COVID-19 will change MS care forever – Commentary

Most “controversies” sections in Multiple Sclerosis Journal (MSJ) have debated academic nuances pertaining to neuroimmunological disease. In this issue, the controversy is different, grappling instead with how MS care itself may be transformed by the threat posed by the COVID-19 pandemic. In the aftermath of such a major event, often two schools of thought emerge: one can be summarized as “nothing will ever be the same”; the other, “let’s not overreact.” In this issue, Meca-Lallana ¹ takes the position that COVID-19 will change MS care forever, while Preziosa et al. ² argue the contrasting view. There are certainly elements of truth to both perspectives.

As it has spread asynchronously across the globe, COVID-19 has dominated our professional and personal concerns, bringing about a sense of forced trivialization, with all other issues temporarily eclipsed. That sensibility informs the position put forth by Meca-Lallana, which of course things will, and must, be different. For those who have been on the COVID front-line—making split-second treatment decisions, awful allocations of scarce life-saving resources, and facing death on an unimaginable scale—it may be hard to return to routine MS care, consisting of risk-cognizant disease-modifying treatment (DMT) choices whose consequences are measured in subtleties and over years, as though nothing has changed. However, we can distinguish three levels of potential impact of the pandemic on MS. One, the fundamentals of MS care, which in my estimation have not been impacted. Two, our approach to clinical decision-making, for which data are presently in short supply. And three, the logistics we employ, which, in the wake of COVID-19, have already been transformed.

Meca-Lallana argues that sweeping changes are needed in healthcare to avoid making the same mistakes that allowed this pandemic to take hold. While this is certainty broadly true, preventing future pandemics may be beyond the scope of what MS specialists will accomplish in our practices. That COVID-19 has not altered the fundamental purpose of our MS treatment paradigm is outlined by Preziosa. The data on COVID-19 and MS DMTs have not as yet raised alarms,^3,4 though as with risk mitigation for PML via the JC virus antibody, we need to collect data about the specific risk/benefit implications of COVID serology with respect to both exposure and, ultimately, vaccination, to be able to make individualized DMT decisions with our patients.

Indeed, as Preziosa noted, given the beneficial role of immune modulation to mitigate cytokine storm in severe COVID-19 infection, it may be the case that even our cell-depleting agents do not confer an increased risk of COVID infection or of severity. It is too soon to know if delaying, interrupting, or switching DMTs due to COVID concerns are indeed warranted, though providers have already adopted diverse approaches. We have never enjoyed consensus on DMT selection, switching, or sequencing, ⁵ and we are not likely to have such unanimity on the issue of holding or delaying highly effective DMTs in the wake of COVID-19. That said, we cannot allow this pandemic to roll back the progress we have made in treating MS with more effective DMTs, as we continue to take the long view that preventing disease activity now may help to ensure years and decades of life with less disability.

Finally, it is likely that the logistics of safe healthcare delivery in general, and how we do our work as MS specialists, will change permanently. COVID-19 has been an accelerant for the adoption of telehealth, as mentioned by both Meca-Lallana and Preziosa. Most of us recall fondly when outpatient care entailed just a clinician and a patient in a room together. For the past decade or so, we have been, of course, joined by computers wielding the electronic health record. Now, it is just us and our computers; the patient is no longer in the room. Video visits now feel novel for patients and providers alike but will ultimately seem as ordinary as using an ATM instead of meeting with a bank teller. In the COVID era, over video-chat, my patients inquire about my health and well-being as I ask about theirs. The MS clinician/patient relationship, though distanced by telemedicine, has become one of mutual concern as we face a common enemy to which we are all vulnerable. I wave goodbye to my patient on the screen, from my home to theirs, and begin the next virtual visit. This is certainly not what it meant to “work in an MS Center” before COVID. The logistics have changed; our commitments have not.