1
|
Graham EL, Bove R, Costello K, Crayton H, Jacobs DA, Shah S, Sorrell F, Stoll SS, Houtchens MK. Practical Considerations for Managing Pregnancy in Patients With Multiple Sclerosis: Dispelling the Myths. Neurol Clin Pract 2024; 14:e200253. [PMID: 38585436 PMCID: PMC10996912 DOI: 10.1212/cpj.0000000000200253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 11/27/2023] [Indexed: 04/09/2024]
Abstract
Purpose of Review Lack of consistent data and guidance have led to variations between clinicians in the management of pregnancy in women with multiple sclerosis (MS). Pregnant and/or lactating women are often excluded from clinical trials conducted in MS, and thus, the labeling for most disease-modifying therapies (DMTs) excludes use during pregnancy. This has led to heterogeneity in interpretation and labeling regarding the safety of DMTs during pregnancy and lactation and the required preconception washout periods. This review identifies key themes where there is conflicting information surrounding family planning and pregnancy in MS, focusing on the most common discussion points between physicians and patients during preconception planning, pregnancy, postpartum, and lactation. The goal was to inform the patient-physician conversation and provide best practice recommendations based on expert clinical expertise and experience. Recent Findings We outline the latest evidence-based data for DMT use during pregnancy and lactation, the effect of MS on fertility and fertility treatments, the risk of adverse pregnancy and delivery outcomes, the risk of postpartum relapse, and immunization and clinical imaging safety during pregnancy and breastfeeding. Summary Management of family planning and pregnancy in patients with MS requires the most current information. Health care providers should discuss family planning early and frequently with patients with MS, and partners where practicable. Because management of pregnant people with MS will often require a risk/benefit analysis of their needs, shared decision-making in family planning discussions is emphasized. Additional data are needed for specific and underrepresented populations with MS (e.g., single parents or those from the LGBTQ+ community) and those at risk of racial and socioeconomic disparities in care. Pregnancy registries and the design and conduct of clinical trials focused on pregnant and lactating patients should provide additional data to guide the ongoing management of patients with MS.
Collapse
Affiliation(s)
- Edith L Graham
- Department of Neurology (ELG), Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Neurology (RB), UCSF Weill Institute for Neurosciences, University of California, San Francisco; Can Do Multiple Sclerosis (KC), Avon, CO; Multiple Sclerosis Center of Greater Washington (HC), Vienna, VA; Department of Neurology (DAJ), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Neurology (SS), Duke University School of Medicine, Durham, NC; Envision Pharma Group (FS), Glasgow, UK; Stoll Medical Group (SSS), Philadelphia, PA; and Brigham Multiple Sclerosis Center (MKH), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Riley Bove
- Department of Neurology (ELG), Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Neurology (RB), UCSF Weill Institute for Neurosciences, University of California, San Francisco; Can Do Multiple Sclerosis (KC), Avon, CO; Multiple Sclerosis Center of Greater Washington (HC), Vienna, VA; Department of Neurology (DAJ), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Neurology (SS), Duke University School of Medicine, Durham, NC; Envision Pharma Group (FS), Glasgow, UK; Stoll Medical Group (SSS), Philadelphia, PA; and Brigham Multiple Sclerosis Center (MKH), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Kathleen Costello
- Department of Neurology (ELG), Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Neurology (RB), UCSF Weill Institute for Neurosciences, University of California, San Francisco; Can Do Multiple Sclerosis (KC), Avon, CO; Multiple Sclerosis Center of Greater Washington (HC), Vienna, VA; Department of Neurology (DAJ), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Neurology (SS), Duke University School of Medicine, Durham, NC; Envision Pharma Group (FS), Glasgow, UK; Stoll Medical Group (SSS), Philadelphia, PA; and Brigham Multiple Sclerosis Center (MKH), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Heidi Crayton
- Department of Neurology (ELG), Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Neurology (RB), UCSF Weill Institute for Neurosciences, University of California, San Francisco; Can Do Multiple Sclerosis (KC), Avon, CO; Multiple Sclerosis Center of Greater Washington (HC), Vienna, VA; Department of Neurology (DAJ), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Neurology (SS), Duke University School of Medicine, Durham, NC; Envision Pharma Group (FS), Glasgow, UK; Stoll Medical Group (SSS), Philadelphia, PA; and Brigham Multiple Sclerosis Center (MKH), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Dina A Jacobs
