Three important questions arise when considering whether to vaccinate MS patients:
1. Are vaccines (including approved COVID RNA vaccines) safe for use in people with MS?
COVID-19 mRNA vaccines are safe in MS. They are non-live/inactivated vaccines. The vector vaccine (Johnson and Johnson) is not a live vaccine.
2. Will immune activation trigger MS relapse?
Any relapse is extremely unlikely to be triggered by the vaccine and any risk must be balanced by the potential benefit of the vaccine in preventing COVID-19 infection which can be life threatening to the MS patient.
3. Are COVID RNA vaccines safe for use in patients with MS on DMTs?
The vaccines are safe to use with MS medications. Possibly some disease modifying therapies (DMTs) may make the vaccine less effective yet providing some protection. This may be affected by the mechanism of action of the DMT.
How does the vaccine produce immunity?
The mRNA vaccine is delivered in a lipid capsule and it is taken up by our immune system. The lipid capsule allows contact with any of our cells and promotes transfer of this RNA fragment into our cells. Once taken up, the immune system produces a peptide that mimics the spike protein of the actual virus, allowing our immune system to react to it. This is recognized as a foreign protein and the immune system reacts as it normally does. Both T and B cells are affected resulting in production of antiviral antibodies and long-lasting memory cells. The B cells produce an antibody response to the spike protein specifically and rapidly. Re-exposure to the same protein (Second Injection) affords a much larger and longer reacting response.
The DMTs effect upon the vaccine is dependent upon its mechanism of action. Some have very little effect and others are known to blunt the response. The following updated guidelines are proposed by the National MS Society in conjunction with consensus of experts in the field:
1. Vaccinate before initiating for the first time any DMT. Wait 4 weeks after the last vaccination before starting the DMT.
2. The recommendation for all DMTS except for anti-CD20 and Lemtrada®, does not require any alteration in the DMT schedule and can be administered as soon as the vaccine is available. In a very recent update regarding Mavenclad®, available data suggest that timing of dosing is unlikely to make a significant difference in vaccine response and thus vaccine can be administered when available.
3. Alteration in scheduling is suggested for Anti-CD 20 and Lemtrada®.
a. Infusions (Ocrelizumab and Rituxan®):
i. Twelve weeks or more after the last infusion dose is required before the vaccination can be administered.
ii. Four weeks after the last vaccination the infusion can be resumed.
iii. It is recognized that altered dosing may not always be possible and getting the vaccine when available maybe more important than the timing of the infusion medication.
b. Subcutaneous injections (Kesimpta®):
i. If you already taking Kesimpta® there is no data to guide the timing of the vaccine in relation to your last injection. However, when possible, Kesimpta® should be resumed two to four weeks after total vaccination.
ii. It is recognized that altered dosing may not always be possible and getting the vaccine when available maybe more important than the timing of the medication injection.
c. If you are already taking Lemtrada®, consider being vaccinated 24 weeks or more from the last dose.
Written By: Jay Rosenberg, MD
Keywords: DMT, DMTs, Multiple Sclerosis, MS, Lemtrada, Kesimpta, Mavenclad.