6a. Clinicians must screen for certain infections (eg, hepatitis, tuberculosis, and varicella-zoster) specific to intended ISIM medications, according to prescribing information (Level A) and should also treat patients who test positive for latent infections (eg, hepatitis and tuberculosis) accordingly before initiating MS treatments (Level B based on feasibility and cost relative to benefit).

6b. In high-risk populations or in countries with high infection burden, clinicians must screen for latent infections (eg, hepatitis and tuberculosis) before starting MS treatment with ISIM medications, even when not specifically mentioned in prescribing information (Level A). Clinicians should consult infectious disease or other specialists (eg, liver specialists) regarding treatment of patients who screen positive for a latent infection before treating them with ISIM medications (Level B).

7a. Although there is no evidence that patients with MS receiving ISIM therapy have an increased risk for morbidity as a result of immunization with live vaccines, clinicians should recommend against the use of live-attenuated vaccines in people with MS who currently receive ISIM therapies or have recently discontinued these therapies (Level B based on importance of outcomes).


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7b. When the risk for infection is high, clinicians may recommend using live-attenuated vaccines, if killed vaccines are unavailable for people with MS who are currently receiving ISIM therapies (Level C based on variation in patient preferences, benefit relative to harm, and importance of outcomes).

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Recommendation regarding immunization for individuals with MS during a relapse.

8. The guideline panel did not identify evidence that suggests vaccination increases the risk for relapse or worsens relapse severity, but studies are limited. However, experts remain concerned that vaccines may worsen relapse severity if administered to patients who are actively experiencing an MS relapse. As such, clinicians should delay vaccinations in this population, until clinical resolution or until the relapse is no longer active (eg, the relapse is no longer progressive but may be associated with residual disability), often many weeks after relapse onset (Level B).

Conclusion

As a result of the increasing body and utility of ISIMs for MS and other chronic diseases, the panel highlighted a need for further research that focuses on the safety, efficacy and possible complications associated with the use of such medications, especially in cases where immunizations are required. The panel recommends developing high quality prospective cohort studies that focus on the risks related to infectious diseases in patients with MS. Results pertaining to the subsequent effect on short- and long-term disability would significantly aid development of future guideline recommendations in this population.

References

1. Farez MF, Correale J, Armstrong MJ, et al. Practice guideline update summary: vaccine preventable infections and immunization in multiple sclerosis [published online August 28, 2019]. Neurology. doi:10.1212/WNL.0000000000008157

2. AAN Issues Guideline On Vaccines And Multiple Sclerosis. [press release]. Minneapolis, MN: PRNewswire; August 28, 2019. https://www.prnewswire.com/news-releases/aan-issues-guideline-on-vaccines-and-multiple-sclerosis-300908216.html. Accessed August 29, 2019.

This article originally appeared on Infectious Disease Advisor