- Department of Neurology (ELG), Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Neurology (RB), UCSF Weill Institute for Neurosciences, University of California, San Francisco; Can Do Multiple Sclerosis (KC), Avon, CO; Multiple Sclerosis Center of Greater Washington (HC), Vienna, VA; Department of Neurology (DAJ), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Neurology (SS), Duke University School of Medicine, Durham, NC; Envision Pharma Group (FS), Glasgow, UK; Stoll Medical Group (SSS), Philadelphia, PA; and Brigham Multiple Sclerosis Center (MKH), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Suma Shah
- Department of Neurology (ELG), Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Neurology (RB), UCSF Weill Institute for Neurosciences, University of California, San Francisco; Can Do Multiple Sclerosis (KC), Avon, CO; Multiple Sclerosis Center of Greater Washington (HC), Vienna, VA; Department of Neurology (DAJ), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Neurology (SS), Duke University School of Medicine, Durham, NC; Envision Pharma Group (FS), Glasgow, UK; Stoll Medical Group (SSS), Philadelphia, PA; and Brigham Multiple Sclerosis Center (MKH), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Francesca Sorrell
- Department of Neurology (ELG), Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Neurology (RB), UCSF Weill Institute for Neurosciences, University of California, San Francisco; Can Do Multiple Sclerosis (KC), Avon, CO; Multiple Sclerosis Center of Greater Washington (HC), Vienna, VA; Department of Neurology (DAJ), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Neurology (SS), Duke University School of Medicine, Durham, NC; Envision Pharma Group (FS), Glasgow, UK; Stoll Medical Group (SSS), Philadelphia, PA; and Brigham Multiple Sclerosis Center (MKH), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Sharon S Stoll
- Department of Neurology (ELG), Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Neurology (RB), UCSF Weill Institute for Neurosciences, University of California, San Francisco; Can Do Multiple Sclerosis (KC), Avon, CO; Multiple Sclerosis Center of Greater Washington (HC), Vienna, VA; Department of Neurology (DAJ), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Neurology (SS), Duke University School of Medicine, Durham, NC; Envision Pharma Group (FS), Glasgow, UK; Stoll Medical Group (SSS), Philadelphia, PA; and Brigham Multiple Sclerosis Center (MKH), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Maria K Houtchens
- Department of Neurology (ELG), Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Neurology (RB), UCSF Weill Institute for Neurosciences, University of California, San Francisco; Can Do Multiple Sclerosis (KC), Avon, CO; Multiple Sclerosis Center of Greater Washington (HC), Vienna, VA; Department of Neurology (DAJ), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Neurology (SS), Duke University School of Medicine, Durham, NC; Envision Pharma Group (FS), Glasgow, UK; Stoll Medical Group (SSS), Philadelphia, PA; and Brigham Multiple Sclerosis Center (MKH), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| |
Collapse
|
3
|
Lescot L, Lefort M, Leguy S, Le Page E, Vukusic S, Edan G, Kerbrat A, Lebrun-Frenay C, De Sèze J, Laplaud DA, Wiertlewski S, Leray E, Michel L. Disease modifying therapies and disease activity during pregnancy and postpartum in a contemporary cohort of relapsing Multiple Sclerosis patients. Mult Scler Relat Disord 2022; 68:104122. [PMID: 36037756 DOI: 10.1016/j.msard.2022.104122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 08/14/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND In Multiple Sclerosis (MS) women, therapeutic management for pregnancy planning and during pregnancy still represents a challenge regarding timing of disease-modifying therapies (DMT) stop, risk of disease reactivation and potential fetal toxicity. The objective of this study was to describe disease activity during pregnancy and postpartum depending on treatment status before conception in women with MS. METHODS 339 MS patients who have achieved a pregnancy between 2007 and 2017 were included. Women were classified according to their exposure to DMT in the 18 months period prior to pregnancy (untreated / first- / second/third-line treatment). RESULTS 122 women were not exposed to DMT prior to conception, whereas 147 were exposed to first-line DMT and 70 to second/third line DMT (73% to natalizumab and 23% to fingolimod) before conception. In the first-line group, the ARR decreased from 0.39 during the year before conception to 0.21 during pregnancy, whereas it increased in the second/third-line group from 0.59 to 0.78. 47.1% of the second/third-line group faced at least one relapse during pregnancy and the time from conception to first relapse was significantly shorter in this group (p < 10-4). The risk of relapse during pregnancy and postpartum was associated with occurrence of pre-conception relapses and second/third line DMT exposure before pregnancy. CONCLUSION Careful consideration should be given to natalizumab and fingolimod exposed patients before conception as they are at higher risk of reactivation of MS during pregnancy.
