Manejo de doenças desmielinizantes do sistema nervoso central na pandemia de doença do coronavírus 2019: uma abordagem prática

APÓSTOLOS-PEREIRA, Samira Luisa; SILVA, Guilherme Diogo; DISSEROL, Caio César Diniz; FEO, Lucas Bueno; MATOS, Aline de Moura Brasil; SCHOEPS, Vinicius Andreoli; GOMES, Ana Beatriz Ayroza Galvão Ribeiro; BOAVENTURA, Mateus; MENDES, Maria Fernanda; CALLEGARO, Dagoberto

doi:10.1590/0004-282X20200056

Introdução: A mais recente pandemia causada pelo coronavírus SARS-CoV-2 (COVID-19, do inglês coronavirus disease 2019) representa uma ameaça potencial para pacientes com doenças autoimunes, incluindo esclerose múltipla (EM) e transtorno do espectro de neuromielite óptica (NMOSD, do inglês neuromyelitis optica spectrum disorders). Esses pacientes são geralmente tratados com medicamentos imunomoduladores ou imunossupressores que podem alterar a resposta normal do organismo a infecções. Até o momento, não há consenso sobre como o manejo dos pacientes com EM e NMOSD deve ser realizado durante a pandemia.

Objetivo: Discutir estratégias para manejar esses pacientes.

Métodos: Focamos em como 1) reduzir o risco de infecção por COVID-19, como distanciamento social, telemedicina e exames laboratoriais e de imagem em intervalos mais amplos; 2) manejo de surtos, incluindo evitar tratamento de surto leve e uso de corticoide oral; 3) gerenciar terapias modificadoras de doença, como a preferência por medicamentos associados a menor risco de infecção (interferons, glatirâmer, teriflunomida e natalizumabe) e infusão em intervalo estendido de natalizumabe, quando seguro; 4) individualizar a escolha da terapia de indução para EM (anticorpos monoclonais anti-CD20, alentuzumabe e cladribina); 5) manejar terapias preventivas de NMOSD, incluindo seleção inicial de terapia e manutenção do tratamento atual; 6) manejar pacientes com EM/NMOSD que foram infectados por COVID-19.

Conclusão: No futuro, séries de casos de pacientes com MS/NMOSD infectados com COVID-19 nos ajudará a definir as melhores estratégias de manejo. Por enquanto, contamos com a experiência e orientação especializadas.

Palavras-chave:
Esclerose Múltipla; Neuromielite Óptica; Coronavírus; Imunossupressor; Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos

[TFN1] MS/NMOSD: multiple sclerosis/neuromyelitis optica spectrum disorder.

	Strategies for MS/NMOSD care
Teleorientation	Education about the COVID-19 pandemic: patients should be instructed - via e-mail, telephone, or video-call - to: 1) follow social distancing, 2) be rigorous about hand hygiene and mask use, 3) go to an emergency room in the presence of red flags for severe SARS-CoV-2 infection (dyspnea, fever), 4) if necessary, ask for a medical report explaining the need for home-office work and influenza vaccination.
Telemonitoring	Laboratory testing: blood count and immunoglobulin levels can be checked through e-mail. We suggest explaining to patients that more flexible monitoring may be more appropriate to reduce infection risk. Magnetic resonance imaging: we recommend annual CNS imaging (MRI) to be checked via telemedicine, e-mail, or online.
Teleconsultation	Outpatient consultation: routine appointments should be rescheduled or performed using telemedicine. When prescribing a DMD, we should discuss drug access strategies (e.g., family member goes to the drugstore instead of the patient). Emergency consultation: relapse evaluation should start by excluding active infections. COVID-19 should be ruled out. Neurological examination and prescription of high-dose oral steroids can be performed using telemedicine to prevent hospitalization.

Interferons Glatiramer Teriflunomide (Low risk)	Safe choice for therapy initiation.
	Safe maintenance of therapy.
Dimethyl fumarate (Low to moderate risk)	Association with increased infection risk is controversial; drug initiation should be discussed on a case-to-case basis
	We suggest maintenance of therapy.
Fingolimod (Moderate risk)	Careful individualized approach should be considered when starting this drug during the pandemic.
	We suggest maintenance of therapy. Lymphopenia should be monitored in a more flexible interval (at 3 months of introduction and every 6 months thereafter) via telemedicine.
Natalizumab (Low Risk)	Safe choice for therapy initiation in highly active disease.
	We recommend the maintenance of natalizumab and suggest extended-interval dosing to reduce the risk of patient exposure to COVID-19. Asymptomatic PML screening should not be interrupted in high-risk patients, even during the pandemic.
Ocrelizumab Rituximab (Moderate risk)	Careful individualized approach should be considered when starting this drug during the pandemic.
	We recommend the maintenance of anti-CD20 therapy. CD19 monitoring can be considered as an aid to prolong infusion interval. Immunoglobulin levels should be checked and replaced if needed. May be an option in aggressive MS.
Cladribine Alemtuzumab (High risk)	Careful individualized approach should be considered when starting this drug during the pandemic.
	It is not clear if postponing the second cycle may compromise treatment efficacy

Rituximab (Moderate risk)	Best choice for therapy initiation.
	Maintain anti-CD20 therapy every 6 months. Immunoglobulin levels should be checked and replaced if needed.
Azathioprine Mycophenolate Methotrexate (Moderate risk)	Alternative choice for therapy initiation.
	Laboratory testing should be performed in a more flexible interval in stable patients (every 6 months for patients with disease and laboratory stability for at least one year) and checked via telemedicine.