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Hassoun HK, Hatem AO, Al-Mahdawi A, Jamal Al-Bajalan S, Kadim Karim A, Abdulrasool Al-Mashta S, Mohammed Tawfeeq S, Salih Hamad M, Sheaheed NM, Mohammed Ridha S, Al-Naqshbandi M, Al-Hamadani HA. Iraqi experts consensus on the management of relapsing remitting multiple sclerosis in adults. Curr Med Res Opin 2024:1-9. [PMID: 38600842 DOI: 10.1080/03007995.2024.2339938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 04/03/2024] [Indexed: 04/12/2024]
Abstract
OBJECTIVE In Iraq, a lack of evidence-based management protocols for diagnosing, treating, and managing multiple sclerosis (MS) poses risks of suboptimal outcomes and clinical practice variability and potential harm to the patients. This study aimed to develop consensus recommendations regarding the diagnosis and management of MS in Iraq, specifically focusing on treatment-naïve patients, suboptimal responders, and women of childbearing age during preconception, pregnancy planning, and lactation. A survey was conducted to collect feedback from a panel of ten key opinion leaders (KOLs), who evaluated and discussed the statements to determine agreement levels. The mini-Delphi method was employed to establish a consensus on the management recommendations, and a meeting was held to analyze the responses and ensure that the recommendations were based on current evidence and followed a consensus-driven approach. RESULTS The Revised McDonald Criteria is recommended for MS diagnosis, which includes evidence of dissemination of disease characteristics in space and time. Disease activity and progression can be monitored using relapses, MRI activity, and short-term disability progression. Experts suggest initiating treatment at diagnosis using higher efficacy medications, such as cladribine, ocrelizumab, natalizumab, or rituximab, for patients with high disease activity after careful risk stratification. Injectable interferon preparations have a tolerable risk profile but have drawbacks, such as the route and frequency of administration. Overall, disease-modifying therapies (DMTs) have shown efficacy in reducing relapse rates and short-term disability. CONCLUSION This article presents expert panel recommendations for managing MS in Iraq, taking into account international guidelines, medication updates, and local resources. However, practical questions remain regarding the real-world use of disease-modifying therapies (DMTs). Personalizing treatment based on disease severity, prognosis, and individual risk factors while adhering to guidelines is crucial. A collaborative approach between healthcare providers and patients, considering individual preferences, is vital for achieving treatment goals.
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Affiliation(s)
| | - Anmar Oday Hatem
- MS Clinic, Baghdad Teaching Hospital, Medical City Complex, Baghdad, Iraq
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2
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Witt L, Thiel S, Hellwig K. [Pregnancy and breastfeeding in women with multiple sclerosis]. DER NERVENARZT 2024; 95:329-334. [PMID: 38393359 DOI: 10.1007/s00115-024-01621-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/19/2024] [Indexed: 02/25/2024]
Abstract
The diagnosis of multiple sclerosis (MS) in women of reproductive age is associated with many uncertainties regarding childbearing and lactation. Pregnancies of MS patients are not usually considered high-risk pregnancies per se. The likelihood of pregnancy complications or adverse pregnancy outcomes is not increased by the disease; however, a careful planning of pregnancy is important in order to choose the treatment option with the greatest benefit for the mother and the least possible risk for the baby. For highly active courses of the disease, anti-CD20 antibodies, cladribine, or continued administration of natalizumab show the best data. Patients with MS can be supported in their desire to breastfeed. If women have had a very active disease course, it is recommended that treatment should be started as soon as possible postpartum. Interferon-beta preparations, glatiramer acetate and ofatumumab are also approved for use during breastfeeding but off-label breastfeeding is also possible with other monoclonal antibodies.
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Affiliation(s)
- Laura Witt
- Neurologische Klinik St. Josef Hospital, Ruhr-Universität Bochum, Gudrunstraße 56, 44791, Bochum, Deutschland
| | - Sandra Thiel
- Neurologische Klinik St. Josef Hospital, Ruhr-Universität Bochum, Gudrunstraße 56, 44791, Bochum, Deutschland
| | - Kerstin Hellwig
- Neurologische Klinik St. Josef Hospital, Ruhr-Universität Bochum, Gudrunstraße 56, 44791, Bochum, Deutschland.
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Kelly EE, Engel C, Pearsall R, Brenton JN, Bove R, Oh U, Goldman MD. Multiple Sclerosis and Family Planning: A Survey Study of the Patient Experience. Neurol Clin Pract 2024; 14:e200222. [PMID: 38148835 PMCID: PMC10751018 DOI: 10.1212/cpj.0000000000200222] [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: 06/27/2023] [Accepted: 11/04/2023] [Indexed: 12/28/2023]
Abstract
Background and Objectives Multiple sclerosis (MS) commonly affects women in their childbearing years, necessitating discussion between patients and their MS treatment team around the issues of family planning, pregnancy, and postpartum experiences. This study assessed the impact of a diagnosis of MS on women's reproductive decision-making and on their perception of counseling received surrounding pregnancy. It also sought to evaluate trends in pregnancy and postpartum experiences and determine whether experiences differed by race, ethnicity, and zip code. Methods Women with an MS diagnosis seen at the University of Virginia MS Clinic or at Virginia Commonwealth University (VCU) MS Clinic were invited to participate in a survey study. MS disease and pregnancy history, and, when appropriate, reasons for pregnancy avoidance were collected. Respondents who had >1 pregnancy following MS diagnosis were asked to evaluate the counseling they received from medical professionals and to share their pregnancy experiences including complications during pregnancy, delivery outcomes, and postpartum experience including breastfeeding. Results Of the 280 respondents, 76.6% were currently receiving MS specialty care. Most of them (79.3%) had not been pregnant following MS diagnosis. Of them, 20.1% indicated that this decision was driven by MS-related concerns: MS worsening with pregnancy (47%); ability to care for child secondary to MS (35%); passing MS onto child (19%); stopping disease-modifying therapies to attempt pregnancy (14%); lack of knowledge about options for pregnancy and MS (9%). Women with a more recent estimated decade of pregnancy were more likely to report neurologist counseling regarding MS and pregnancy (pregnancy before 2000: 40%, 2000-2010: 64.7%, 2010- present: 83.3%; χ2 0.020). Breastfeeding initiation was reported in 71.4% of postdiagnosis pregnancies (median duration 6 months, interquartile range 1.75-11). Discussion Over the past few decades, women with MS have received a wide range of evolving guidance surrounding family planning, pregnancy, and postpartum care. Survey data suggest improvements in MS/pregnancy counseling and medical management in recent years, which may be driven by an increase in research in the field. There remains an important need and opportunity to improve counseling of women with MS who are considering pregnancy.
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Affiliation(s)
- Erin E Kelly
- Virginia Commonwealth University School of Medicine (EEK), Richmond; Virginia Tech Carilion School of Medicine (CE), Roanoke; College of Arts and Sciences (RP); Division of Child Neurology (JNB), Department of Neurology, University of Virginia, Charlottesville; UCSF Weill Institute for Neurosciences (RB), University of California San Francisco; and Virginia Commonwealth University (UO, MDG)
| | - Casey Engel
- Virginia Commonwealth University School of Medicine (EEK), Richmond; Virginia Tech Carilion School of Medicine (CE), Roanoke; College of Arts and Sciences (RP); Division of Child Neurology (JNB), Department of Neurology, University of Virginia, Charlottesville; UCSF Weill Institute for Neurosciences (RB), University of California San Francisco; and Virginia Commonwealth University (UO, MDG)
| | - Rylan Pearsall
- Virginia Commonwealth University School of Medicine (EEK), Richmond; Virginia Tech Carilion School of Medicine (CE), Roanoke; College of Arts and Sciences (RP); Division of Child Neurology (JNB), Department of Neurology, University of Virginia, Charlottesville; UCSF Weill Institute for Neurosciences (RB), University of California San Francisco; and Virginia Commonwealth University (UO, MDG)
| | - J Nicholas Brenton
- Virginia Commonwealth University School of Medicine (EEK), Richmond; Virginia Tech Carilion School of Medicine (CE), Roanoke; College of Arts and Sciences (RP); Division of Child Neurology (JNB), Department of Neurology, University of Virginia, Charlottesville; UCSF Weill Institute for Neurosciences (RB), University of California San Francisco; and Virginia Commonwealth University (UO, MDG)
| | - Riley Bove
- Virginia Commonwealth University School of Medicine (EEK), Richmond; Virginia Tech Carilion School of Medicine (CE), Roanoke; College of Arts and Sciences (RP); Division of Child Neurology (JNB), Department of Neurology, University of Virginia, Charlottesville; UCSF Weill Institute for Neurosciences (RB), University of California San Francisco; and Virginia Commonwealth University (UO, MDG)
| | - Unsong Oh
- Virginia Commonwealth University School of Medicine (EEK), Richmond; Virginia Tech Carilion School of Medicine (CE), Roanoke; College of Arts and Sciences (RP); Division of Child Neurology (JNB), Department of Neurology, University of Virginia, Charlottesville; UCSF Weill Institute for Neurosciences (RB), University of California San Francisco; and Virginia Commonwealth University (UO, MDG)
| | - Myla D Goldman
- Virginia Commonwealth University School of Medicine (EEK), Richmond; Virginia Tech Carilion School of Medicine (CE), Roanoke; College of Arts and Sciences (RP); Division of Child Neurology (JNB), Department of Neurology, University of Virginia, Charlottesville; UCSF Weill Institute for Neurosciences (RB), University of California San Francisco; and Virginia Commonwealth University (UO, MDG)
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4
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Klehmet J, Begus-Nahrmann Y, Taipale K, Niemczyk G, Rehberg-Weber K. Pregnancy outcomes in female multiple sclerosis patients exposed to intramuscular interferon beta-1a or peginterferon beta-1a reported in a German Patient Support Programme - results from the non-interventional post-authorization safety study PRIMA. Ther Adv Neurol Disord 2023; 16:17562864231214041. [PMID: 38107443 PMCID: PMC10725088 DOI: 10.1177/17562864231214041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 10/27/2023] [Indexed: 12/19/2023] Open
Abstract
Background Based on data from two large cohort studies, a label update became applicable for the class of interferon beta therapies in 9/2019, allowing interferons during pregnancy and breastfeeding. Objective To assess pregnancy outcomes of women with multiple sclerosis (MS) exposed to peginterferon beta-1a or intramuscular interferon beta-1a therapy (IFN). Design Non-interventional post-authorization safety study. Methods PRIMA was conducted from April to October 2021 in Germany. Retrospective pregnancy data were retrieved from adult female patients diagnosed with relapsing-remitting MS or clinically isolated syndrome, exposed to IFN before or during pregnancy and registered in the patient support programme (PSP) of the marketing authorization holder's MS Service Centre. The primary endpoint was the outcome of pregnancy. Prospective postpartum data were collected from mothers reporting live births. Results In total, 426 women reporting 542 pregnancies between December 2001 and July 2020 (14 pregnancies after the label update) were enrolled. Among patients with confirmed exposure during pregnancy (N = 362), 306 pregnancies (84.5%) resulted in live births (77.6% without defects, 1.9% with defects and 4.4% preterm). Spontaneous abortion, elective termination and stillbirth were reported in 10.9%, 2.8% and 0.2% of the cases, respectively. Higher rates of spontaneous abortions were reported in women with continuous IFN use. A total of 162 women completed the questionnaire for 192 live births within the prospective study part. Mothers restarted IFN therapy or switched to another disease-modifying therapy postpartum in 51.0% and 14.1% of cases, respectively. 158/192 infants (82.3%) were breastfed [34/158 (21.5%)] during IFN therapy. Postpartum relapse activity was low (mothers of 87.3% of breastfed infants remained relapse-free during lactation). Conclusion Overall, the prevalence of spontaneous abortions and congenital anomalies of females exposed to IFN exposure before or during pregnancy was within the range reported for the general population. Most mothers paused IFN during pregnancy and breastfeeding. Relapse activity during pregnancy and lactation was observed to be low. These real-world data from a PSP corroborate European and Scandinavian registry data. Trial registration NCT04655222, EUPAS38347.
