Recommendations for vaccination in patients with multiple sclerosis who are eligible for immunosuppressive therapies: Spanish consensus statement

Immunogenicity and safety of vaccines in multiple sclerosis: A systematic review and meta-analysis

BACKGROUND

Seroconversion rate of vaccines varies and requires further elucidation in patients with multiple sclerosis (MS) under treatment with disease-modifying therapies (DMTs). We aimed to investigate this in a systematic review and meta-analysis.

METHODS

MEDLINE(PubMed) and Cochrane databases were searched based on a pre-specified protocol (PROSPERO: CRD42020202018). Studies reporting on patients with MS, diagnosed with McDonald criteria getting vaccinated with any type of vaccine were included in the analysis. The primary endpoint was the incidence of patients being seropositive and experience adverse events after vaccination. Outcomes were expressed as proportions with respective 95% confidence interval (CI). Two reviewers independently screened and reviewed existing literature and assessed study quality with the Methodological index for non-randomized studies.

RESULTS

Of 295 articles, 45 studies were analyzed. Seroconversion after COVID-19 vaccines was 76% (95% CI, 70-80; I2 = 95%; 20 studies including 5601 patients. Protection was lower in patients treated with anti-CD20 antibodies and sphingosine-1-phosphate receptor (S1PR) modulators compared to untreated patients or treatment with other DMTs. Relapse occurred in 2% (95% CI, 1-3; I2 = 86%; 16 studies including 7235 patients). Seroconversion after seasonal influenza vaccines was 82% (95% CI, 65-91; I2 = 90%; 6 studies including 490 patients). Relapse rate was similar to this after COVID-19 vaccination.

CONCLUSION

The majority of MS patients vaccinated for COVID-19 or seasonal influenza mount an adequate immune response without safety concerns. Data on other vaccines are limited.

Multiple sclerosis and pregnancy: Pathogenesis, influencing factors, and treatment options

Multiple sclerosis (MS) is an autoimmune-mediated degenerative disease of the central nervous system, characterized by inflammatory demyelination. It is primarily found in women of childbearing age, making pregnancy a significant concern for both patients with MS and clinicians. To assist these patients in achieving their desire for pregnancy, reducing MS relapses during all stages of pregnancy, preventing the progression of MS, mitigating the impact of MS treatment on the course and outcome of pregnancy, and a thorough understanding of the relationship between pregnancy and MS, as well as specific management and the application of relevant medications for MS patients at each stage of pregnancy, are essential. This article provides an update on pregnancy-related issues in women with MS, including the general recommendations for management at each stage of pregnancy.

Safety of anti-varicella zoster virus vaccination in patients with multiple sclerosis treated with natalizumab: A case series

The vaccination with live attenuated vaccines is generally not recommended during natalizumab (NTZ), as it is included among immunosuppressive/immunomodulating therapies. Nevertheless, considering the lack of evidence of a non-Central Nervous System (CNS) immunosuppressive effect of NTZ, after a risk/benefit evaluation, we decided to vaccinate four multiple sclerosis (MS) patients (three with an indication to switch to ocrelizumab for high-risk Progressive Multifocal Leukoencephalopathy (PML) and one for pregnancy planning). No vaccine-related adverse events of any type nor varicella zoster virus (VZV) infections were observed. To the best of our knowledge, these case series represent the first description of the good safety profile of anti-VZV vaccination in MS patients during NTZ treatment.

Blood CD8+ Naïve T-Cells Identify MS Patients with High Probability of Optimal Cellular Response to SARS-CoV-2 Vaccine

This single-center study included 68 multiple sclerosis (MS) patients who received the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination from one of several approved vaccine preparations in Spain. Blood samples were collected one to three months after the second dose of the vaccine had been administered. Cellular immune responses to the vaccine were assessed using QuantiFERON analysis, and peripheral blood mononuclear cell subsets were assayed using flow cytometry. Response associated with higher percentages of total lymphocytes, naïve CD4+ T-cells (p = 0.028), CD8+ T-cells (p = 0.013), and, mostly, naïve CD8+ T-cells (p = 0.0003). These results were confirmed by analyzing absolute numbers (p = 0.019; p = 0.002, and p = 0.0003, respectively). Naïve CD8 T-cell numbers higher than 17 cells/μL were closely associated with an optimal cellular response to SARS-CoV-2 vaccination (odds ratio: 24.0, confidence interval: 4.8-460.3; p = 0.0001). This finding clearly shows that independent of the treatment received, higher numbers of naïve CD8+ T-cells yield a strong cellular response to SARS-CoV-2 vaccines in MS patients. If this finding is validated with other viruses/vaccines, it could provide a good tool for identifying MS patients undergoing treatment who will develop strong cellular responses to anti-virus vaccines.

