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Background: There is a lack information regarding risk factors associated with worse COVID-19 outcomes in patients with multiple sclerosis (MS) in the MENA region., Methods: This is a multicenter, retrospective cohort study that included all MS patients with a suspected or confirmed COVID-19 infection using the MENACTRIMS registry. The association of demographics, disease characteristics, and use of disease-modifying therapies (DMTs) with outcomes and severity of COVID-19 were evaluated by multivariate logistic model., Results: A total of 600 MS patients with confirmed (n = 542) or highly suspected (n = 58) COVID-19 were analyzed. Seventy-three patients (12.2 %) had a COVID-19 severity score of ≥3 on a 7-point ordinal scale (ranging from 1 [not hospitalized with no limitations on activities] to 7 [death] with a cutoff at 3 [hospitalized and not requiring supplemental oxygen]), and 15 patients (2.5 %) died. Out of 73 patients with a severity score ≥3, 90.4 % were on DMTs; 50.6 % of them were on anti-CD20, including ocrelizumab and rituximab. Multivariate logistic regression showed that older age (odds ratio per 10 years, 1.4 [95 %CI, 1.0-1.8]), disability (OR for EDSS 3.0-5.5, 2.9 [95 %CI. 1.5-5.7], OR for EDSS ≥6.0, 2.3 [95 %CI. 1.0-5.1]), obesity (OR, 3.0 [95 %CI, 1.5-6.0]), and treatment with rituximab (OR, 9.0 [95 %CI, 3.1-25.3]) or off-label immunosuppressive medications (OR, 5.6 [95 %CI. 1.1-27.8]) were risk factors for moderate or severe COVID-19., Conclusion: In this registry-based study of MS patients, age, sex, EDSS, obesity, progressive MS were risk factors for severe COVID-19. Moreover, there was an association found between exposure to anti-CD20 DMTs and COVID-19 severity., Competing Interests: Declaration of competing interest No conflict of interest., (Copyright © 2024. Published by Elsevier B.V.)

With evolving diagnostic criteria and the advent of new oral and parenteral therapies for Multiple Sclerosis (MS), most current diagnostic and treatment algorithms need revision and updating. The diagnosis of MS relies on incorporating clinical and paraclinical findings to prove dissemination in space and time and exclude alternative diseases that can explain the findings at hand. The differential diagnostic workup should be guided by clinical and laboratory red flags to avoid unnecessary tests. Appropriate selection of MS therapies is critical to maximize patient benefit. The current guidelines review the current diagnostic criteria for MS and the scientific evidence supporting treatment of acute relapses, radiologically isolated syndrome, clinically isolated syndrome, relapsing remitting MS, progressive MS, pediatric cases and pregnant women. The purpose of these guidelines is to provide practical recommendations and algorithms for the diagnosis and treatment of MS based on current scientific evidence and clinical experience., Competing Interests: Declaration of competing interest The authors received honoraria from Biologix (the distributor for Biogen Idec across the Middle East and North Africa region) for serving on their advisory board and from other pharmaceutical companies including Novartis, GSK, Bayer, Merck, Sanofi and Roche. The manuscript represents the views and opinions of the members involved in the development of the guidelines. There is no industrial or pharmaceutical support or bias in the selection of the members or the recommendations reached. This effort was sponsored and carried out under the supervision of MENACTRIMS (The Middle East and North Africa Committee for Treatment and Research In Multiple Sclerosis)., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Background: Multiple sclerosis (MS) management varies markedly between different countries of the Middle East and North Africa (MENA) region based on the availability and accessibility of disease-modifying therapies (DMTs)., Objective: To evaluate the accessibility to DMTs in each MENA country, identify barriers to treatment and make recommendations for improved access to DMTs across the region., Methods: This is a descriptive, survey-based study whereby we extracted data collected, between October 2019 and April 2020, for countries in the MENA region by the Multiple Sclerosis International Federation (MSIF) through their Atlas of MS survey., Results: 16 out of 19 countries in the MENA region were included in this study. Sudan and Syria did not have any originator