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Affiliation(s)
- Juliane Klehmet
- Jüdisches Krankenhaus Berlin, Heinz-Galinski-Straße 1, Berlin 13347, Germany
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5
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Klehmet J, Begus-Nahrmann Y, Taipale K, Niemczyk G, Rehberg-Weber K. Impact of interferon beta exposure on birth outcome and child development - Results from the post-authorisation safety study PRIMA. Mult Scler Relat Disord 2023; 77:104844. [PMID: 37393802 DOI: 10.1016/j.msard.2023.104844] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 05/26/2023] [Accepted: 06/19/2023] [Indexed: 07/04/2023]
Abstract
BACKGROUND Interferon beta therapies are well-established disease-modifying treatments for patients with relapsing multiple sclerosis (MS). Based on clinical evidence from two large cohort studies, both, the EMA and FDA updated the labels of the interferon beta class in terms of pregnancy and breastfeeding in 2019 and 2020, respectively. To complement pregnancy label updates with patient-reported real-world data, this study examined German pregnancy and outcome reports including available data on child development from women with MS treated with peginterferon beta-1a or intramuscular (IM) interferon beta-1a. METHODS The post-authorisation safety study PRIMA included adult women diagnosed with relapsing-remitting MS or clinically isolated syndrome, who were treated with peginterferon beta-1a or IM interferon beta-1a before or during pregnancy and registered in the marketing authorisation holder's MS Service center patient support program. In the prospective part of the study, conducted from April to October 2021, data on developmental milestones of the newborns were collected via telephone interview from mothers reporting live births. RESULTS In total, 426 women were enrolled, reporting 542 pregnancies that resulted in 466 live births. A total of 162 women completed the questionnaire for 192 live births (53.1% male). Newborns had Apgar scores indicative of healthy infants. Weight, length and head circumference at birth and physical growth curves up to 48 months lay within the expected range of the German general population. Most newborn screenings and examinations during check-ups were inconspicuous over the study period of 48 months. Out of 158 breastfed infants, 112 (70.9%) were breastfed exclusively until month 5. CONCLUSION Study results confirmed former reports indicating that exposure to interferon beta therapies during pregnancy or lactation had no adverse effects on intrauterine growth and child development over the study period, which covered the first 4 years of life. These real-world data obtained within the scope of a patient support program for peginterferon beta-1a or IM interferon beta-1a corroborate German and Scandinavian registry data and support the label update of all interferon beta therapies. REGISTRATION NCT04655222, EUPAS38347.
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Affiliation(s)
- Juliane Klehmet
- Department of Neurology, Jüdisches Krankenhaus Berlin, Heinz-Galinski-Strasse 1, Berlin-Mitte 13347, Federal Republic of Germany.
| | | | - Kirsi Taipale
- Biogen GmbH, Riedenburger Straße 7, München 81677, Federal Republic of Germany
| | - Gabriele Niemczyk
- Biogen GmbH, Riedenburger Straße 7, München 81677, Federal Republic of Germany
| | - Karin Rehberg-Weber
- Biogen GmbH, Riedenburger Straße 7, München 81677, Federal Republic of Germany
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6
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Ciplea AI, Kurzeja A, Thiel S, Haben S, Adamus E, Hellwig K. Safety evaluations of offspring breastfed by mothers receiving glatiramer acetate for relapsing multiple sclerosis. Mult Scler Relat Disord 2023; 75:104771. [PMID: 37245349 DOI: 10.1016/j.msard.2023.104771] [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: 02/22/2023] [Revised: 05/05/2023] [Accepted: 05/21/2023] [Indexed: 05/30/2023]
Abstract
BACKGROUND Although the relapse risk is increased after birth in women with relapsing multiple sclerosis (RMS), only a very few disease-modifying therapies (DMTs) are approved during breastfeeding. Glatiramer acetate (GA, Copaxone®) is one of three DMTs that can be used in breastfeeding. The real-world safety of Copaxone® in Offsprings of Breastfeeding and treated RMS pAtients (COBRA) study demonstrated that offspring parameters (hospitalisations, antibiotic use, developmental delays, growth parameters) were similar between offspring breastfed by mothers taking GA or no DMT (control) during breastfeeding. COBRA data analyses were extended to provide further safety data on the impact of maternal GA treatment during breastfeeding on offspring. METHODS COBRA was a non-interventional, retrospective study using German Multiple Sclerosis and Pregnancy Registry data. Participants had RMS, gave birth and had GA or no DMT during breastfeeding. Offspring total adverse events (AEs), non-serious AEs (NAEs) and serious AEs (SAEs) up to 18 months postpartum were assessed. Reasons for offspring hospitalisations and antibiotic treatments were explored. RESULTS Baseline maternal demographics and disease characteristics were similar between cohorts. Each cohort had 60 offspring. Numbers of offspring AEs were comparable between cohorts; total AEs: 82 (GA) vs 83 (control); NAEs: 59 vs 61; SAEs: 23 vs 22. AEs in both cohorts were diverse with no specific patterns. Duration of GA-exposed breastfeeding was 6 to >574 days for offspring with any AE. For all-cause hospitalisations, 11 offspring had 12 hospitalisations (GA cohort) and 12 control offspring had 16 hospitalisations. Most common reason for hospitalisation was infection: 5/12 (41.7%; GA) vs 4/16 (25.0%, control). Two out of 12 (16.7%) hospitalisations due to infection occurred during GA-exposed breastfeeding; the others occurred 70, 192 and 257 days after discontinuation of GA-exposed breastfeeding. Median (range) duration of GA-exposed breastfeeding was 110 (56 to ≥285) days for offspring hospitalised for infections and 137 (88-396) days for those hospitalised for other reasons. Nine offspring had 13 antibiotic treatments (GA cohort) and nine control offspring had 10 treatments. Ten out of 13 (76.9%) antibiotic treatments occurred during GA-exposed breastfeeding, of which four were primarily due to double kidney with reflux. Other antibiotic treatments occurred 193, 229 and 257 days after discontinuation of GA-exposed breastfeeding. CONCLUSIONS GA treatment of mothers with RMS during breastfeeding did not increase AEs, hospitalisations or antibiotic use in their offspring versus control offspring. These data support previous COBRA data that the benefit of maternal RMS treatment with GA during breastfeeding outweighs the potential, apparently low risk of untoward events, in their breastfed offspring.
