CMSC Panel Discusses Latest COVID Recommendations for People with MS

Patricia Coyle, MD, speaks to the room about COVID-19 and multiple sclerosis.
Image courtesy: Shmulik Almany

The public health emergency for the COVID-19 pandemic was officially declared over by the Centers for Disease Control and Prevention (CDC) on May 11, 2023. But as any healthcare professional knows, the ongoing presence of COVID is far from over. Patricia Coyle, MD, a leading expert on COVID as it relates to neurologic disease, led a hot topics panel discussion at the 2023 CMSC Annual Meeting that included the latest COVID-19 treatment and prevention strategies for people with multiple sclerosis (MS).

COVID-19 is responsible for the deaths of at least 1.13 million people in the United States as of May 11. “To me, that’s kind of shocking,” admitted Coyle, director of the MS Comprehensive Care Center at Stony Brook Neurosciences Institute. The Omicron subvariant XBB.1.5 has been the dominant lineage recently, making up about 64% of cases. Prevalence of this variant is now starting to wane, Coyle noted, making room for its close relatives XBB.1.9.2, XBB.1.16, and XBB.1.9.1.

Long COVID

As with the acute infection, post-acute sequelae of SARS-CoV-2 (PASC) is not leaving anytime soon. Also known as “post-Covid syndrome,” “long Covid,” or “long-haul Covid,” PASC occurs in about 1 of 5 infected individuals. Neurologic manifestations are predominant in PASC, especially fatigue, which occurs in 86% of those affected. PASC-related neurologic symptoms (neuro‐PASC) now counts as the third-leading neurologic disorder in the US, Coyle told the audience. In addition to fatigue, symptoms of neuro-PASC include brain fog, headache, anosmia, dizziness, myalgia, dysgeusia numbness/tingling, pain (other than chest), tinnitus, and blurred vision.

On May 25, JAMA published findings of the RECOVER study involving 9764 individuals with PASC, in an effort to better characterize the condition.¹ This study defined PASC as persistence of symptoms 6 months after COVID infection, which the panel agreed was more realistic than trying to characterize long COVID after 1 month.

From left: Patricia Coyle, MD; Patricia Melville, NP-C, CCRC, MSCN; and Marijean Buhse, PhD, NP-BC, MSCN.
Image courtesy: Shmulik Almany

Current Vaccination Recommendations

Coyle and fellow Stony Brook panelists, Patricia Melville, NP-C, CCRC, MSCN, and Marijean Buhse, PhD, NP-BC, MSCN, agreed that the current Pfizer and Moderna vaccines are safe and highly recommended for people with MS. These vaccines have been updated as of April 18, 2023, Coyle said. Current recommendations include:

• Persons aged 6 years and older should receive 1 updated Pfizer‐BioNTech or Moderna COVID‐19 vaccine;
• Persons aged 65 years and older may get 1 additional dose, at least 4 months after first updated dose;
• People who are moderately or severely compromised may get 1 additional updated dose at least 2 months after last updated dose.

Antiviral Therapies

Antiviral therapies not only reduce the duration and severity of illness from COVID, but also reduce the risk of acquiring PASC, the panel said. The oral agent nirmatrelvir plus ritonavir (Paxlovid; Pfizer) is the firstline antiviral therapy for patients aged 12 and over and has advanced emergency use status to full approval. Secondline antiviral therapy is intravenous remdesivir (Veklury; Gilead), while third-line is oral molnupiravir (Lagevrio; MErck), which offers lower efficacy rates against infection. The antiviral monoclonal antibody therapy, tixagevimab–cilgavimad (Evusheld; AstraZeneca) was found to be ineffective against the Omicron subvariants and therefore is no longer recommended.

MS care professionals should encourage patients with MS to keep up to date on vaccines and should prescribe nirmatrelvir plus ritonavir for patients who do not have contraindications for the drug, Coyle said. “Many of our patients with MS do not have primary care providers and rely on the MS care provider for COVID treatment and advice,” Melville added. “We owe it to our patients to educate ourselves about antiviral drugs and current vaccination recommendations.”

REFERENCES
1. Thaweethai T, Jolley SE, Karlson EW, et al. Development of a Definition of Postacute Sequelae of SARS-CoV-2 Infection. JAMA. Published online May 25, 2023. doi:10.1001/jama.2023.8823