Multiple Sclerosis

Established in 1982, the Multiple Sclerosis (MS) Clinic is a part of the Mobility Program at St. Michael’s and is one of many specialty centres of MS care across Canada that is dedicated to treatment, education and research in MS. The clinic is one of the largest of its kind in North America, and one of seven adult centres in Ontario focusing on diagnosis and treatments. The clinic is staffed by eight MS neurology specialists and accommodates more than 7,000 patients from the Greater Toronto Area. The clinic takes a multidisciplinary approach through allied health professionals that provide occupational therapy and social work services.

Referral form

9 Donnelly Wing South, 30 Bond St.
416-864-5377
Fax: 416-864-5378
Monday to Friday, 9 a.m. to 5 p.m.

Evusheld update – December 2022

In accordance with Ontario Health recommendations, we are no longer recommending Evusheld in people with MS. Please refer to the following links for additional information.

September 2022 update

The Ontario Ministry of Health is offering bivalent COVID-19 vaccine boosters to vulnerable populations immediately, and all Ontarians aged 18+ eligible starting Sept. 26, 2022.

In people with MS and other neuro-inflammatory diseases, the bivalent COVID-19 vaccine booster is currently available only to those who are on an anti-CD20 agent (e.g. rituximab, ocrelizumab, ofatumumab), high-dose systemic corticosteroids, S1P-receptor agonists (fingolimod, siponimod, and ozanimod), cyclophosphamide, azathioprine, and mycophenolate mofetil. On Sept. 26, 2022 the bivalent COVID-19 vaccine booster will be available to all adults.

All adults (even those not in a vulnerable population) can book an appointment through the COVID-19 vaccination portal or by calling the Provincial Vaccine Contact Centre (PVCC) at 1-833-943-3900. Eligible individuals can also book an appointment directly through public health units that use their own booking systems, indigenous-led vaccination clinics, participating health care providers and participating pharmacies.

Additional information

If you are eligible for the bivalent COVID-19 vaccine booster and are a patient of the MS Clinic at St. Michael’s Hospital, and need a letter from your MS specialist, please contact the MS clinic at 416-864-5377.

July 2022 update

COVID vaccine fourth dose for all MS patients

We recommend that all of our patients follow provincial recommendations regarding the fourth COVID vaccine dose. Specifically, as of July 15, 2022: individuals 18 years of age and older may receive their fourth dose at least five months (140 days) after their third dose. However, fourth doses can be administered as early as three months (84 days), with consent. In addition, If a patient has been recently infected with COVID-19, the recommendation is to receive their fourth dose three months after symptom onset or a positive test (if asymptomatic). With informed consent, eligible individuals may receive their fourth dose once they are asymptomatic and have completed their isolation.

For people with MS on Ocrevus, Kesimpta, and Mavenclad, we generally recommend following our prior recommendations regarding timing of the COVID vaccine dose in relation to dosing of the medication (see below for posting from March 10, 2021). Further questions regarding fourth COVID vaccine doses should be directed to the treating neurologist.

COVID vaccine fifth dose for select MS patients

The Ontario Ministry of Health is offering fifth doses of a COVID-19 vaccine to select vulnerable populations.

In people with MS and other neuro-inflammatory diseases, this new policy currently applies only to those who are on an anti-CD20 agent (e.g. rituximab, ocrelizumab, ofatumumab), high-dose systemic corticosteroids, S1P-receptor agonists (fingolimod, siponimod, and ozanimod), cyclophosphamide, azathioprine, and mycophenolate mofetil.

In order to receive a fifth dose of COVID-19 vaccine, you will need to book an appointment AND bring a letter from your MS specialist stating your name and the reason you qualify for the fifth dose, and bring the letter to the vaccine clinic with you.

You can book an appointment around the province by calling the Provincial Vaccine Contact Centre at 1‑833‑943‑3900. Appointments can also be booked directly through public health units that use their own booking system, participating pharmacies, Indigenous-led vaccination clinics, select primary care settings and more.

If you are eligible for a fifth dose of COVID-19 vaccine, are a patient of the MS Clinic at St. Michael’s Hospital, and need a letter from your MS specialist, please contact the MS clinic at 416-864-5377.

PLEASE NOTE:

The MS Clinic at St. Michael’s Hospital cannot guarantee that all vaccine clinics will accept the referral forms for a fifth dose of a COVID-19 vaccine provided to our patients. Though our forms are aligned with Ministry of Health guidelines, a standardized form has not yet been provided for use across all hospitals, health centres, vaccine clinics and pharmacies in the province, leading to some variability in patients being able to access fifth doses.