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Affiliation(s)
- Andrea I Ciplea
- Department of Neurology, St Josef Hospital, Katholisches Klinikum Bochum gGmbH, Ruhr University Bochum, Bochum, Germany
| | - Anna Kurzeja
- European Medical Affairs, Teva Pharmaceuticals Europe B.V., Amsterdam, the Netherlands
| | - Sandra Thiel
- Department of Neurology, St Josef Hospital, Katholisches Klinikum Bochum gGmbH, Ruhr University Bochum, Bochum, Germany
| | - Sabrina Haben
- Department of Neurology, St Josef Hospital, Katholisches Klinikum Bochum gGmbH, Ruhr University Bochum, Bochum, Germany
| | - Evelyn Adamus
- Department of Neurology, St Josef Hospital, Katholisches Klinikum Bochum gGmbH, Ruhr University Bochum, Bochum, Germany
| | - Kerstin Hellwig
- Department of Neurology, St Josef Hospital, Katholisches Klinikum Bochum gGmbH, Ruhr University Bochum, Bochum, Germany.
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7
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Krysko KM, Dobson R, Alroughani R, Amato MP, Bove R, Ciplea AI, Fragoso Y, Houtchens M, Jokubaitis VG, Magyari M, Abdelnasser A, Padma V, Thiel S, Tintore M, Vukusic S, Hellwig K. Family planning considerations in people with multiple sclerosis. Lancet Neurol 2023; 22:350-366. [PMID: 36931808 DOI: 10.1016/s1474-4422(22)00426-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 09/16/2022] [Accepted: 10/07/2022] [Indexed: 03/17/2023]
Abstract
Multiple sclerosis is often diagnosed in patients who are planning on having children. Although multiple sclerosis does not negatively influence most pregnancy outcomes, less is known regarding the effects of fetal exposure to novel disease-modifying therapies (DMTs). The withdrawal of some DMTs during pregnancy can modify the natural history of multiple sclerosis, resulting in a substantial risk of pregnancy-related relapse and disability. Drug labels are typically restrictive and favour fetal safety over maternal safety. Emerging data reporting outcomes in neonates exposed to DMTs in utero and through breastfeeding will allow for more careful and individualised treatment decisions. This emerging research is particularly important to guide decision making in women with high disease activity or who are treated with DMTs associated with risk of discontinuation rebound. As increasing data are generated in this field, periodic updates will be required to provide the most up to date guidance on how best to achieve multiple sclerosis stability during pregnancy and post partum, balanced with fetal and newborn safety.
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Affiliation(s)
- Kristen M Krysko
- Division of Neurology, Department of Medicine, St Michael's Hospital, University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, Toronto, ON, Canada
| | - Ruth Dobson
- Preventive Neurology Unit, Wolfson Institute of Population Health, Queen Mary University London, London, UK; Department of Neurology, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Raed Alroughani
- Department of Medicine, Division of Neurology, Amiri Hospital, Sharq, Kuwait
| | - Maria Pia Amato
- Department NEUROFARBA, Section of Neurosciences, University of Florence, Florence, Italy; IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy
| | - Riley Bove
- UCSF Weill Institute for Neuroscience, Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - Andrea I Ciplea
- Department of Neurology, Katholisches Klinikum, Ruhr University Bochum, Bochum, Germany
| | - Yara Fragoso
- Multiple Sclerosis and Headache Research Institute, Santos, Brazil; Departamento de Neurologia, Universidade Metropolitana de Santos, Santos, Brazil
| | - Maria Houtchens
- Department of Neurology, Partners MS Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Vilija G Jokubaitis
- Department of Neuroscience, Monash University, Melbourne, VIC, Australia; Department of Neurology, Alfred Health, Melbourne, VIC, Australia
| | - Melinda Magyari
- Danish Multiple Sclerosis Center, Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Azza Abdelnasser
- Department of Neurology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Vasantha Padma
- Department of Neurology, Neurosciences Center, AIIMS, New Delhi, India
| | - Sandra Thiel
- Department of Neurology, Katholisches Klinikum, Ruhr University Bochum, Bochum, Germany
| | - Mar Tintore
- Department of Neurology-Neuroimmunology, Multiple Sclerosis Centre of Catalonia, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Sandra Vukusic
- Hospices Civils de Lyon, Hôpital Neurologique Pierre Wertheimer, Service de Neurologie, sclérose en plaques, pathologies de la myéline et neuro-inflammation, Bron, France; Centre de Recherche en Neurosciences de Lyon, Observatoire Français de la Sclérose en Plaques, INSERM 1028 et CNRS UMR 5292, Lyon, France; Université Claude Bernard Lyon 1, Université de Lyon, Lyon, France; Eugène Devic EDMUS Foundation against multiple sclerosis, state-approved foundation, Bron, France
| | - Kerstin Hellwig
- Department of Neurology, Katholisches Klinikum, Ruhr University Bochum, Bochum, Germany.
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8
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Hassoun HK, Almahdawi A, Al-Bajalan SJ, Sheaheed NM, Kamil MA, Saeed Ridha SM, Al-Owath MM, Abd MF, Al-Khammasi B, Hasan ZN, Hatem AO, Al-Naqshbandi M, Rieckmann P. Expert opinion on the pharmacological management of multiple sclerosis in women of childbearing age in Iraq. Heliyon 2023; 9:e13350. [PMID: 36816245 PMCID: PMC9932647 DOI: 10.1016/j.heliyon.2023.e13350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 01/02/2023] [Accepted: 01/26/2023] [Indexed: 02/01/2023] Open
Abstract
Background Multiple sclerosis (MS) is often diagnosed in women of childbearing age (WCBA), with a mean age of onset of 30 years. Women with MS have long been cautioned to carefully plan their pregnancies and, traditionally, disease-modifying therapies (DMTs) have not been recommended for use in patients engaged in family planning. In 2020, the United States Food and Drug Administration (FDA) approved a label update for interferon beta (IFN ß) by adding new safety data on pregnancy and breastfeeding. Because current management guidelines do not yet reflect the recent label update, a panel of neurology experts from Iraq decided to discuss the potential need for changes in treatment strategies in Iraq. Methods A panel of experts consisting of 8 neurologists from Iraq and one international neurology expert from Germany convened to develop an expert opinion that would provide practical guidance for the pharmacological management of WCBA with MS in Iraq. They considered the latest label update and relevant published literature, along with local clinical practice and available resources. Results Interferon and Glatiramer acetate have no evidence of harm during pregnancy. IFN β can be continued safely through pregnancy. Switching treatment during pregnancy is generally not recommended. Short-term intravenous methylprednisolone can be used to treat disabling relapses. Conclusion Given the complexity of managing MS in pregnant women, it is the opinion of the expert panel that family planning should be discussed early in the disease course, planned pregnancy should be encouraged, and open communication with patient for her treatment decisions is paramount. Patients who are engaged in family planning are no longer discouraged from treatment with some of the currently available DMTs.
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Affiliation(s)
- Hayder K. Hassoun
- Kufa University, Kufa College of Medicine, Al-Najaf, Iraq
- Corresponding author.
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9
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Vukusic S, Carra-Dalliere C, Ciron J, Maillart E, Michel L, Leray E, Guennoc AM, Bourre B, Laplaud D, Androdias G, Bensa C, Bigaut K, Biotti D, Branger P, Casez O, Cohen M, Daval E, Deschamps R, Donze C, Dubessy AL, Dulau C, Durand-Dubief F, Guillaume M, Hebant B, Kremer L, Kwiatkowski A, Lannoy J, Maarouf A, Manchon E, Mathey G, Moisset X, Montcuquet A, Pique J, Roux T, Marignier R, Lebrun-Frenay C. Pregnancy and multiple sclerosis: 2022 recommendations from the French multiple sclerosis society. Mult Scler 2023; 29:11-36. [PMID: 36317497 DOI: 10.1177/13524585221129472] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE The objective of this study was to develop evidence-based recommendations on pregnancy management for persons with multiple sclerosis (MS). BACKGROUND MS typically affects young women in their childbearing years. Increasing evidence is available to inform questions raised by MS patients and health professionals about pregnancy issues. METHODS The French Group for Recommendations in Multiple Sclerosis (France4MS) reviewed PubMed and university databases (January 1975 through June 2021). The RAND/UCLA appropriateness method was developed to synthesise the scientific literature and expert opinions on healthcare topics; it was used to reach a formal agreement. Fifty-six MS experts worked on the full-text review and initial wording of recommendations. A group of 62 multidisciplinary healthcare specialists validated the final proposal of summarised evidence. RESULTS A strong agreement was reached for all 104 proposed recommendations. They cover diverse topics, such as pregnancy planning, follow-up during pregnancy and postpartum, delivery routes, locoregional analgesia or anaesthesia, prevention of postpartum relapses, breastfeeding, vaccinations, reproductive assistance, management of relapses and disease-modifying treatments. CONCLUSION The 2022 recommendations of the French MS society should be helpful to harmonise counselling and treatment practice for pregnancy in persons with MS, allowing for better and individualised choices.