ECTRIMS/EAN consensus on vaccination in people with multiple sclerosis: Improving immunization strategies in the era of highly active immunotherapeutic drugs

BACKGROUND

With the new highly active drugs available for people with multiple sclerosis (pwMS), vaccination becomes an essential part of the risk management strategy.

OBJECTIVE

To develop a European evidence-based consensus for the vaccination strategy of pwMS who are candidates for disease-modifying therapies (DMTs).

METHODS

This work was conducted by a multidisciplinary working group using formal consensus methodology. Clinical questions (defined as population, interventions, and outcomes) considered all authorized DMTs and vaccines. A systematic literature search was conducted and quality of evidence was defined according to the Oxford Centre for Evidence-Based Medicine Levels of Evidence. The recommendations were formulated based on the quality of evidence and the risk-benefit balance.

RESULTS

Seven questions, encompassing vaccine safety, vaccine effectiveness, global vaccination strategy and vaccination in sub-populations (pediatric, pregnant women, elderly and international travelers) were considered. A narrative description of the evidence considering published studies, guidelines, and position statements is presented. A total of 53 recommendations were agreed by the working group after three rounds of consensus.

CONCLUSION

This first European consensus on vaccination in pwMS proposes the best vaccination strategy according to current evidence and expert knowledge, with the goal of homogenizing the immunization practices in pwMS.

Influenza Vaccination among Multiple Sclerosis Patients during the COVID-19 Pandemic

In the context of the COVID-19 pandemic, the co-circulation of influenza and SARS-CoV-2 viruses may have severe complications for vulnerable populations. For this reason, the World Health Organization pointed to the 2020-2021 anti-influenza campaign as being of special relevance. Our aim was to assess the 2020-2021 influenza vaccination coverage, and its associated factors, among patients in a Spanish multiple sclerosis (MS) unit. A cross-sectional study was conducted. People attending the MS unit of the Clinical Hospital of Zaragoza during 2020 were included. Variables were obtained by reviewing records. Associations with 2020-2021 influenza vaccination were analyzed using bivariate analysis and a multiple logistic regression model. A total of 302 patients were studied; 62.6% were women, whose mean age (standard deviation) was 47.3 (11.5) years. The 2020-2021 influenza vaccination coverage was 55.3% (59.8% in women and 47.8% in men). A total of 89.7% had at least one other indication for vaccination (e.g., immunosuppressive treatment in 225 patients). The variables associated with getting vaccinated were being female (adjusted odds ratio (95% confidence interval) (aOR (95%CI) = 2.12 (1.12-3.99)), having received the 2019-2020 influenza vaccine (aOR (95%CI) = 31.82 (14.71-68.86)) and being born in Spain (aOR (95%CI) = 12.91 (1.07-156.28)). Coverage is moderate compared to other countries. It is necessary to develop strategies to improve it, especially in men and those born outside Spain.

Expert-Agreed Practical Recommendations on the Use of Cladribine

Cladribine is a disease-modifying selective immune reconstitution oral therapy for adult patients with highly active relapsing multiple sclerosis (RMS). It was approved in the USA in 2019 and in Europe in 2017, thus there are still gaps in existing guidelines for using cladribine tablets in clinical practice. Nine experts with extensive experience in managing patients with multiple sclerosis in Spain identified some of the unanswered questions related to the real-life use of cladribine tablets. They reviewed the available clinical trial data and real-world evidence, including their own experiences of using cladribine, over the course of three virtual meetings held between November 2020 and January 2021. This article gathers their practical recommendations to aid treatment decision-making and optimise the use of cladribine tablets in patients with RMS. The consensus recommendations cover the following areas: candidate patient profiles, switching strategies (to and from cladribine), managing response to cladribine and safety considerations.

Influenza Vaccination Coverage among Multiple Sclerosis Patients: Evolution over Time and Associated Factors

Our objective was to determine the influenza vaccination rate in a Spanish cohort of multiple sclerosis (MS) patients. A retrospective cohort study was carried out. Patients who attended the MS unit of the Lozano Blesa Hospital of Zaragoza between January 2015 and 2020 were included. The variables were obtained by reviewing the specialized and primary care records. Associations between receiving the vaccine in each flu season and the other variables were analyzed using bivariate analysis and multiple logistic regression models. A total of 260 patients were studied, with a median age of 31 years at the time of diagnosis. A total of 62.3% (162/260) were women. Vaccination coverage ranged from 20.4% in the 2015−2016 and 2016−2017 seasons to 41.5% in the 2019−2020 season (p = 0.000). Having been vaccinated in the previous season (ORa: 16.47−390.22; p = 0.000) and receiving a vaccination recommendation from the hospital vaccination unit (ORa: 2.44−3.96; p < 0.009) were associated with being vaccinated. The coverage is in an intermediate position compared to other countries. It is necessary to improve the referral system of these patients to the hospital vaccination unit because the information obtained by this service contributed to higher vaccination rates.