The MS Clinic at St. Michael’s Hospital continues to advocate for patients and provide appropriate documentation for a fifth dose, where appropriate.

Thank you for your understanding.

April 2022 update

For patients who have a confirmed or suspected COVID-19 infection, we recommend that you use this self-assessment tool (link below) for further direction/recommendations and to assess your eligibility for available therapies to prevent severe COVID-19 illness. The second link below will direct you to COVID-19 assessment and potential treatment sites near you:

We recommend for ALL our patients to continue to follow public health guidelines, including vaccination recommendations (as previously published below.)

Link between EBV and MS

(Jan. 20, 2022) – We are aware of the recent study published in Science (Bjornevik et al, Jan 2022), outlining the link between Epstein-Barr virus (EBV) and MS.

While this study is important for the field and adds to our knowledge on the many factors that potentially cause MS, it does NOT have any therapeutic implications at this time. As such, we would NOT recommend any changes to your MS treatment at this time. Currently, there are no treatments for EBV, and no vaccines available to prevent EBV; however, this is under study.

In addition, since the vast majority of people in the general population are exposed to EBV by the age of 18 (more than 90 per cent of people), we would not recommend that you get tested for EBV.

COVID-19 alert

The Ontario Ministry of Health is offering fourth doses of a COVID-19 vaccine to select vulnerable populations.

In order to receive a fourth dose of COVID-19 vaccine, you will need to book an appointment AND bring a letter from your MS specialist stating your name and the reason you qualify for the fourth dose, and bring the letter to the vaccine clinic with you.

You can also book an appointment around the province by calling the Provincial Vaccine Contact Centre at 1‑833‑943‑3900. Appointments can also be booked directly through public health units that use their own booking system, participating pharmacies, Indigenous-led vaccination clinics, select primary care settings and more.

If you are eligible for a fourth dose of COVID-19 vaccine, are a patient of the MS Clinic at St. Michael’s Hospital, and need a letter from your MS specialist, please contact the MS clinic at 416-864-5377.

PLEASE NOTE:

The MS Clinic at St. Michael’s Hospital cannot guarantee that all vaccine clinics will accept the referral forms for a third dose of a COVID-19 vaccine provided to our patients. Though our forms are aligned with Ministry of Health guidelines, a standardized form has not yet been provided for use across all hospitals, health centres, vaccine clinics and pharmacies in the province, leading to some variability in patients being able to access third doses.

The MS Clinic at St. Michael’s Hospital continues to advocate for patients and provide appropriate documentation for a third dose, where appropriate.

Thank you for your understanding.

At Unity Health, we are asking patients who meet the eligibility criteria for vaccination, including those in the highest risk category for health conditions (which includes people with MS), to book an appointment through the provincial COVID-19 Vaccine Call Centre (1-833-943-3900, 8 a.m. – 8 p.m. daily)

For patients who live a distance from Unity Health Toronto, the provincial COVID-19 Vaccine Call Centre may be easier to use, as appointments can be booked at COVID vaccine sites close to your home.

In accordance with public health guidelines, we recommend that MS patients or those with other neuroinflammatory disorders get whichever COVID vaccine is available to them for dose 2, regardless of what type of vaccine they received for dose 1. In other words, you may receive one vaccine product for your first dose and a different vaccine product for your second dose to complete your two-dose vaccine series. Please see full guidelines issued by the government of Canada.

Please note: we are asking patients to book their own appointments to ensure appointments are booked at a convenient time for you. Because of the large number of patients at Unity Health, our teams are unable to book patients’ appointments as this would delay booking and access to appointment slots. The MS clinic cannot control the timing of your second dose of COVID vaccine.

Multiple Sclerosis at St. Michael's Hospital

NOTE: The recommendations in this document are general guidelines that should be applied when you become eligible for a vaccine in Ontario’s phased vaccination program.

Data on the safety and effectiveness of COVID-19 vaccines in those with multiple sclerosis (MS) and other neuroimmunological disorders are not yet available. Our guide is based on data from the general population in the vaccine clinical trials and data from studies of other vaccines in MS. Our guide will be updated as more is learned about the vaccines. These statements are in line with what is recommended by the Canadian Network of MS Clinics and the National (USA) MS Society recommendations. Full statements from both organizations can be found here:

The following statements have been approved by the neurologists at the St. Michael’s Hospital MS Clinic, and are intended to be used as guidance statements regarding COVID-19 vaccination in people with MS (pwMS) and other neuroimmunological disorders who are eligible to receive their vaccination in their jurisdiction. In specific situations, it may be necessary to discuss timing of specific medications further with your treating neurologist at your next clinic appointment (details below).