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Affiliation(s)
- Sandra Vukusic
- Sclérose en Plaques, Pathologies de la Myéline et Neuro-Inflammation, Service de Neurologie, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Bron, France/INSERM 1028 et CNRS UMR 5292, Observatoire Français de la Sclérose en Plaques, Centre de Recherche en Neurosciences de Lyon, Bron, France/Université Claude Bernard Lyon 1, Université de Lyon, Lyon, France/Eugène Devic EDMUS Foundation against Multiple Sclerosis, State-approved Foundation, Bron, France
| | | | - Jonathan Ciron
- Centre Ressources et Compétences sclérose en plaques (CRC-SEP) et Service de Neurologie B4, Hôpital Pierre-Paul Riquet, CHU Toulouse Purpan, Toulouse, France INSERM UMR1291 - CNRS UMR5051, Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity), Université Toulouse 3, Toulouse, France
| | - Elisabeth Maillart
- Neurology Department, Pitié-Salpêtrière Hospital, CRC-SEP, Paris, France
| | - Laure Michel
- Neurology Department, CIC_P1414 INSERM, Rennes University Hospital, Rennes, France
| | - Emmanuelle Leray
- EHESP, CNRS, Inserm, Arènes - UMR 6051, RSMS (Recherche sur les Services et Management en Santé) - U 1309, Université de Rennes, Rennes, France
| | | | | | - David Laplaud
- Center for Research in Transplantation and Translational Immunology, UMR 1064, Nantes Université and INSERM, Nantes, France/CIC INSERM 1413, CRC-SEP Pays de la Loire, CHU Nantes, Nantes, France
| | - Géraldine Androdias
- Sclérose en Plaques, Pathologies de la Myéline et Neuro-Inflammation, Service de Neurologie, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Bron, France/Clinique de la Sauvegarde, Ramsay Santé, Lyon, France
| | - Caroline Bensa
- CRC-SEP, Neurology Department, Hôpital Fondation Adolphe de Rothschild, Paris, France
| | - Kevin Bigaut
- CRC-SEP, Service de Neurologie, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Damien Biotti
- Centre Ressources et Compétences sclérose en plaques (CRC-SEP) et Service de Neurologie B4, Hôpital Pierre-Paul Riquet, CHU Toulouse Purpan, Toulouse, France INSERM UMR1291 - CNRS UMR5051, Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity), Université Toulouse 3, Toulouse, France
| | - Pierre Branger
- Service de Neurologie, CHU de Caen Normandie, Caen, France
| | - Olivier Casez
- Pathologies Inflammatoires du Système Nerveux, Neurologie, CHU Grenoble Alpes, Grenoble, France/Translational Research in Autoimmunity and Inflammation Group (T-RAIG), TIMC-IMAG, Université de Grenoble Alpes, Grenoble, France
| | - Mikael Cohen
- CRCSEP Côte d'Azur, CHU de Nice Pasteur 2, Nice, France/Université Nice Côte d'Azur UR2CA-URRIS, Nice, France
| | - Elodie Daval
- Service de Neurologie, CHU de Besançon, Besançon, France
| | - Romain Deschamps
- CRC-SEP, Neurology Department, Hôpital Fondation Adolphe de Rothschild, Paris, France
| | - Cécile Donze
- Hôpital saint Philibert, Groupement des Hôpitaux de l'Institut Catholique de Lille, Faculté de médecine et de maïeutique de Lille, Lomme, France
| | - Anne-Laure Dubessy
- Department of Neurology, Saint-Antoine Hospital, APHP-6, Paris, France/Sorbonne University, Paris, France
| | - Cécile Dulau
- CRC-SEP, Hôpital Pellegrin, CHU de Bordeaux, Bordeaux, France
| | - Françoise Durand-Dubief
- Sclérose en Plaques, Pathologies de la Myéline et Neuro-Inflammation, Service de Neurologie, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Bron, France
| | | | | | - Laurent Kremer
- CRC-SEP, Service de Neurologie, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Arnaud Kwiatkowski
- Department of Neurology, Lille Catholic Hospitals, Lille Catholic University, Lille, France
| | - Julien Lannoy
- Service de Neurologie, Centre Hospitalier de Lens, Lens, France
| | - Adil Maarouf
- CRMBM, UMR 7339, CNRS, Aix-Marseille Université, Marseille, France/APHM Hôpital de la Timone, Marseille, France
| | - Eric Manchon
- Department of Neurology, Gonesse Hospital, Gonesse, France
| | - Guillaume Mathey
- Service de neurologie, Centre Hospitalier Régional Universitaire de Nancy - Hôpital Central, Nancy, France
| | - Xavier Moisset
- Neuro-Dol, Inserm, Université Clermont Auvergne, Clermont-Ferrand, France/Department of neurology et CRC-SEP, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | | | - Julie Pique
- Sclérose en Plaques, Pathologies de la Myéline et Neuro-Inflammation, Service de Neurologie, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Bron, France/INSERM 1028 et CNRS UMR 5292, Centre de Recherche en Neurosciences de Lyon, Bron, France/Université Claude Bernard Lyon 1, Lyon, France
| | - Thomas Roux
- Neurology Department, Pitié-Salpêtrière Hospital, CRC-SEP, Paris, France
| | - Romain Marignier
- Sclérose en Plaques, Pathologies de la Myéline et Neuro-Inflammation, Service de Neurologie, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Bron, France/INSERM 1028 et CNRS UMR 5292, Centre de Recherche en Neurosciences de Lyon, Lyon, France/Université Claude Bernard Lyon 1, Université de Lyon, Lyon, France
| | - Christine Lebrun-Frenay
- Service de Neurologie, CHU de Besançon, Besançon, France/Université Nice Côte d'Azur UR2CA-URRIS, Nice, France
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10
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Trofin F, Dorneanu OS, Constantinescu D, Nastase EV, Luncă C, Iancu LS, Andrioaie IM, Duhaniuc A, Cianga CM, Pavel-Tanasa M, Anton-Păduraru DT, Cianga P. Cytokines and Chemokines in Breastmilk of SARS-CoV-2 Infected or COVID-19 Vaccinated Mothers. Vaccines (Basel) 2022; 10:2001. [PMID: 36560410 PMCID: PMC9784508 DOI: 10.3390/vaccines10122001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 11/20/2022] [Accepted: 11/22/2022] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION The COVID-19 disease and anti-SARS-CoV-2 vaccination were accompanied by alterations in several inflammatory markers. The aim of our research was to check to what extent such cytokines are transferred to infants via the breastmilk of SARS-CoV-2-infected or vaccinated mothers. Thus, we wanted to check if breastfeeding is safe during SARS-CoV-2 infection or after COVID-19 mRNA-vaccination. MATERIAL AND METHOD The Luminex Multiplexing Assay was used for quantifying 10 cytokine in the human breastmilk of SARS-CoV-2-infected or COVID-19-vaccinated mothers, compared with anti-SARS-CoV-2 IgG naïve mothers. Two milk samples were collected at 30 and 60 days either after the booster dose or afterthe onset of symptoms. A single milk sample was collected from the mothers within the control group. RESULTS The cytokine concentrations were mostly found within the reference intervals for all mothers. The status of the vaccinated/infected mother, the age of the breastfed child, the parity of the mother and the maternal age were variation factors of the above-mentioned cytokine concentrations. The type of birth and the presence of IgG in the milk had no influence on these cytokine concentrations in milk. Furthermore, no statistically significant differences were recorded between the cytokine concentrations of the two milk samples. CONCLUSION Our study provides data that support the safety of breastfeeding in the case of mild COVID-19 infection or after Pfizer or Moderna vaccinations.
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Affiliation(s)
- Felicia Trofin
- Microbiology Department, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania
- Clinical Hospital of Infectious Diseases “Sf. Parascheva”, 700116 Iasi, Romania
| | - Olivia Simona Dorneanu
- Microbiology Department, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania
- Clinical Hospital of Infectious Diseases “Sf. Parascheva”, 700116 Iasi, Romania
| | - Daniela Constantinescu
- Immunology Department, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania
- Immunology Laboratory, “Sf. Spiridon” Clinical Hospital, 700111 Iasi, Romania
| | - Eduard Vasile Nastase
- Clinical Hospital of Infectious Diseases “Sf. Parascheva”, 700116 Iasi, Romania
- Infectious Diseases Department, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania
| | - Cătălina Luncă
- Microbiology Department, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania
- ”Sf. Maria” Children Emergency Hospital, 700309 Iasi, Romania
| | - Luminița Smaranda Iancu
- Microbiology Department, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania
- National Institute of Public Health, Iasi Regional Center for Public Health, 700465 Iasi, Romania
| | - Ioana-Maria Andrioaie
- Microbiology Department, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania
- Clinical Hospital of Infectious Diseases “Sf. Parascheva”, 700116 Iasi, Romania
| | - Alexandru Duhaniuc
- Microbiology Department, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania
- Clinical Hospital of Infectious Diseases “Sf. Parascheva”, 700116 Iasi, Romania
| | - Corina Maria Cianga
- Immunology Department, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania
- Immunology Laboratory, “Sf. Spiridon” Clinical Hospital, 700111 Iasi, Romania
| | - Mariana Pavel-Tanasa
- Immunology Department, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania
- Immunology Laboratory, “Sf. Spiridon” Clinical Hospital, 700111 Iasi, Romania
| | - Dana-Teodora Anton-Păduraru
- ”Sf. Maria” Children Emergency Hospital, 700309 Iasi, Romania
- Mother and Child Medicine Department, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania
| | - Petru Cianga
- Immunology Department, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania
- Immunology Laboratory, “Sf. Spiridon” Clinical Hospital, 700111 Iasi, Romania
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11
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Capone F, Albanese A, Quadri G, Di Lazzaro V, Falato E, Cortese A, De Giglio L, Ferraro E. Disease-Modifying Drugs and Breastfeeding in Multiple Sclerosis: A Narrative Literature Review. Front Neurol 2022; 13:851413. [PMID: 35493841 PMCID: PMC9051389 DOI: 10.3389/fneur.2022.851413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 02/15/2022] [Indexed: 11/16/2022] Open
Abstract
Pregnancy-related issues in women with multiple sclerosis (MS) have been receiving increasing attention, with particular interest for the use of disease-modifying therapies (DMTs) before conception, during pregnancy, and postpartum, including breastfeeding. The risk of relapse is higher in the early postpartum period, especially in cases of significant disease activity prior to pregnancy, and thus treatment resumption and/or switching strategies might be necessary. Moreover, breastfeeding provides unmatched health benefits for babies and mothers, and is recommended as the best source of nutrition for infants. Furthermore, a protective role of breastfeeding on MS disease course has not been fully demonstrated and it remains debatable. At the same time, a source of concern is the potential transfer of DMTs into breastmilk and the resulting infant exposure. The use of most DMTs is unlicensed during breastfeeding mainly due to the limited data available on the excretion in human milk and on the effects on infants' exposure. Consequently, women have to face the difficult challenge of choosing between breastfeeding and DMT resumption. The present narrative review summarizes and discusses the available evidence on the safety of DMTs during breastfeeding and the relative approved labels. At the time of diagnosis of MS, specific counseling should be offered to women of childbearing age, making them aware of the possible therapeutic options and their impact on pregnancy and breastfeeding. Women can be encouraged to breastfeed, if clinically feasible, following a review of their medications and clinical status, with a personalized approach.