Updated Perspectives on the Challenges of Managing Multiple Sclerosis During Pregnancy

Multiple sclerosis (MS) is a chronic immune-mediated, inflammatory, and degenerative disease that is up to three times more frequent in young women. MS does not alter fertility and has no impact on fetal development, the course of pregnancy, or childbirth. The Pregnancy in Multiple Sclerosis Study in 1998 showed that pregnancy, mostly in untreated women, did not adversely affect MS, as disease activity decreased during pregnancy (although it significantly increased in the first trimester postpartum). These findings, together with the limited information available on the potential risks of fetal exposure to disease modifying treatments (DMTs), meant that women were advised to delay the onset of DMTs, stop them prior to conception, or, in case of unplanned pregnancy, discontinue them when pregnancy was confirmed. Now, many women with MS receive DMTs before pregnancy and, despite being considered a period of MS stability, up to 30% of patients could relapse in the first trimester postpartum. Factors associated with an increased risk of relapse and disability during pregnancy and postpartum include relapses before and during pregnancy, a greater disability at the time of conception, the occurrence of relapses after DMT cessation before conception, and the use of high-efficacy DMTs before conception, especially natalizumab or fingolimod. Strategies to prevent postpartum activity are needed in some patients, but consensus is lacking regarding the therapeutic strategies for women with MS of a fertile age. This, along with the increasing number of DMTs, means that the decision-making processes in aspects related to family planning and therapeutic strategies before, during, and after pregnancy are increasingly more complex. The purpose of this review is to provide an update on pregnancy-related issues in women with MS, including recommendations for counseling, general management, use of DMTs in pre-pregnancy, pregnancy, and postpartum periods, and breastfeeding-related aspects of DMTs.

Vaccinations in multiple sclerosis patients receiving disease-modifying drugs

PURPOSE OF REVIEW

This review focuses on new evidence supporting the global immunization strategy for multiple sclerosis (MS) patients receiving disease-modifying drugs (DMDs), including the recently available vaccines against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.

RECENT FINDINGS

New data strengthen the evidence against a causal link between MS and vaccination. Recent consensus statements agree on the need to start vaccination early. Timings for vaccine administration should be adjusted to ensure safety and optimize vaccine responses, given the potential interference of DMDs. Patients treated with Ocrelizumab (and potentially other B-cell depleting therapies) are at risk of diminished immunogenicity to vaccines. This has relevant implications for the upcoming vaccination against SARS-CoV-2.

SUMMARY

An early assessment and immunization of MS patients allows optimizing vaccine responses and avoiding potential interference with treatment plans. Vaccinations are safe and effective but some specific considerations should be followed when vaccinating before, during, and after receiving immunotherapy. A time-window for vaccination taking into account the kinetics of B cell repopulation could potentially improve vaccine responses. Further understanding of SARS-CoV-2 vaccine response dynamics in MS patients under specific therapies will be key for defining the best vaccination strategy.

Assessing and mitigating risk of infection in patients with multiple sclerosis on disease modifying treatment

Introduction: The important development that the multiple sclerosis (MS) treatment field has experienced in the last years comes along with the need of dealing with new adverse events such as the increase risk of infections. In the shared therapeutic decision-making process, the MS expert neurologist should also balance the risks of specific infections under each particular treatment and be familiar with new mitigation strategies.Areas covered: In this review, the authors provide an up-to-date review of the infection risk associated with MS treatments with a specific focus on risk mitigating strategies. The search was conducted using Pubmed® database (2000 - present) to identify publications that reported infection rates and infection complications for each treatment (interferon beta, glatiramer acetate, teriflunomide, dimethyl fumarate, fingolimod, cladribine, natalizumab, alemtuzumab, rituximab, and ocrelizumab).Expert opinion: Since the emergence of the first natalizumab-related PML case, the arrival of new MS therapies has come hand in hand with new infectious complications. MS-specialist neurologist has to face new challenges regarding the management of immunosuppression-related infectious complications. The implementation of patient-centered management focus on preventive and mitigating strategies with a multidisciplinary approach should be seen in the future as a marker of excellence of MS management.