We recommend that all persons with MS and other neuroimmunological disorders receive their COVID-19 immunization when eligible to receive it, since the risks of COVID-19 infection appear to outweigh the potential risks of the vaccine.
The currently available vaccines (from Pfizer/BioNtech, Moderna, AstraZeneca, Johnson & Johnson) do not contain live virus and will not cause COVID-19 infection. We have no reason to believe these COVID-19 vaccines will be dangerous for people with MS, including those on immunosuppressive drugs. It is unlikely that these vaccines will exacerbate MS or its symptoms, provoke a relapse, or prevent disease modifying therapies (DMTs) from being effective.
Patients should not delay receiving the vaccine once they are eligible unless their MS treatment necessitates it (see below). This is because people with progressive MS, those who are older, those who have a higher level of physical disability, and those with certain medical conditions (e.g., diabetes, high blood pressure, obesity, heart and lung disease) are among groups with the highest risk for hospitalization due to COVID-19.
It is important to continue your disease modifying therapy (DMT) UNLESS advised by your MS healthcare provider to stop or delay it. Stopping some DMTs abruptly can cause your MS to worsen. Overall, it will generally not be advisable for people to change their MS treatment to increase the efficacy of vaccines, because the potential harm would outweigh the potential benefit. Even a reduced response is better than none, so you should still get vaccinated when eligible — even if on these therapies.
For those taking Ocrevus (ocrelizumab) or Rituxan (rituximab) —you may need to coordinate the timing of your vaccine with the timing of your next dose. We generally recommend receiving the COVID-19 vaccine 4 – 5 months after your last dose. Once you complete the COVID-19 vaccine schedule, (for many of the above listed vaccines, 2 doses are required), you can receive the next dose of Ocrevus or Rituxan 4 weeks later. When you receive notification that you will be able to receive a COVID-19 vaccine, please let the infusion support program know (COMPASS) so that your treating neurologist will provide recommendations to adjust the timing of your next dose as necessary.
For those taking Kesimpta (ofatumumab) —you may need to coordinate the timing of your vaccine with the timing of your next dose. We generally recommend receiving the COVID-19 vaccine 4 weeks after your last dose. Once you complete the COVID-19 vaccine schedule, you can receive the next dose of Kesimpta 4 weeks later. When you receive notification that you will be able to receive a COVID-19 vaccine, please let the patient support program know (GO program) so that your treating neurologist will provide recommendations to adjust the timing of your next dose as necessary.
For those taking Mavenclad (cladribine tablets), the COVID-19 vaccine should be taken 3-6 months after the last dose, ideally when lymphocyte counts have recovered. If you are due for Treatment Cycle 2 of Mavenclad, you may want to discuss delaying Cycle 2 until you have received the COVID-19 vaccine. When you receive notification that you will be able to receive a COVID-19 vaccine, please let the Mavenclad support program know (Adveva) so that your treating neurologist will provide recommendations to adjust the timing of your next dose as necessary.If you have completed two treatment cycles of Mavenclad, and it has been more than 6 months after the last tablet of Cladribine, and your lymphocyte counts have recovered, we would recommend that you get the COVID-19 vaccine when available to you, as long as you do not have any other contraindications.
For those taking Lemtrada (alemtuzumab), the COVID-19 vaccine should be taken 3-6 months after the last dose ideally when lymphocyte counts have recovered. If you are due for Treatment Cycle 2, you may want to discuss delaying this until you have received the COVID-19 vaccine. When you receive notification that you will be able to receive a COVID-19 vaccine, please let the Lemtrada support program know (One to One) so that your treating neurologist will provide recommendations to adjust the timing of your next dose as necessary.If you have completed two treatment cycles of Lemtrada, and it has been more than 6 months after the last dose, and your lymphocyte counts have recovered, we would recommend that you get the COVID-19 vaccine when it is available to you, as long as you do not have any other contraindications.
In some instances, after discussion with you, your neurologist may recommend delaying initiation of Ocrevus, Kesimpta, Mavenclad, or Lemtrada until you get the COVID-19 vaccine. However, for patients with very active MS, risk of disease progression if treatment is delayed may outweigh risk of potential COVID-19 infection. This decision will be easier once we have a better idea of the vaccination schedule for the public.
For patients on fingolimod (Gilenya or generic fingolimod), Ozanimod (Zeposia), or siponimod (Mayzent) the response to the COVID-19 vaccine may be decreased, but we would recommend that you still get the vaccine (as long as you do not have any other contraindications) even if the response is not complete, since even a reduced response is better than none.
Most other disease-modifying treatments are not perceived to interfere with vaccine responses, including glatiramer acetate (Copaxone and Glatect), teriflunomide (Aubagio), dimethyl fumarate (Tecfidera), interferon beta agents (Avonex, Plegridy, Rebif, Betaseron, Extavia), and natalizumab (Tysabri). PwMS on these medications are recommended to get the COVID-19 vaccine as soon as it is available to you, as long as you do not have any other contraindications.
For patients on azathioprine (Imuran), mycophenolate mofetil (Cellcept), or daily prednisone the response to the COVID-19 vaccine may be decreased, but we would recommend that you still get the vaccine (as long as you do not have any other contra-indications) even if the response is not complete, since even a reduced response is better than none.
For patients who have received high-dose steroids in the recent past for a relapse (intravenous methylprednisolone [solumedrol]) or high-dose prednisone (1000-1250 mg daily for 3-5 days), we would recommend delaying the COVID vaccine until 2-4 weeks after the last dose.
The safety and efficacy of the COVID-19 vaccines are unclear in pregnant/breastfeeding women, but pregnant/breastfeeding women may be at a higher risk of COVID-19 and complications. For pwMS and other neuroimmunological disorders who are pregnant/breastfeeding, COVID-19 vaccination should be discussed with all involved health care providers, including your obstetrician, family doctor and neurologist.
Vaccination with the COVID-19 vaccine does not guarantee immunity to COVID-19. Even after getting vaccinated, we strongly recommend that all of our patients continue to remain cautious and follow all public health precautions. In addition to getting vaccinated, wearing a face mask, social distancing and washing your hands are the best ways to slow the spread of the virus and should be continued even once you get a COVID-19 vaccine.

