- Limited data exist on the course of COVID-19 in patients with underlying neuro-inflammatory disorders on immunomodulatory therapies 
- Data from the prior SARS and MERS-CoV outbreaks showed no increased risk of adverse outcomes in patients on immunomodulatory therapies [2,3]
- Case reports describing SARS-CoV-2 infection in cardiac and renal transplant patients reported that the clinical course and outcomes in these immuncompromised patients mirrored those of immunocompetent patients [4-6]
- Therapeutic considerations for COVID-19 include immunomodulatory drugs such as tocilizumab, an interleukin-6 inhibitor, posited to prevent the cytokine storm syndrome described in COVID-19 
- Tocilizumab has also successfully been used to treat neuroinflammatory conditions in the pre-COVID-19 era after first-line therapies have failed, including myasthenia gravis and vasculitis [8,9]
CNS Demyelinating Disorders:
- For multiple sclerosis patients with active COVID-19, consider holding disease-modifying therapy pending respiratory recovery 
- For multiple sclerosis exacerbations, hold corticosteroids in patients who have active COVID-19 and consider holding corticosteroids or arranging home administration of corticosteroids in non-infected patients, as risk of hospitalization for inpatient immunotherapy likely outweighs benefits of earlier recovery
- In the absence of active COVID-19:
- Glatiramer acetate, teriflunomide, dimethyl fumarate, beta-interferons: not thought to increase the severity of infection and should not be discontinued 
- Alemtuzumab, ocrelizumab, cladribine: thought to potentially impede immune response to SARS-CoV-2 infection; consider delaying infusion, as these medications may remain effective for multiple months after administration 
- Natalizumab: should not be discontinued given a risk of rebound with severe multiple sclerosis flares 
- Fingolimod: can cause reactivation of other viral infections, however, discontinuation carries a risk of rebound flares; benefits of continuing may outweigh risks, though patients being considered for new initiation of fingolimod may benefit from an alternative disease-modifying therapy at this time given the risk 
- Patients with evidence of an acute myasthenic flare in the setting of SARS-CoV-2 may benefit from acute treatment with intravenous immunoglobulins (IVIg) or plasmapheresis; IVIg carries a risk of thrombotic events, which may be higher in the setting of an inflammatory response related to COVID-19, however, small case series have demonstrated safe use in this patient population ; see management of neuromuscular respiratory failure here
- Azathioprine, mycophenolate mofetil, methotrexate, corticosteroids: continue therapy as normal; benefits in terms of preventing a myasthenic flare likely outweigh any risk of immunosuppression 
- Infliximab, rituximab, ocrelizumab: moderately increase the risk of viral infections, so individuals may be more prone to COVID-19 and its complications, however, benefits in terms of preventing a myasthenic flare likely outweigh any risk of immunosuppression; treatment may be delayed in selected cases, though it should not be discontinued altogether 
- Tocilizumab, which is currently being used experimentally in the treatment of COVID-19, is likely safe for use in patients with myasthenia gravis; the data on safety of hydroxychloroquine are mixed [9,14].
- Azithromycin is being used experimentally in the treatment of COVID-19 ; it has been shown to exacerbate myasthenic symptoms in a handful of published patient case studies and should be avoided in myasthenic patients if possible 
- D’Antiga L. Coronaviruses and immunosuppressed patients. The facts during the third epidemic. Liver Transpl. 2020.
- Hui DS, Azhar EI, Kim YJ, et al. Middle East respiratory syndrome coronavirus: risk factors and determinants of primary, household, and nosocomial transmission. Lancet Infect. Dis. 2018.
- Stockman LJ, Massoudi MS, Helfand R, et al. Severe acute respiratory syndrome in children. Pediatr. Infect. Dis. J. 2007.
- Li F, Cai J, Dong N. First Cases of COVID-19 in Heart Transplantation From China. J. Hear. Lung Transplant. 2020.
- Zhu L, Xu X, Ma K, et al. Successful recovery of COVID-19 pneumonia in a renal transplant recipient with long-term immunosuppression. Am. J. Transplant 2020.
- Guillen E, Pineiro GJ, Revuelta I, et al. Case report of COVID-19 in a kidney transplant recipient: Does immunosuppression alter the clinical presentation? Am. J. Transplant 2020.
- Xu X, Han M, Li T, et al. Effective Treatment of Severe COVID-19 Patients with Tocilizumab. chinaXiv 2020.
- Salvarani C, Magnani L, Catanoso M, et al. Tocilizumab: A novel therapy for patients with large-vessel vasculitis. Rheumatology 2012.
- Jonsson DI, Pirskanen R, Piehl F. Beneficial effect of tocilizumab in myasthenia gravis refractory to rituximab. Neuromuscul. Disord. 2017.
- Ming Lim, Gavin Giovannoni PA. ABN Guidance on the use of disease-modifying therapies in multiple sclerosis in response to the threat of a coronavirus epidemic [Internet]. ABN Exec. 2020; Available from: https://cdn.ymaws.com/www.theabn.org/resource/collection/6750BAE6-4CBC-4DDB-A684-116E03BFE634/ABN_Guidance_on_DMTs_for_MS_and_COVID19_APPROVED_11_March.pdf
- Update on coronavirus COVID-19 and multiple sclerosis [Internet]. Mult. Scler. Trust 2020;[cited 2020 Apr 5 ] Available from: https://www.mstrust.org.uk/news/update-coronavirus-covid-19-and-multiple-sclerosis
- Cao W, Liu X, Bai T, et al. High-dose intravenous immunoglobulin as a therapeutic option for deteriorating patients with Coronavirus Disease 2019. Open Forum Infect. Dis. 2020.
- Association of British Neurologists Guidance on COVID-19 for people with neurological conditions, their doctors and carers [Internet]. ABN Exec. 2020;[cited 2020 Apr 5 ] Available from: https://cdn.ymaws.com/www.theabn.org/resource/collection/6750BAE6-4CBC-4DDB-A684-116E03BFE634/ABN_Neurology_COVID-19_Guidance_22.3.20.pdf.
- Jallouli M, Saadoun D, Eymard B, et al. The association of systemic lupus erythematosus and myasthenia gravis: A series of 17 cases, with a special focus on hydroxychloroquine use and a review of the literature. J. Neurol. 2012.
- Gautret P, Lagier J-C, Parola P, et al. Hydroxychloroquine and azithromycin as a treatment of COVID-19: results of an open-label non-randomized clinical trial. Int. J. Antimicrob. Agents 2020.
- Gilhus NE, Romi F, Hong Y, Skeie GO. Myasthenia gravis and infectious disease. J. Neurol. 2018.