Table 1

Recommended management of immunosuppressants

Patients initiating treatmentPatients already on treatment
DMTs/treatments with low risk of infections
 Beta interferon
 Glatiramer acetate
 Dimethyl fumarate*
 Teriflunomide†
 IVIg/ SCIg
 PLEX		General health advice.
Initiate treatment as usual.		General health advice.
Continue treatment.
DMTs/treatments with risk of infections but associated with risk of rebound disease activity
 Fingolimod‡
 Natalizumab§		General health advice.
Consider delaying initiation of treatment or an alternate DMT, taking into account the risks and benefits.		General health advice.
Continue treatment.
DMTs/treatments with risk of infections with a long duration of action
 Ocrelizumab
 Rituximab
 Cyclophosphamide		General health advice.
Consider delaying initiation of treatment or an alternative DMT, taking into account the risks and benefits.
Anti-CD20 antibodies may significantly suppress adaptive humoural immunity to novel pathogens.		General health advice.
If treatment is due, consider checking CD19 count along with routine FBC and immunoglobulin levels. If patient is neutropaenic, lymphopaenic and/or CD19 <1% consider delaying treatment course, taking into account the risks and benefits.
Immune-reconstitution therapies
 Cladribine
 Alemtuzumab
 HSCT		General health advice.
Do not initiate treatment, consider an alternative DMT.		General health advice.
Delay further courses of treatment, taking into account the risks and benefits, and reassess periodically.
Steroid-sparing agents
 Azathioprine*
 Methotrexate
 Mycophenolate		General health advice.
Consider delaying initiation of treatment or an alternate DMT, taking into account the risks and benefits.		General health advice.
If clinically stable, then continue treatment, taking into account the risks and benefits, and reassess periodically.
NB. Risk of relapse risk and relapse treatment.

  • *Careful attention should be paid to lymphocyte counts, ensure >0.5×109.

  • †If initiating teriflunomide, be aware of the need for 2 weekly blood test monitoring and the risks of frequent hospital visits in an epidemic.

  • ‡Careful attention should be paid to lymphocyte counts, ensure >0.2×109.

  • §In patients on natalizumab, consider extended interval dosing after discussion of risks and benefits to reduce hospital visits in an epidemic.

  • DMT, disease modifying therapy; FBC, full blood count; HSCT, haematopoietic stem cell transplantation; IVIg, intravenous immunoglobulin; NB, nota bene; PLEX, plasma exchange; SCIg, subcutaneous immunoglobulin.