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Affiliation(s)
- Fioravante Capone
- Neurology, Neurophysiology and Neurobiology Unit, Department of Medicine, Università Campus Bio-Medico, Rome, Italy
- *Correspondence: Fioravante Capone
| | - Angela Albanese
- Merck Serono S.p.A., An Affiliate of Merck KGaA, Rome, Italy
| | - Giorgia Quadri
- Merck Serono S.p.A., An Affiliate of Merck KGaA, Rome, Italy
| | - Vincenzo Di Lazzaro
- Neurology, Neurophysiology and Neurobiology Unit, Department of Medicine, Università Campus Bio-Medico, Rome, Italy
| | - Emma Falato
- Neurology, Neurophysiology and Neurobiology Unit, Department of Medicine, Università Campus Bio-Medico, Rome, Italy
| | - Antonio Cortese
- Multiple Sclerosis Centre, S. Filippo Neri Hospital, Rome, Italy
| | - Laura De Giglio
- Multiple Sclerosis Centre, S. Filippo Neri Hospital, Rome, Italy
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12
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Houtchens M, Mahlanza T, Ciplea AI, Manieri MC, Ramia NF, Zhao Y, England S, Avila R, Altincatal A, Vignos M, Hellwig K. Peginterferon beta-1a concentrations in breast milk of lactating multiple sclerosis patients. Mult Scler Relat Disord 2022; 60:103700. [DOI: 10.1016/j.msard.2022.103700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 02/08/2022] [Accepted: 02/19/2022] [Indexed: 10/19/2022]
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13
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Villaverde-González R. Updated Perspectives on the Challenges of Managing Multiple Sclerosis During Pregnancy. Degener Neurol Neuromuscul Dis 2022; 12:1-21. [PMID: 35023987 PMCID: PMC8743861 DOI: 10.2147/dnnd.s203406] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 12/20/2021] [Indexed: 11/23/2022] Open
Abstract
Multiple sclerosis (MS) is a chronic immune-mediated, inflammatory, and degenerative disease that is up to three times more frequent in young women. MS does not alter fertility and has no impact on fetal development, the course of pregnancy, or childbirth. The Pregnancy in Multiple Sclerosis Study in 1998 showed that pregnancy, mostly in untreated women, did not adversely affect MS, as disease activity decreased during pregnancy (although it significantly increased in the first trimester postpartum). These findings, together with the limited information available on the potential risks of fetal exposure to disease modifying treatments (DMTs), meant that women were advised to delay the onset of DMTs, stop them prior to conception, or, in case of unplanned pregnancy, discontinue them when pregnancy was confirmed. Now, many women with MS receive DMTs before pregnancy and, despite being considered a period of MS stability, up to 30% of patients could relapse in the first trimester postpartum. Factors associated with an increased risk of relapse and disability during pregnancy and postpartum include relapses before and during pregnancy, a greater disability at the time of conception, the occurrence of relapses after DMT cessation before conception, and the use of high-efficacy DMTs before conception, especially natalizumab or fingolimod. Strategies to prevent postpartum activity are needed in some patients, but consensus is lacking regarding the therapeutic strategies for women with MS of a fertile age. This, along with the increasing number of DMTs, means that the decision-making processes in aspects related to family planning and therapeutic strategies before, during, and after pregnancy are increasingly more complex. The purpose of this review is to provide an update on pregnancy-related issues in women with MS, including recommendations for counseling, general management, use of DMTs in pre-pregnancy, pregnancy, and postpartum periods, and breastfeeding-related aspects of DMTs.
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Abstract
PURPOSE OF REVIEW To provide the latest evidence and treatment advances of multiple sclerosis in women of childbearing age prior to conception, during pregnancy and postpartum. RECENT FINDINGS Recent changes permitting interferon beta (IFN-β) use in pregnancy and breastfeeding has broadened the choices of disease modifying treatments (DMTs) for patients with high relapse rates. Natalizumab may also be continued until 34 weeks of pregnancy for patients requiring persisting treatment. Drugs with a known potential of teratogenicity such as fingolimod or teriflunomide should be avoided and recommended wash-out times for medications such as cladribine, alemtuzumab or ocrelizumab should be considered. Teriflunomide and fingolimod are not recommended during breastfeeding, however, glatiramer acetate and IFN-β are considered to be safe. SUMMARY The evidence of potential fetotoxicities and adverse pregnancy outcomes associated with DMTs is increasing, although more research is needed to evaluate the safety of drugs and to track long-term health outcomes for the mother and the child.
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Affiliation(s)
- Guoda Varytė
- Clinic of Obstetrics and Gynaecology, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
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15
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Simone IL, Tortorella C, Ghirelli A. Influence of Pregnancy in Multiple Sclerosis and Impact of Disease-Modifying Therapies. Front Neurol 2021; 12:697974. [PMID: 34276545 PMCID: PMC8280312 DOI: 10.3389/fneur.2021.697974] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 05/26/2021] [Indexed: 01/25/2023] Open
Abstract
Purpose of this Review: This article is a systematic review on the influence pregnancy has on multiple sclerosis and the resulting impact of disease-modifying therapies. Findings: Multiple sclerosis predominantly affects young women with a clinical onset most often during the child-bearing age. The impact of multiple sclerosis and disease-modifying therapies on fertility, pregnancy, fetal outcome, and breastfeeding is a pivotal topic when it comes to clinical practice. The introduction of disease-modifying therapies has changed not only the natural history of the disease but also the perspective of pregnancy in women with multiple sclerosis. Family planning requires careful consideration, especially because many disease-modifying drugs are contraindicated during pregnancy. In this article, we review current evidence collected from published literature and drug-specific pregnancy registers on the use of disease-modifying therapies. Additionally, we discuss safety profiles for each drug and correlate them to both risk for the exposed fetus and risk for the mothers interrupting treatments when seeking pregnancy.
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Affiliation(s)
- Isabella Laura Simone
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari, Bari, Italy
| | - Carla Tortorella
- Department of Neurosciences, San Camillo-Forlanini Hospital, Rome, Italy
| | - Alma Ghirelli
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari, Bari, Italy
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16
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Family Planning for People with Multiple Sclerosis in Saudi Arabia: an Expert Consensus. Mult Scler Int 2021; 2021:6667006. [PMID: 33628508 PMCID: PMC7899766 DOI: 10.1155/2021/6667006] [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: 10/09/2020] [Accepted: 02/01/2021] [Indexed: 11/18/2022] Open
Abstract
More than half of all patients with multiple sclerosis (MS) in the Kingdom of Saudi Arabia (KSA) are women of childbearing age. Raising a family is an important life goal for women in our region of the world. However, fears and misconceptions about the clinical course of relapsing-remitting MS (RRMS) and the effects of disease-modifying drugs (DMDs) on the foetus have led many women to reduce their expectations of raising a family, sometimes even to the point of avoiding pregnancy altogether. The increase in the number of DMDs available to manage RRMS and recent studies on their effects in pregnancy have broadened management options for these women. Interferon beta now has an indication in Europe for use during pregnancy (according to clinical need) and can be used during breastfeeding. Glatiramer acetate is a further possible option for women with lower levels of RRMS disease activity who are, or about to become, pregnant; natalizumab may be used up to 30 weeks in patients with higher levels of disease activity. Where possible, physicians need to support and encourage women to pursue their dream of a fulfilling family life, supported where necessary by active interventions for RRMS that are increasingly evidence based.