Collapse
Affiliation(s)
- Lucile Lescot
- Neurology Department, CRCSEP, Rennes Clinical Investigation Centre CIC-P 1414, Service de Neurologie, CHU Pontchaillou, Rennes University Hospital Rennes University INSERM, Rennes 35033, France
| | - Mathilde Lefort
- EHESP, CNRS, Inserm, Arènes - UMR 6051, RSMS (Recherche sur les Services et Management en Santé) - U 1309, University Rennes, Rennes F-35000, France
| | - Soizic Leguy
- Neurology Department, CRCSEP, Rennes Clinical Investigation Centre CIC-P 1414, Service de Neurologie, CHU Pontchaillou, Rennes University Hospital Rennes University INSERM, Rennes 35033, France
| | - Emmanuelle Le Page
- Neurology Department, CRCSEP, Rennes Clinical Investigation Centre CIC-P 1414, Service de Neurologie, CHU Pontchaillou, Rennes University Hospital Rennes University INSERM, Rennes 35033, France
| | - Sandra Vukusic
- Service de neurologie, Sclérose en plaques, Pathologies de la myéline et neuro-inflammation et centre de recherche, Ressources et compétences sur la sclérose en plaques, Hospices civils de Lyon, Bron 69677, France; Inserm 1028 et CNRS UMR 5292, Observatoire français de la sclérose en plaques, Centre de recherche en neurosciences de Lyon, Lyon 69003, France; Université de Lyon, Université Claude-Bernard Lyon 1, Lyon 69000, France; Eugène Devic EDMUS Foundation against multiple sclerosis, State-approved foundation, Bron 69677, France
| | - Gilles Edan
- Neurology Department, CRCSEP, Rennes Clinical Investigation Centre CIC-P 1414, Service de Neurologie, CHU Pontchaillou, Rennes University Hospital Rennes University INSERM, Rennes 35033, France
| | - Anne Kerbrat
- Neurology Department, CRCSEP, Rennes Clinical Investigation Centre CIC-P 1414, Service de Neurologie, CHU Pontchaillou, Rennes University Hospital Rennes University INSERM, Rennes 35033, France
| | | | - Jérome De Sèze
- Centre d'investigation clinique, INSERM U1434, Centre Hospitalier Universitaire de Strasbourg, 1 Place de l'Hôpital, Strasbourg 67000, France
| | - David Axel Laplaud
- Centre de Recherche en Transplantation et Immunologie UMR1064, INSERM, Université de Nantes, Nantes, France
| | - Sandrine Wiertlewski
- Centre de Recherche en Transplantation et Immunologie UMR1064, INSERM, Université de Nantes, Nantes, France
| | - Emmanuelle Leray
- EHESP, CNRS, Inserm, Arènes - UMR 6051, RSMS (Recherche sur les Services et Management en Santé) - U 1309, University Rennes, Rennes F-35000, France
| | - Laure Michel
- Neurology Department, CRCSEP, Rennes Clinical Investigation Centre CIC-P 1414, Service de Neurologie, CHU Pontchaillou, Rennes University Hospital Rennes University INSERM, Rennes 35033, France; Microenvironment, Cell Differentiation, Immunology and Cancer unit, INSERM, Rennes I University, French Blood Agency, Rennes, France.
| |
Collapse
|