Central American and Caribbean Consensus for the Treatment of Multiple Sclerosis and Therapeutic Attitudes Facing the COVID-19 Pandemic

Abstract

Therapeutic decisions for multiple sclerosis have become more complex in the Central American and Caribbean region (CAC), with new treatments appearing every year but with well-known limitations in terms of access and application. Concomitantly, the advent of the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pandemic, with an increasing number of cases in the region, has increased the need for a consensus on therapeutic decisions to be made for people with multiple sclerosis. Under these circumstances, a reference framework is needed to gather current information to assist neurologists in making therapeutic decisions.
 An evidence-based consensus on the use of disease-modifying therapies for multiple sclerosis was proposed and accomplished by the Central American and Caribbean Multiple Sclerosis Forum (FOCEM), including recommendations for treatment during the pandemic. Using the consensus panel development methodology, after a bibliographic review of the best quality and actualized information, a final report was written; this includes statements that reached more than 70% consensus among the panel of experts.
 The recommendations encompass indications for drugs available for multiple sclerosis, definitions of therapeutic failure, patient follow-up, factors of poor prognosis, discontinuation of treatment, treatment during pregnancy and lactation and specific recommendations to apply during the SARS-CoV-2 pandemic.

COVID-19 and the Nervous System from a Cuban Experience

“…In the management of DMT in MS patients during the COVID-19 pandemic, the International Multiple Sclerosis Federation recommends continuing the treatment together with general measures of social isolation and special monitoring of lymphocyte counts for those undergoing treatments with S1P receptor modulators, dimethylfumarate, or teriflunomide [ 60 , 61 , 62 ]. For example, it is not recommended to modify the frequency or dose of treatment with natalizumab, considering that the risk of reactivation may be greater than the risk of contracting the viral infection, although it is possible to consider administration in prolonged intervals.…”

“…In cases of DMT with the anti-CD20 monoclonal antibody, it is recommended to delay the doses until the risk of COVID-19 infection is reduced [ 62 ] and to use rituximab. In addition, in cases of severe relapse with hospitalization, the use of intravenous methylprednisolone is recommended together with the use of plasmapheresis as an alternate intervention [ 60 , 61 ].…”

“…In cases of DMT with the anti-CD20 monoclonal antibody, it is recommended to delay the doses until the risk of COVID-19 infection is reduced [62] and to use rituximab. In addition, in cases of severe relapse with hospitalization, the use of intravenous methylprednisolone is recommended together with the use of plasmapheresis as an alternate intervention [60,61]. In the first mechanism, SLE triggers inflammatory events on normal-functioning astrocytes in the CNS, producing the glial hyper-reactivity (increase in GFAP levels and S100B secretion) found in NPSLE (1).…”