Experts Publish Guidance on Managing MG and LEMS During COVID-19 Pandemic

A group of experts have provided a series of recommendations for people with myasthenia gravis (MG) and Lambert-Eaton myasthenic syndrome (LEMS) who rely on immunosuppressants to help manage their condition during the COVID-19 outbreak.

Their guidelines, titled “Guidance for the management of myasthenia gravis (MG) and Lambert-Eaton myasthenic syndrome (LEMS) during the COVID-19 pandemic,” were published in the Journal of the Neurological Sciences.

COVID-19 is a respiratory illness caused by the new severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Nearly every country in the world has reported cases of COVID-19, leading the World Health Organization to declare a pandemic.

There are no proven medications yet to treat COVID-19, nor a vaccine that can prevent people from being infected. It is also unclear at this point how COVID-19 may affect people with autoimmune diseases such as MG or LEMS who use immunosuppressive medications.

“However, because most patients with MG are on immunosuppressive or immunomodulatory therapies and may also have respiratory muscle weakness, there is a theoretical concern that MG/LEMS patients may be at higher risk of contracting the infection or experiencing severe manifestations of COVID-19,” the researchers wrote.

Based on information available up to March 23, a panel of international MG experts gathered to help guide the treatment of those with MG or LEMS during the pandemic. Their recommendations have since been endorsed by the American Association of Neuromuscular & Electrodiagnostic Medicine.

To start, the experts recommend that patients with MG or LEMS follow the specific guidelines of their country or geographic region for those at risk of serious complications from COVID-19. Guidance from the Centers for Disease Control and Prevention in the U.S. can be found here.

Patients are also advised to continue taking their routine medications as instructed, unless told otherwise by their healthcare provider. Those on immunosuppressive medications — such as rituximab (sold as MabThera and Rituxan), azathioprine, mycophenolate, and ocrelizumab (sold as Ocrevus to treat multiple sclerosis) — should be extra vigilant, follow social distancing, and avoid public exposure as much as possible to minimize the risk of infection.

People who are on treatments that require hospital visits — such as plasma exchange or infusion therapies — should discuss the risks or benefits with their physicians, and when possible switch over to a treatment regimen that can be administered at home. The same principle applies to those who rely on frequent blood tests to monitor their condition.

According to the experts, there is no evidence at this point to suggest that certain medications commonly used to manage MG or LEMS — including Firdapse (pyridostigmine), Ruzurgi (3,4-diaminopyridine), intravenous immunoglobulin, and plasma exchange — increase the risk of infection by SARS-CoV-2.

For patients currently participating in clinical trials, the panel recommends “that any decision regarding ongoing need for in-person evaluations and treatments under the clinical trial be based with consideration for patients’ best interest.”

If a patient becomes infected and develops severe symptoms of COVID-19 that require hospitalization, it may be necessary to suspend treatment with immunosuppressive agents, the team added.

“Importantly, treatment escalation or change decisions need to be individualized based on the relative severity of COVID-19 infection and MG/LEMS in consultation with local expert(s),” they wrote.

The experts say they will continue to closely monitor the situation and make changes to the guidelines if necessary.

“As decisions regarding immunotherapy use should be individualized and made by the person with MG and his/her healthcare provider, we encourage that patients contact their MG provider with questions and for further guidance,” they wrote.