Review: COVID-19 and Neuromuscular Disorders
Key findings
- Both increased rates of neuromuscular disease worsening and increased incidence of new presentations can be expected during the COVID-19 pandemic
- While consensus guidance exists for some disorders such as myasthenia gravis, there are no evidence-based neuromuscular-specific recommendations for patients who contract COVID-19. Moderate- to high-risk neuromuscular patients should be monitored closely
- In a patient using an immunosuppressive or immunomodulatory agent who develops symptoms of infection, continued therapy or treatment with a different medication may be possible after discussion of risks and benefits
- Switching from an infusion center to home infusion may be appropriate for some patients on immunotherapy
- For now there are no neuromuscular-specific recommendations for patients who contract COVID-19, but moderate- to high-risk patients should be monitored closely
Neuromuscular complications of severe coronaviruses (SARS-CoV, Middle East respiratory syndrome coronavirus and now SARS-CoV-2) have rarely been mentioned in medical literature. It is possible, though, that neuromuscular complications occur and are overshadowed by systemic manifestations.
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Amanda C. Guidon, MD, director of the Myasthenia Gravis Clinic at in the Department of Neurology at Massachusetts General Hospital, and Anthony A. Amato, MD, of Brigham and Women's Hospital, recently reviewed in Neurology the potential neuromuscular complications of COVID-19, mitigation of COVID-19–related risks for patients with pre-existing neuromuscular disease and management of immunotherapy during the pandemic.
Risk of Complications
The risk of neuromuscular complications from COVID-19 among patients with existing neuromuscular disease depends on the specific disease, other comorbidities, age and whether the patient is using immunotherapy (a table in the review gives agent-specific guidance).
In general, patients are at higher risk if they:
- Have a neuromuscular disorder that affects swallowing and/or ventilatory muscles
- Have cardiomyopathy
- Are receiving immunotherapy
Importantly, patients with low-risk neuromuscular disorders may be in a higher risk category due to other demographic or health factors.
Risk of a New Neuromuscular Disorder
Viral infection is a known risk factor for Guillain-Barré syndrome, and one case of Guillain-Barré syndrome in association with COVID-19 has been reported in Lancet Neurology. However, direct causality is uncertain. There is no current evidence that SARS-CoV-2 invades motor neurons and peripheral nerves as seen in some viral infections.
Exacerbation/Unmasking of Neuromuscular Disorders
Infection commonly triggers exacerbation or progression of neuromuscular disorders. Therefore, both increased rates of disease worsening and increased incidence of new presentations can be expected during the COVID-19 pandemic.
Exacerbation of both acquired and inherited disorders is primarily related to degree of baseline cardiac and respiratory dysfunction, bulbar weakness, underlying pathophysiology of disease and other comorbidities.
Managing Immunotherapy
Patients should be educated to call their neurologist if they develop symptoms of infection to discuss whether adjustments in immunosuppressive or immunomodulatory agents are needed.
Continuing therapy or switching to a different agent may be possible after discussion between patient and provider about risks and benefits. Factors to consider are age, comorbidities, geographic location, household and occupational risk factors and the severity of the underlying neuromuscular disease.
Reliance on infusion centers may increase a patient's overall risk of infection. The benefit of switching to home infusion depends on overall COVID-19 risk, transportation needs, geography/local resources and insurance coverage.
As a form of social distancing, patients should minimize trips to pharmacies. Where possible, providers should refill prescriptions for 90-day supplies and encourage delivery from mail order pharmacies.
Managing Patients Who Develop COVID-19
For now there are no neuromuscular-specific recommendations for patients who contract COVID-19. However, in the SARS outbreak of 2002–2004, up to one-third of patients manifested myalgias and rhabdomyolysis.
- Moderate- to high-risk patients with neuromuscular disease should be monitored closely for more rapid decline in respiratory function or worsening of underlying disease
- Patients with metabolic myopathies (e.g., lipid storage diseases and mitochondrial disorders) are at increased of rhabdomyolysis with fever, infection or loss of appetite
- Weakness related to muscle fiber atrophy from disuse will be a consideration in some COVID-19 patients
- Patients who develop COVID-19 may not return to their prior baseline
The review presents a wealth of other information, including tips on incorporating telemedicine into neuromuscular care, potential risks of investigational COVID-19 therapies and vaccines for patients with neuromuscular disease and how to support colleagues whose training or research has been affected by COVID-19.
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