kalb et al 2020 Multiple Sclerosis) and diet. For example, the autoimmune diet is helpful in improving symptoms in many autoimmune diseases like MS, including those that often occur in people with hypermobility. And the importance of diagnosing and treating sleep disorders, which have a high prevalence in MS, cannot be overstated, since fatigue has been found to be one of the most disabling quality of life issues in MS.