Background

The COVID-19 crisis has created unanticipated changes in health care delivery for people living with multiple sclerosis (MS). The pandemic’s rapid evolution has resulted in a knowledge gap about how COVID-19 has affected practice patterns of MS clinicians.

Objectives

To understand how the COVID-19 pandemic has affected clinical practice patterns of a nationwide cohort of MS clinicians across the United States.

Methods

In collaboration with the National Multiple Sclerosis Society (NMSS), we used SurveyMonkey^TM to develop a 28-item electronic questionnaire exploring MS specialists’ perceptions of how COVID-19 has altered how they prescribe MS disease-modifying therapies (DMTs) and provide telehealth and other services, and issues affecting their own well-being including re-deployment to the front lines of COVID-19 care and availability of personal protective equipment. NMSS staff sent a recruitment email containing the electronic survey link to 188 clinicians who serve on regional NMSS Healthcare Provider Councils across the United States, 86 of whom were MS specialist physicians.

Results

Eighty-six respondents (46% of 188 clinicians) from 32 U.S. states completed the survey including 45 physicians, 18 rehabilitation therapists, 7 psychologists, 6 advanced practice clinicians, 4 social workers, 2 nurses, a pharmacist and a researcher. More than 72% of all respondents believed they have adequate personal protective equipment at work, while only 37.2% indicated they could safely distance themselves from others at work. Nearly 6% of respondents reported they had been re-deployed to the front lines of COVID-19 patient care, and an additional 15% anticipated being re-deployed. The physician subgroup had a 54% response rate and included 41 neurologists, 3 physiatrists and 1 family physician. More than one-third of physicians indicated that since the pandemic began, they use telemedicine to provide more than 75% of their clinical care. Nearly 80% believed COVID-19 may have changed how they prescribe DMTs. DMTs prescribed more often during the pandemic included β-interferons (28.6% of 42 prescribers), natalizumab (25%) and glatiramer acetate (21.4%), while DMTs prescribed less often included alemtuzumab (64.2%), cladribine (52.4%), and B cell-depleting agents including ocrelizumab and rituximab (50%). Some MS specialists reported suspending certain DMTs during the pandemic (21.4% each for alemtuzumab and B cell-depleting agents) and/or extending the dosing intervals (38.1% for natalizumab and 11.9% for fingolimod and siponimod).

Conclusions

In this nationwide survey, MS specialist physicians and other clinicians serving on regional NMSS Healthcare Provider Councils across the U.S. reported major changes in their delivery of MS care during the COVID-19 pandemic. Further research is warranted to explore these trends and to develop consensus guidelines on best treatment practices for patients living with MS.

Background

Multiple sclerosis (MS) is an acquired, chronic demyelinating disease, affecting more than 2.3 million worldwide.
Tumor necrosis factor alpha (TNFα) is a pro-inflammatory cytokine produced by activated macrophages which in turn activate microglia.
Interleukin-6(IL-6) is a pro-inflammatory, anti-inflammatory myokine secreted by T cells, supporting B cell growth and inhibiting TNFα and regulatory T cells.
Tecfidera® (dimethyl fumarate: DMF) has been FDA-approved for treatment of RRMS since 2013. DMF decreases TNFα and IL-6 synthesis in activated microglia and astrocytes in vitro.

Objectives

A. To obtain TNFα and IL-6 levels in attack-free patients on DMF
B. To check correlations between TNFα, IL-6, EDSS, vitamin D levels, age, duration of disease, or number of MRI lesions

Methods

This was a 6-year retrospective study of patients seen by a single neurologist (WSB) Jan 1, 2014-Oct 31, 2019. Patients were diagnosed based on the 2010 McDonald MS criteria. Those with clinically isolated syndrome were included. Longitudinal data analysis was performed using generalized linear models.