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17
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Krysko KM, Bove R, Dobson R, Jokubaitis V, Hellwig K. Treatment of Women with Multiple Sclerosis Planning Pregnancy. Curr Treat Options Neurol 2021; 23:11. [PMID: 33814892 PMCID: PMC8008016 DOI: 10.1007/s11940-021-00666-4] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2021] [Indexed: 02/01/2023]
Abstract
PURPOSE OF REVIEW We review data available for treatment of multiple sclerosis (MS) before, during, and after pregnancy. We present recent data on disease-modifying therapies (DMT) before/during pregnancy and while breastfeeding, with treatment recommendations. RECENT FINDINGS Observational data support the safety of injectable DMTs (glatiramer acetate, interferon-beta) for use in pregnancy, while some oral DMTs might be associated with fetal risk. Monoclonal antibodies (mAbs) before pregnancy such as rituximab or natalizumab likely do not pose significant fetal risks, but can cross the placenta with neonatal hematological abnormalities if given in the second trimester or later. Breastfeeding is associated with decreased risk of postpartum relapses. Finally, injectables and mAbs likely have low transfer into breastmilk. SUMMARY Many women with MS do not require DMTs during pregnancy, although injectables could be continued. For women with highly active MS, cell-depleting therapies could be given before conception, or natalizumab could be continued through pregnancy, with monitoring of the fetus. Women should be encouraged to breastfeed, and those with higher relapse risk could consider injectables or mAbs while breastfeeding. Further data on safety of DMTs around pregnancy are needed. Maximizing function through non-pharmacologic approaches is complementary to DMTs. Special considerations for pregnancy and DMTs during the COVID-19 pandemic are needed.
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Affiliation(s)
- Kristen M. Krysko
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California San Francisco, 675 Nelson Rising Lane, San Francisco, CA 94158 USA
- Division of Neurology, Department of Medicine, St. Michael’s Hospital, University of Toronto, 9 Donnelly Wing South, 30 Bond Street, Toronto, Ontario M5B 1W8 Canada
| | - Riley Bove
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California San Francisco, 675 Nelson Rising Lane, San Francisco, CA 94158 USA
| | - Ruth Dobson
- Preventive Neurology Unit, Wolfson Institute of Preventive Neurology, Queen Mary University of London, Charterhouse Square, London, UK
- Department of Neurology, Royal London Hospital, Whitechapel, London, UK
| | - Vilija Jokubaitis
- Department of Neuroscience, Monash University, Melbourne, VIC Australia
- Department of Neurology, Alfred Health, Melbourne, VIC Australia
| | - Kerstin Hellwig
- Department of Neurology, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
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18
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Cohan SL, Hendin BA, Reder AT, Smoot K, Avila R, Mendoza JP, Weinstock-Guttman B. Interferons and Multiple Sclerosis: Lessons from 25 Years of Clinical and Real-World Experience with Intramuscular Interferon Beta-1a (Avonex). CNS Drugs 2021; 35:743-767. [PMID: 34228301 PMCID: PMC8258741 DOI: 10.1007/s40263-021-00822-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/28/2021] [Indexed: 12/15/2022]
Abstract
Recombinant interferon (IFN) β-1b was approved by the US Food and Drug Administration as the first disease-modifying therapy (DMT) for multiple sclerosis (MS) in 1993. Since that time, clinical trials and real-world observational studies have demonstrated the effectiveness of IFN therapies. The pivotal intramuscular IFN β-1a phase III trial published in 1996 was the first to demonstrate that a DMT could reduce accumulation of sustained disability in MS. Patient adherence to treatment is higher with intramuscular IFN β-1a, given once weekly, than with subcutaneous formulations requiring multiple injections per week. Moreover, subcutaneous IFN β-1a is associated with an increased incidence of injection-site reactions and neutralizing antibodies compared with intramuscular administration. In recent years, revisions to MS diagnostic criteria have improved clinicians' ability to identify patients with MS and have promoted the use of magnetic resonance imaging (MRI) for diagnosis and disease monitoring. MRI studies show that treatment with IFN β-1a, relative to placebo, reduces T2 and gadolinium-enhancing lesions and gray matter atrophy. Since the approval of intramuscular IFN β-1a, a number of high-efficacy therapies have been approved for MS, though the benefit of these high-efficacy therapies should be balanced against the increased risk of serious adverse events associated with their long-term use. For some subpopulations of patients, including pregnant women, the safety profile of IFN β formulations may provide a particular benefit. In addition, the antiviral properties of IFNs may indicate potential therapeutic opportunities for IFN β in reducing the risk of viral infections such as COVID-19.
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Affiliation(s)
- Stanley L. Cohan
- Providence Multiple Sclerosis Center, Providence Brain and Spine Institute, Portland, OR USA
| | | | | | - Kyle Smoot
- Providence Multiple Sclerosis Center, Providence Brain and Spine Institute, Portland, OR USA
| | | | | | - Bianca Weinstock-Guttman
- Department of Neurology, Jacobs Comprehensive MS Treatment and Research Center, Jacobs School of Medicine and Biomedical Sciences, State University of New York, 1010 Main St., 2nd floor, Buffalo, NY, 14202, USA.
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19
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Krysko KM, Graves JS, Dobson R, Altintas A, Amato MP, Bernard J, Bonavita S, Bove R, Cavalla P, Clerico M, Corona T, Doshi A, Fragoso Y, Jacobs D, Jokubaitis V, Landi D, Llamosa G, Longbrake EE, Maillart E, Marta M, Midaglia L, Shah S, Tintore M, van der Walt A, Voskuhl R, Wang Y, Zabad RK, Zeydan B, Houtchens M, Hellwig K. Sex effects across the lifespan in women with multiple sclerosis. Ther Adv Neurol Disord 2020; 13:1756286420936166. [PMID: 32655689 PMCID: PMC7331774 DOI: 10.1177/1756286420936166] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 05/28/2020] [Indexed: 02/06/2023] Open
Abstract
Multiple sclerosis (MS) is an autoimmune inflammatory demyelinating central nervous system disorder that is more common in women, with onset often during reproductive years. The female:male sex ratio of MS rose in several regions over the last century, suggesting a possible sex by environmental interaction increasing MS risk in women. Since many with MS are in their childbearing years, family planning, including contraceptive and disease-modifying therapy (DMT) counselling, are important aspects of MS care in women. While some DMTs are likely harmful to the developing fetus, others can be used shortly before or until pregnancy is confirmed. Overall, pregnancy decreases risk of MS relapses, whereas relapse risk may increase postpartum, although pregnancy does not appear to be harmful for long-term prognosis of MS. However, ovarian aging may contribute to disability progression in women with MS. Here, we review sex effects across the lifespan in women with MS, including the effect of sex on MS susceptibility, effects of pregnancy on MS disease activity, and management strategies around pregnancy, including risks associated with DMT use before and during pregnancy, and while breastfeeding. We also review reproductive aging and sexual dysfunction in women with MS.
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Affiliation(s)
- Kristen M Krysko
- Department of Neurology, UCSF Weill Institute for Neurosciences, University of California San Francisco, 675 Nelson Rising Lane, Suite 221, San Francisco, CA 94158, USA
| | - Jennifer S Graves
- Department of Neurosciences, University of California San Diego, UCSD ACTRI, La Jolla, CA, USA
| | - Ruth Dobson
- Preventive Neurology Unit, Wolfson Institute of Preventive Neurology, Queen Mary University of London, London, UK
| | - Ayse Altintas
- Department of Neurology, School of Medicine, Koc University, Istanbul, Turkey
| | - Maria Pia Amato
- Department NEUROFARBA, Section of Neurosciences, University of Florence, Florence, Italy
| | - Jacqueline Bernard
- Department of Neurology, Oregon Health Science University, Portland, OR, USA
| | - Simona Bonavita
- Department of Advanced Medical and Surgical Sciences, University of Campania, "Luigi Vanvitelli", Naples, Italy
| | - Riley Bove
- Department of Neurology, UCSF Weill Institute for Neurosciences, University of California San Francisco, San Francisco CA, USA
| | - Paola Cavalla
- Department of Neuroscience and Mental Health, City of Health and Science University Hospital of Torino, Turin, Italy
| | - Marinella Clerico
- Department of Clinical and Biological Sciences, University of Torino, San Luigi Gonzaga Hospital, Orbassano, Turin, Italy
| | - Teresa Corona
- Clinical Laboratory of Neurodegenerative Disease, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico
| | - Anisha Doshi
- Department of Neuroinflammation, Queen Square Multiple Sclerosis Centre, University College London (UCL) Institute of Neurology, London, UK
| | - Yara Fragoso
- Multiple Sclerosis & Headache Research Institute, Santos, SP, Brazil
| | - Dina Jacobs
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Vilija Jokubaitis
- Department of Neuroscience, Monash University, Melbourne, VIC, Australia
| | - Doriana Landi
- Department of Systems Medicine, Multiple Sclerosis Center and Research Unit, Tor Vergata University and Hospital, Rome, Italy
| | | | | | | | - Monica Marta
- Neurosciences and Trauma Centre, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Luciana Midaglia
- Department of Neurology-Neuroimmunology, Multiple Sclerosis Centre of Catalonia, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Suma Shah
- Department of Neurology, Duke University, Durham, NC, USA
| | - Mar Tintore
- Department of Neurology-Neuroimmunology, Multiple Sclerosis Centre of Catalonia, Vall d'Hebron University Hospital, Barcelona, Spain
| | | | - Rhonda Voskuhl
- Department of Neurology, University of California Los Angeles, Los Angeles, CA, USA
| | - Yujie Wang
- Department of Neurology, Johns Hopkins University, Baltimore, MD, USA
| | - Rana K Zabad
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, USA
| | - Burcu Zeydan
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Maria Houtchens
- Department of Neurology, Partners MS Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kerstin Hellwig
- Department of Neurology, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
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Liguori NF, Alonso R, Pinheiro AA, Balbuena ME, Barboza A, Bestoso S, Burgos M, Cáceres F, Carnero Contentti E, Carrá A, Cristiano E, Curbelo MC, Deri N, Fiol M, Gaitán MI, Garcea O, Halfon M, Hryb J, Jacobo M, José G, Knorre E, López P, Luetic G, Mainella C, Martínez A, Miguez J, Nofal P, Pagani Cassará F, Marcilla MP, Piedrabuena R, Pita C, Quarracino C, Rojas JI, Silva B, Sinay V, Steinberg J, Tarulla A, Tavolini D, Tkachuk V, Tizio S, Villa A, Vrech C, Ysrraelit C, Patrucco L. Consensus recommendations for family planning and pregnancy in multiple sclerosis in argentina. Mult Scler Relat Disord 2020; 43:102147. [PMID: 32442883 DOI: 10.1016/j.msard.2020.102147] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 03/30/2020] [Accepted: 04/22/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Multiple sclerosis (MS) is the most common chronic immune-mediated neurological disorder in young adults, more frequently found in women than in men. Therefore, pregnancy-related issues have become an object of concern for MS professionals and patients. The aim of this work was to review the existing data to develop the first Argentine consensus for family planning and pregnancy in MS patients. METHODS A panel of expert neurologists from Argentina engaged in the diagnosis and care of MS patients met both virtually and in person during 2019 to carry out a consensus recommendation for family planning and pregnancy in MS. To achieve consensus, the procedure of the "formal consensus-RAND/UCLA method" was used. RESULTS Recommendations were established based on published evidence and expert opinion focusing on pre-pregnancy counseling, pregnancy, and postpartum issues. CONCLUSION The recommendations of these consensus guidelines are intended to optimize the management and treatment of MS patients during their reproductive age in Argentina.