DMTs approved. Interferons were the most widely low-efficacy originator approved DMTs. Three countries did not have any high efficacy DMTs approved. Moreover, follow-on DMTs were approved in half (50%) of the countries. Cost of treatment was the most important barrier, reported in nearly half (47%) of the MENA countries., Conclusion: Although most MENA countries have access to DMTs, more than half of countries report problems with treatment continuation, highlighting the need for a targeted regional strategy to address the variations in access to MS treatments., Competing Interests: Declaration of Competing Interest Maya Zeineddine has received honororia for lectures from Biologix, Biogen, Janssen, Hikma Pharmaceuticals, Novartis, Merck, Roche and Sanofi-Genyme. She received travel grants from Novartis, Merck and Roche and a research grant from Biogen. She has no conflict of interest related to this study. Amal Al-Hajje declares that there is no conflict of interest. Pascale Salameh declares that there is no conflict of interest. Anne Helme and Michael Gunnar Thor declare the following: Multiple Sclerosis International Federation (MSIF) is an alliance of national multiple sclerosis (MS) organizations. MSIF receives income from a wide range of sources, including healthcare and other companies, individuals, member organizations, campaigns, foundations and trusts. Over the last 5 years, MSIF received funding from the following companies: Biogen, BristolMyersSquibb, Coloplast, Janssen, Merck, Mylan, Novartis, Roche and Sanofi – all of which is publicly disclosed. MSIF has not received any funding from industry for its access to medicines work in 2019, 2020, 2021 or 2022. Farid Boumediene declares that there is no conflict of interest. Bassem Yamout has received speaker honoraria from Bayer, Biogen, Merck, Novartis, Roche and Sanofi; research grants from Bayer, Biogen, Merck, Novartis and Pfizer; and advisory board honoraria from Bayer, Biogen, Merck, Novartis, Roche and Sanofi. He has no conflict of interest related to this study., (Copyright © 2023. Published by Elsevier B.V.)

Patients with multiple sclerosis (MS) should be vaccinated against COVID-19. All COVID-19 vaccines are effective and do not appear to carry any additional risk for patients with MS. Patients with MS should get a COVID-19 vaccine as soon as it becomes available. The risks of COVID-19 disease outweigh any potential risks from the vaccine. Even if vaccinated, patients with MS should continue to practice standard and recommended precautions against COVID-19, such as wearing a face mask, social distancing and washing hands. There is no evidence that patients with MS are at higher risk of complications from the mRNA, non-replicating viral vector, inactivated virus or protein COVID-19 vaccines, compared to the general population. COVID-19 Vaccines are safe to use in patients with MS treated with disease-modifying therapies (DMTs). The effectiveness of vaccination may be affected by few of the DMTs but yet some protection is still provided. For certain DMTs we may consider coordinating the timing of the vaccine with the timing of the DMT dose to increase vaccine efficacy., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background: The epidemiology of multiple sclerosis (MS) has been studied in many countries of the Middle East but the prevalence and incidence of MS in Lebanon is still unknown., Objectives: To determine the incidence and prevalence of MS in Lebanon., Methods: Lebanese patients diagnosed with MS between January 2018 and December 2018 were identified using the database of governmental third-party payers. The crude, age- and sex-specific 2018 prevalence and incidence among Lebanese patients were calculated., Results: 2248 MS patients were identified of whom 67.1% were women (female: male ratio 2:1) with a mean age of 41.8 ± 12.96 years. The 2018 prevalence of MS was 62.91 cases per 100,000 persons (95% CI: 60.41 - 65.41). The overall incidence of MS in Lebanon was 8.36 cases per 100,000 (95% CI: 7.45 - 9.27) with a mean age at onset of 34.5 ± 12.5 years., Conclusion: This is the first study to assess prevalence and incidence of MS in Lebanon, confirming that Lebanon is a moderate to high-risk area for MS. Those high rates are commensurate with recently published studies from the Middle East, pointing to a significant rise in incidence and prevalence of this disease in our region., (Copyright © 2021. Published by Elsevier B.V.)

