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Global healthcare systems are rapidly having to change and adapt in the face of the COVID-19 pandemic. At a more individual level, neurologists are being faced with complex decisions regarding the risk of infection in specific patient groups, and in particular those receiving immunosuppressant or immunomodulatory therapy. One such important patient group is those individuals with multiple sclerosis (MS) receiving disease-modifying therapies (DMTs). It has previously been established that people with MS (PwMS) have an increased risk of infections compared with the general population. These infections can lead to significant morbidity and may also contribute to relapses and a worsening of neurological symptoms. First-generation DMTs such as interferon-beta (IFN-β) or glatiramer acetate (GA) are not thought to be associated with a significantly increased risk of infection, although more efficacious second generation DMTs have demonstrated a higher risk profile. However, the majority of these observations are derived from clinical trials of MS DMTs which, because of restricted inclusion criteria and short-term follow-up, may underestimate the overall risk. Real-world experience with longer term follow-up in representative patient groups may be necessary to achieve a more accurate picture, although these data are currently limited. In the context of the evolving COVID-19 pandemic, it has become particularly important to understand these risks to make informed decisions regarding treatment and to be able to communicate this information effectively to patients. In all cases any increased risk of infection and associated morbidity will need to be carefully balanced against risks of stopping treatment and rebound disease activity. From an historical perspective, it is also interesting to note that the coronavirus family has been previously investigated for a potential association with MS, and more recently has been utilised to make a mouse model of the disease (coronavirus-induced encephalomyelitis). We should also not assume that effects of COVID-19 infection, and in particular the rarer but more serious secondary hyperinflammation syndrome, should necessarily be worsened in PwMS on DMTs and they may even be protective; inhaled treatment with interferon-beta as well as Fingolimod are currently under investigation as a potential treatment for COVID-19 infection. Nevertheless, understanding the risk of infection in MS patients remains important, especially with regard to decisions concerning therapeutic management. In this month’s journal club, we consider three papers relevant to the risk of infection in patients with MS. These studies highlight the general increased risk of infections in PwMS and those of specific treatments. Although data from many DMTs are considered in these studies, there are some—notably alemtuzumab and ocrelizumab that are not currently captured by these predominantly registry-based studies. In the meantime, many national neurology associations as well as MS charitable bodies have issued guidance with regard to the use of all DMTs in light of the current pandemic and are a useful practical resource for neurologists to review.

Multiple sclerosis and the risk of infection: considerations in the threat of the novel coronavirus, COVID-19/SARS-CoV-2