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Affiliation(s)
- Nora Fernández Liguori
- Hospital Universitario Sanatorio Güemes, Buenos Aires, Argentina; Sección Neurología, Hospital Enrique Tornú, Buenos Aires, Argentina.
| | - Ricardo Alonso
- Hospital Universitario Sanatorio Güemes, Buenos Aires, Argentina; Centro Universitario de Esclerosis Múltiple, Hospital Dr. J. M. Ramos Mejía, Buenos Aires, Argentina
| | | | - María E Balbuena
- Sección de Neuroinmunología y Enfermedades Desmielinizantes, Servicio de Neurología, Hospital de Clínicas José de San Martín, Argentina
| | | | | | | | | | | | - Adriana Carrá
- Fundación Favaloro/INECO, Buenos Aires, Argentina; MS Section Hospital Británico, Buenos Aires, Argentina
| | | | | | - Norma Deri
- Centro de Investigaciones Diabaid, Argentina; Hospital Fernández de Buenos Aires, Argentina
| | - Marcela Fiol
- Department of Neurology, Institute for Neurological Research Dr Raul Carrea, FLENI, Argentina
| | - María I Gaitán
- Department of Neurology, Institute for Neurological Research Dr Raul Carrea, FLENI, Argentina
| | - Orlando Garcea
- Centro Universitario de Esclerosis Múltiple, Hospital Dr. J. M. Ramos Mejía, Buenos Aires, Argentina
| | | | - Javier Hryb
- Servicio de Neurología, Hospital Carlos G. Durand, CABA
| | - Miguel Jacobo
- RIAPEM (Red Integral Asistencial al Paciente con EM), Santiago del Estero, Argentina
| | - Gustavo José
- Servicio de Neurología, Hospital Ángel Padilla, Tucumán, Argentina
| | - Eduardo Knorre
- Servicio de Neurología, Hospital Teodoro Álvarez, Buenos Aires, Argentina
| | - Pablo López
- Department of Neuroscience - Neuroimmunology Unit, Hospital Alemán, Buenos Aires, Argentina
| | | | | | | | | | - Pedro Nofal
- Hospital de Clínicas Ntra. Sra. del Carmen, San Miguel de Tucumán, Argentina
| | | | | | | | - Cecilia Pita
- Centro Universitario de Esclerosis Múltiple, Hospital Dr. J. M. Ramos Mejía, Buenos Aires, Argentina
| | - Cecilia Quarracino
- Departamento de neurología, Instituto de Investigaciones Médicas Alfredo Lanari
| | - Juan I Rojas
- Centro de Esclerosis Múltiple de Buenos Aires, Argentina
| | - Berenice Silva
- Centro Universitario de Esclerosis Múltiple, Hospital Dr. J. M. Ramos Mejía, Buenos Aires, Argentina
| | | | | | - Adriana Tarulla
- Hospital de Agudos Parmenio Piñero, Municipalidad de Ciudad de Buenos Aires, MCBA, Argentina
| | - Darío Tavolini
- INECO Neurociencias Oroño. Fundación INECO Rosario, Argentina
| | - Verónica Tkachuk
- Sección de Neuroinmunología y Enfermedades Desmielinizantes, Servicio de Neurología, Hospital de Clínicas José de San Martín, Argentina
| | - Santiago Tizio
- Departamento de Neurología, Hospital Italiano y Español de La Plata, Argentina
| | - Andrés Villa
- Sección Neuroinmunología, Hospital Ramos Mejía, Buenos Aires, Argentina
| | - Carlos Vrech
- Departamento de Enfermedades desmielinizantes, Sanatorio Allende Córdoba, Argentina
| | - Célica Ysrraelit
- Department of Neurology, Institute for Neurological Research Dr Raul Carrea, FLENI, Argentina
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Ciplea AI, Langer-Gould A, Stahl A, Thiel S, Queisser-Wahrendorf A, Gold R, Hellwig K. Safety of potential breast milk exposure to IFN-β or glatiramer acetate: One-year infant outcomes. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2020; 7:7/4/e757. [PMID: 32434802 PMCID: PMC7251509 DOI: 10.1212/nxi.0000000000000757] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 02/19/2020] [Indexed: 01/05/2023]
Abstract
Objective To determine whether potential breast milk exposure to interferon-beta (IFN-β) or glatiramer acetate (GA) is safe for the infant. Methods We identified 74 infants born to 69 women with MS who breastfed under IFN-β (n = 39), GA (n = 34), or both (n = 1). Women had been enrolled into the German Multiple Sclerosis and Pregnancy Registry during pregnancy. Data were obtained from standardized, telephone-administered questionnaires completed by the mother during pregnancy and at 1, 3, 6, and 12 months postpartum and the infant's take-home medical record. Results The median duration of exposed breastfeeding was 8.5 months (wide interquartile range: 4.9–12.7 months). Physical growth curves during the first year of life were consistent with national, sex-specific growth curves. Median body measurements were consistent with national medians. Most children (n = 71, 96%) had normal motor and language development. Gross motor delay was reported in 3 children, of whom 1 remained delayed at last follow-up (3.9 years old) and 2 were normal by 0.9 and 4.1 years old. The proportion of children hospitalized at least once (girls n = 2, 7%, and boys n = 6, 14%) and the proportion of children with at least one episode of systemic antibiotic use during the first year of life (girls n = 7, 23%, and boys n = 8, 18%) are consistent with national averages. Conclusion Potential breast milk exposure to IFN-β or GA did not increase the risk of common adverse infant outcomes in the first year of life. Taken together with the benefits of breastfeeding and low biological plausibility of risk, women with MS who wish to resume IFN-β or GA postpartum can be encouraged to breastfeed.
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Affiliation(s)
- Andrea Ines Ciplea
- From the Department of Neurology (A.I.C., S.T., R.G., K.H.), St. Josef Hospital, Ruhr-University Bochum; Institute of Clinical Pharmacy and Pharmacotherapy (A.I.C.), Heinrich-Heine-University, Dusseldorf, Germany; Department of Neurology (A.L.-G.), Southern California Permanente Medical Group/Kaiser Permanente, Los Angeles Medical Center; Department of Paediatrics (A.S.), St. Josef Hospital, Ruhr-University Bochum; and Centre of Paediatrics and Youth Medicine (A.Q.-W.), Johannes Gutenberg University of Mainz, Germany
| | - Annette Langer-Gould
- From the Department of Neurology (A.I.C., S.T., R.G., K.H.), St. Josef Hospital, Ruhr-University Bochum; Institute of Clinical Pharmacy and Pharmacotherapy (A.I.C.), Heinrich-Heine-University, Dusseldorf, Germany; Department of Neurology (A.L.-G.), Southern California Permanente Medical Group/Kaiser Permanente, Los Angeles Medical Center; Department of Paediatrics (A.S.), St. Josef Hospital, Ruhr-University Bochum; and Centre of Paediatrics and Youth Medicine (A.Q.-W.), Johannes Gutenberg University of Mainz, Germany
| | - Anna Stahl
- From the Department of Neurology (A.I.C., S.T., R.G., K.H.), St. Josef Hospital, Ruhr-University Bochum; Institute of Clinical Pharmacy and Pharmacotherapy (A.I.C.), Heinrich-Heine-University, Dusseldorf, Germany; Department of Neurology (A.L.-G.), Southern California Permanente Medical Group/Kaiser Permanente, Los Angeles Medical Center; Department of Paediatrics (A.S.), St. Josef Hospital, Ruhr-University Bochum; and Centre of Paediatrics and Youth Medicine (A.Q.-W.), Johannes Gutenberg University of Mainz, Germany
| | - Sandra Thiel
- From the Department of Neurology (A.I.C., S.T., R.G., K.H.), St. Josef Hospital, Ruhr-University Bochum; Institute of Clinical Pharmacy and Pharmacotherapy (A.I.C.), Heinrich-Heine-University, Dusseldorf, Germany; Department of Neurology (A.L.-G.), Southern California Permanente Medical Group/Kaiser Permanente, Los Angeles Medical Center; Department of Paediatrics (A.S.), St. Josef Hospital, Ruhr-University Bochum; and Centre of Paediatrics and Youth Medicine (A.Q.-W.), Johannes Gutenberg University of Mainz, Germany
| | - Annette Queisser-Wahrendorf
- From the Department of Neurology (A.I.C., S.T., R.G., K.H.), St. Josef Hospital, Ruhr-University Bochum; Institute of Clinical Pharmacy and Pharmacotherapy (A.I.C.), Heinrich-Heine-University, Dusseldorf, Germany; Department of Neurology (A.L.-G.), Southern California Permanente Medical Group/Kaiser Permanente, Los Angeles Medical Center; Department of Paediatrics (A.S.), St. Josef Hospital, Ruhr-University Bochum; and Centre of Paediatrics and Youth Medicine (A.Q.-W.), Johannes Gutenberg University of Mainz, Germany
| | - Ralf Gold
- From the Department of Neurology (A.I.C., S.T., R.G., K.H.), St. Josef Hospital, Ruhr-University Bochum; Institute of Clinical Pharmacy and Pharmacotherapy (A.I.C.), Heinrich-Heine-University, Dusseldorf, Germany; Department of Neurology (A.L.-G.), Southern California Permanente Medical Group/Kaiser Permanente, Los Angeles Medical Center; Department of Paediatrics (A.S.), St. Josef Hospital, Ruhr-University Bochum; and Centre of Paediatrics and Youth Medicine (A.Q.-W.), Johannes Gutenberg University of Mainz, Germany
| | - Kerstin Hellwig
- From the Department of Neurology (A.I.C., S.T., R.G., K.H.), St. Josef Hospital, Ruhr-University Bochum; Institute of Clinical Pharmacy and Pharmacotherapy (A.I.C.), Heinrich-Heine-University, Dusseldorf, Germany; Department of Neurology (A.L.-G.), Southern California Permanente Medical Group/Kaiser Permanente, Los Angeles Medical Center; Department of Paediatrics (A.S.), St. Josef Hospital, Ruhr-University Bochum; and Centre of Paediatrics and Youth Medicine (A.Q.-W.), Johannes Gutenberg University of Mainz, Germany.