Inclusion criteria:

1. Patients aged 18 or above either with a new or pre-existing diagnosis of MS or CIS

2. Patients with baseline laboratory data (TNFα and IL-6) every 3-4 months afterwards (at least three times), and MRI prior to starting DMF and afterwards (at least twice)

3. Patients who were naïve to MS medications or have been off treatment for at least 1 year prior to starting DMF

Exclusion criteria:

1. Those still on immunomodulatory agents at the time of the initial visit

2. Those non-compliant with either follow up visits, lab tests, MRIs or taking DMF

3. Patients with concurrent infectious or inflammatory/autoimmune conditions

4. Patients who relapsed during the study period

Results

84 patients were started on DMF either as de novo or second-line therapy. After exclusion criteria, 11 were included in the analysis. 10 were female and 1 was male. The average age was 46.9 years; the average age of onset 33.3. The average time from onset till diagnosis was 6.6 years. The average baseline EDSS score was 2.56. The average baseline number of T2-FLAIR lesions was 21.55 and 6.45 for T1 black holes. The median baseline number of T2-FLAIR lesions was 10 and 1 for T1 black holes. The average baseline vitamin D level was 25.84ng/ml.

There was a significant decrease in TNFα levels after initiating DMF in nearly all the cases. The decreasing TNFα levels separated into different groups based on the number of T2 lesions, age, and EDSS.

An insignificant trend towards a decrease in IL-6 levels was observed after initiating DMF in nearly all the cases. The decreasing IL-6 levels separated into different groups based on the number of T2 lesions, and age.

Conclusions

TNFα levels decreased significantly, whereas IL-6 showed only a decreasing trend after initiating DMF.

TNFα may be a promising serum biomarker in monitoring DMF therapy in MS.

Background

The COVID-19 crisis has created unanticipated changes in health care delivery for people living with multiple sclerosis (MS). The pandemic’s rapid evolution has resulted in a knowledge gap about how COVID-19 has affected practice patterns of MS clinicians.

Objectives

To understand how the COVID-19 pandemic has affected clinical practice patterns of a nationwide cohort of MS clinicians across the United States.

Methods

In collaboration with the National Multiple Sclerosis Society (NMSS), we used SurveyMonkey^TM to develop a 28-item electronic questionnaire exploring MS specialists’ perceptions of how COVID-19 has altered how they prescribe MS disease-modifying therapies (DMTs) and provide telehealth and other services, and issues affecting their own well-being including re-deployment to the front lines of COVID-19 care and availability of personal protective equipment. NMSS staff sent a recruitment email containing the electronic survey link to 188 clinicians who serve on regional NMSS Healthcare Provider Councils across the United States, 86 of whom were MS specialist physicians.

Results

Eighty-six respondents (46% of 188 clinicians) from 32 U.S. states completed the survey including 45 physicians, 18 rehabilitation therapists, 7 psychologists, 6 advanced practice clinicians, 4 social workers, 2 nurses, a pharmacist and a researcher. More than 72% of all respondents believed they have adequate personal protective equipment at work, while only 37.2% indicated they could safely distance themselves from others at work. Nearly 6% of respondents reported they had been re-deployed to the front lines of COVID-19 patient care, and an additional 15% anticipated being re-deployed. The physician subgroup had a 54% response rate and included 41 neurologists, 3 physiatrists and 1 family physician. More than one-third of physicians indicated that since the pandemic began, they use telemedicine to provide more than 75% of their clinical care. Nearly 80% believed COVID-19 may have changed how they prescribe DMTs. DMTs prescribed more often during the pandemic included β-interferons (28.6% of 42 prescribers), natalizumab (25%) and glatiramer acetate (21.4%), while DMTs prescribed less often included alemtuzumab (64.2%), cladribine (52.4%), and B cell-depleting agents including ocrelizumab and rituximab (50%). Some MS specialists reported suspending certain DMTs during the pandemic (21.4% each for alemtuzumab and B cell-depleting agents) and/or extending the dosing intervals (38.1% for natalizumab and 11.9% for fingolimod and siponimod).

Conclusions

In this nationwide survey, MS specialist physicians and other clinicians serving on regional NMSS Healthcare Provider Councils across the U.S. reported major changes in their delivery of MS care during the COVID-19 pandemic. Further research is warranted to explore these trends and to develop consensus guidelines on best treatment practices for patients living with MS.