Background: Fingolimod is associated with different infections including lower respiratory tract, herpes virus, cryptococcal meningitis, histoplasmosis, progressive multifocal leukoencephalopathy, atypical mycobacterial infections, kaposi sarcoma and reactivation of hepatitis c., Objectives: To describe five cases of skin warts in MS patients treated with fingolimod at the American University of Beirut Medical Center (AUBMC) MS center (MSC)., Methods: We reviewed all MS patients treated with fingolimod at our MSC and identified patients who developed skin warts during treatment. We also reviewed a control group of patients treated with different interferons matched for age and sex., Results: Of 220 patients treated with fingolimod at our MSC, 5 (2.2%) developed skin warts. In 220 patients treated with different interferons and matched for age and sex, no cases of skin warts could be detected., Conclusions: In conclusion, we report five patients who developed skin warts during fingolimod therapy, especially HPV-related, for an overall incidence of 2.2%. Larger cohorts are needed to confirm this proposed higher susceptibility of fingolimod-treated patients to HPV infections., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: Relapse rate in women with Multiple Sclerosis (MS) is reduced during pregnancy especially in the third trimester according to the previous studies., Objectives: To measure the annual relapse rate (ARR) in women with MS during pregnancy., Methods: A retrospective study was conducted using prospectively collected data from two MS registries in Kuwait and Lebanon. Demographics, clinical characteristics including relapses, disease modifying therapies (DMTs) and their washout periods were extracted. The annual relapse rates pre and post pregnancies were compared and the relationship between relapses and prior use of different DMTs was assessed., Results: Data of 164 pregnancies (132 MS patients) was reviewed. Mean age and disease duration at the time of pregnancy confirmation were 32.4 ± 5.3 and 7.8 ± 4.7 years respectively. Most patients (91.7%; n = 121) were on DMTs in the year prior to pregnancy. The pre-pregnancy ARR was 0.10 (95% CI: 0.04 - 0.13), which increased to 0.20 (95% CI: 0.13- 0.29) during pregnancy. Most relapses occurred either during the 1 st (ARR = 0.24; 95% CI: 0.12 - 0.44) or 3 rd (ARR = 0.32; 95%CI: 0.17 - 0.53) trimesters. Fingolimod (31.8%) and natalizumab (22.7%) were the most commonly prescribed DMTs in patients who sustained relapses during pregnancy. The mean washout period was significantly longer among subjects with relapses (9.3 ± 6.6 vs. 2.5 ± 3.9; p < 0.001) than those of without relapses., Conclusions: Relapse rate during pregnancy was higher than previous studies conducted in patients on platform therapies or untreated. Longer washout period prior to conception was associated with increased relapses especially in fingolimod and natalizumab treated patients., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Objectives: To estimate JCV seroprevalence and risk of seroconversion against JCV among MS patients in the Middle East., Methods: This multicenter study was conducted by implementing a cross-sectional design to assess JCV seroprevalence, and a longitudinal design to assess the risk of JCV seroconversion. Multivariable logistic and Poisson regression analyses were used to assess the relationship between clinical variables and JCV seropositivity and risk of seroconversion., Results: Of 581 MS patients, 64.9% patients were females. Mean age and mean disease duration were 33.9 and 8.4years respectively. JCV seroprevalence was 48.7%. Male gender (p=0.002), age at onset (p=0.001) and disease duration of 20 or more years (p=0.007) were significantly associated with JCV seropositivity. Among patients (n=125), followed longitudinally, the risk of JCV seroconversion was 17.6% (95% CI: 11.4%-25.4%) during a median follow-up of 18months. The proportion of seroreverted and pseudoconverted patients was 4% and 3.2% respectively., Conclusions: JCV seroprevalence among MS patients in the Middle East was lower than international figures. Male gender, age at onset and disease duration were significantly associated with JCV seropositivity. Risk of JCV seroconversion was higher than previously reported figures. Observed JCV sero-reversion or pseudo-conversion entail watchful period before embarking on a clinical decision., (Copyright © 2015 Elsevier B.V. All rights reserved.)