Pulse immunosuppressive therapy for multiple sclerosis during the SARS-CoV-2 lockdown de-escalation plan: safety algorithm

The COVID-19 pandemic is changing approaches to diagnosis, treatment, and care provision in multiple sclerosis (MS). During both the initial and peak phases of the epidemic, the administration of disease-modifying drugs, typically immunosuppressants administered in pulses, was suspended due to the uncertainty about their impact on SARS-CoV-2 infection, mainly in contagious asymptomatic/presymptomatic patients. The purpose of this study is to present a safety algorithm enabling patients to resume pulse immunosuppressive therapy (PIT) during the easing of lockdown measures. We developed a safety algorithm based on our clinical experience with MS and the available published evidence; the algorithm assists in the detection of contagious asymptomatic/presymptomatic cases and of patients with mild symptoms of SARS-CoV-2 infection with a view to withdrawing PIT in these patients and preventing new infections at day hospitals. We developed a clinical/microbiological screening algorithm consisting of a symptom checklist, applied during a teleconsultation 48 h before the scheduled session of PIT, and PCR testing for SARS-CoV-2 in nasopharyngeal exudate 24 h before the procedure. The application of our safety algorithm presents a favourable risk-benefit ratio despite the fact that the actual proportion of asymptomatic and presymptomatic individuals is unknown. Systematic PCR testing, which provides the highest sensitivity for detecting presymptomatic cases, combined with early detection of symptoms of SARS-CoV-2 infection may reduce infections and improve detection of high-risk patients before they receive PIT. La pandemia por SARS-CoV-2 está condicionando los abordajes diagnósticos, terapéuticos y asistenciales establecidos en esclerosis múltiple (EM). Durante las fases inicial y pico de la epidemia, los fármacos modificadores del curso de la EM caracterizados por ser inmunosupresores administrados en pulsos (TIP), vieron pospuesta su administración debido a la incertidumbre sobre su influencia en la infección, principalmente en contagiosos asintomáticos/presintomáticos. El objetivo de este trabajo es presentar un algoritmo basado en criterios de seguridad que permita reanudar los TIP durante la fase de desescalado. Se elabora un algoritmo, cuya estructura se sustenta en la experiencia clínica en EM de los autores y en una revisión bibliográfica del conocimiento acumulado, que facilita la detección de contagiosos asintomáticos, presintomáticos o con síntomas leves d