Appointments

Due to the evolving COVID-19 situation, our Multiple Sclerosis Clinic physicians are working towards offering telephone or virtual appointment visits. You will be contacted by reception with further information to arrange these appointments. If you are unable to receive a telephone or virtual appointment, we will postpone your appointment to a later date. This is for the safety of our patients, staff and community and to help slow the transmission of COVID-19.

Relapses or attacks

If you are experiencing an MS relapse or attack (which is the sudden onset of a new MS symptom that is lasting longer than 24-48 hours in the absence of an infection or fever), please call the relapse line at 416-864-5333 and press 1. You will be prompted to leave a message. A registered nurse will call you back with directions. Please only use the Emergency Department for emergencies.

Questions about COVID-19

If you have questions regarding COVID-19, please contact Telehealth at 1-866-797-0000 or your local public health unit.

Your medications and COVID-19

If you are on a disease-modifying therapy (DMT) for your multiple sclerosis, please do not stop your medication before speaking with the clinic.

MS itself does not increase the risk of getting COVID-19 however, certain factors associated with your MS may increase your risk of infection or complications:

Certain disease-modifying therapies
Other chronic health conditions
Age greater than 60

The following DMTs generally do not suppress the immune system and do not place you at risk of infections –including COVID-19. These include:

Copaxone (Glatiramer acetate)
Glatect
Interferons (Betaseron, Rebif, Avonex, Extavia, Plegridy)
Aubagio (Teriflunomide)
Tysabri (Natalizumab)

The following DMTs may slightly weaken your immune system and may place you at a low risk of infections, including COVID-19. These include:

Tecfidera (Dimethyl fumarate)
Gilenya (Fingolimod)

The following DMTs will weaken your immune system and may place you at a greater risk of infections, including COVID-19. These include:

Ocrevus (Ocrelizumab)
Mavenclad (Cladribine)
Lemtrada (alemtuzumab) *only those who recently received an infusion of Lemtrada)

Some physicians may have decided to postpone your Ocrevus (ocrelizumab) infusion or delay your Mavenclad (cladribine) therapy. We encourage you to stay in contact with your patient support program for ongoing updates. They will be contacting you under the direction of your neurologist.

We encourage you to follow all preventive measures recommended by public health: social distancing, washing hands often, avoiding touching your face and self-isolating for 14 days after travel.

For reliable, up-to-date information on COVID-19, check the following websites:

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Last updated February 06, 2023