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Vorobeychik G, Black D, Cooper P, Cox A. Multiple sclerosis and related challenges to young women's health: Canadian expert review. Neurodegener Dis Manag 2020; 10:1-13. [PMID: 32372725 DOI: 10.2217/nmt-2020-0010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Multiple sclerosis (MS) is among the most common chronic neurological diseases, with a highly variable degree of disability during its long-term course. The majority of patients develop significant permanent disability later in life. MS is often diagnosed in women of childbearing age, with a 3:1 ratio of young women to young men with MS. Comorbidities such as depression, anxiety, migraines and reproductive, urological and bowel issues are common and negatively impact patients' quality of life. The objective of this supplement is to review the most common comorbidities occurring in young women with MS, and to propose a multidisciplinary, holistic approach to management.
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Affiliation(s)
- Galina Vorobeychik
- Department of Medicine, University of British Columbia, Vancouver, BC V5Z 1M9.,Fraser Health Multiple Sclerosis Clinic, Burnaby Hospital, Burnaby, BC V5G 2X6
| | - Denise Black
- Seine River Medical Centre, Winnipeg, MB R2N 0A5
| | - Paul Cooper
- Department of Clinical Neurological Sciences, Western University, London, ON N6A 3K7.,Schulich School of Medicine & Dentistry, London, ON N6A 5C1
| | - Ashley Cox
- Department of Urology, Dalhousie University, Halifax, NS B3H 1Y6
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23
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Canibaño B, Deleu D, Mesraoua B, Melikyan G, Ibrahim F, Hanssens Y. Pregnancy-related issues in women with multiple sclerosis: an evidence-based review with practical recommendations. J Drug Assess 2020; 9:20-36. [PMID: 32128285 PMCID: PMC7034025 DOI: 10.1080/21556660.2020.1721507] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Accepted: 01/21/2020] [Indexed: 12/18/2022] Open
Abstract
Objective: To review the current evidence regarding pregnancy-related issues in multiple sclerosis (MS) and to provide recommendations specific for each of them. Research design and methods: A systematic review was performed based on a comprehensive literature search. Results: MS has no effect on fertility, pregnancy or fetal outcomes, and pregnancies do not affect the long-term disease course and accumulation of disability. There is a potential risk for relapse after use of gonadotropin-releasing hormone agonists during assisted reproduction techniques. At short-term, pregnancy leads to a reduction of relapses during the third trimester, followed by an increased risk of relapses during the first three months postpartum. Pregnancies in MS are not per se high risk pregnancies, and MS does not influence the mode of delivery or anesthesia unless in the presence of significant disability. MRI is not contraindicated during pregnancy; however, gadolinium contrast media should be avoided whenever possible. It is safe to use pulse dose methylprednisolone infusions to manage acute disabling relapses during pregnancy and breastfeeding. However, its use during the first trimester of pregnancy is still controversial. Women with MS should be encouraged to breastfeed with a possible favorable effect of exclusive breastfeeding. Disease-modifying drugs can be classified according to their potential for pregnancy-associated risk and impact on fetal outcome. Interferon beta (IFNβ) and glatiramer acetate (GA) may be continued until pregnancy is confirmed and, after consideration of the individual risk-benefit if continued, during pregnancy. The benefit of continuing natalizumab during the entire pregnancy may outweigh the risk of recurring disease activity, particularly in women with highly active MS. GA and IFNβ are considered safe during breastfeeding. The use of natalizumab during pregnancy or lactation requires monitoring of the newborn. Conclusions: This review provides current evidence and recommendations for counseling and management of women with MS preconception, during pregnancy and postpartum.
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Affiliation(s)
- Beatriz Canibaño
- Department of Neurology, Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Dirk Deleu
- Department of Neurology, Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Boulenouar Mesraoua
- Department of Neurology, Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Gayane Melikyan
- Department of Neurology, Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Faiza Ibrahim
- Department of Neurology, Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Yolande Hanssens
- Clinical Services Unit, Pharmacy, Hamad Medical Corporation, Doha, Qatar
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24
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Abstract
PURPOSE OF REVIEW This article provides practical guidance on successful management of women with multiple sclerosis (MS) through pregnancy and the postpartum period. RECENT FINDINGS Recent studies indicate that most women diagnosed with MS today can have children, breast-feed, and resume beta interferons or glatiramer acetate per their preferences without incurring an increased risk of relapses during the postpartum period. More than 40% of women with mild MS do not require any treatment before conception or in the postpartum period. Women with highly active MS can now become well-controlled before, throughout, and after pregnancy via highly effective treatments. Unfortunately, pregnancy does not protect against relapses following the cessation of fingolimod or natalizumab, and some women experience severe rebound relapses during pregnancy. Accidental first-trimester exposure to teriflunomide or fingolimod increases the risk of fetal harm. SUMMARY Most women with MS can have normal pregnancies and breast-feed without incurring harm. Clinicians should avoid prescribing medications with known teratogenic potential (teriflunomide, fingolimod), known risk of severe rebound relapses (fingolimod, natalizumab), or unclear but plausible risks (dimethyl fumarate, alemtuzumab) to women of childbearing age who desire pregnancy or are not on reliable birth control. If a treatment needs to be resumed during breast-feeding, clinicians should opt for glatiramer acetate, interferon beta, natalizumab, or rituximab/ocrelizumab, as biologically plausible risks to the infant are exceedingly low.
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Abstract
Multiple sclerosis (MS) and neuromyelitis optica (NMO) are chronic inflammatory demyelinating disorders of the central nervous system that often affect women during childbearing years. Therefore, issues of conception, pregnancy, and delivery are of significant importance to patients and treating physicians. The current review provides updated information regarding the effects of pregnancy on MS and NMO, as well as the available safety data on immunomodulatory MS therapies for pregnant and lactating women. Management issues of women with MS and NMO during conception, gestation, and the postpartum period also are addressed.
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26
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Coyle PK, Oh J, Magyari M, Oreja-Guevara C, Houtchens M. Management strategies for female patients of reproductive potential with multiple sclerosis: An evidence-based review. Mult Scler Relat Disord 2019; 32:54-63. [PMID: 31030020 DOI: 10.1016/j.msard.2019.04.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 03/08/2019] [Accepted: 04/02/2019] [Indexed: 12/22/2022]
Abstract
Multiple sclerosis (MS) is an inflammatory, demyelinating, neurodegenerative, immune-mediated disease primarily diagnosed in early adulthood. Multiple sclerosis mostly impacts women of reproductive potential, with pregnancy and birth outcomes being major concerns for many patients. While there is ample evidence that the disease itself has no impact on pregnancy, many women living with MS still question their ability to have children, and the impact of childbearing on their disease in the short and long term. Such questions emphasize the importance of proper guidance from healthcare professionals, particularly neurologists. Management considerations are also complicated by the growing list of available treatment options. This review will summarize current evidence and expert opinion around the management of female MS patients of reproductive potential, from family planning to the postpartum period. Current guidelines on the use of disease-modifying therapies throughout pregnancy will be discussed, as well as other general medical recommendations, to minimize MS disease activity in the peripartum period.
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Affiliation(s)
- Patricia K Coyle
- Department of Neurology, Stony Brook University, Stony Brook, NY, USA.
| | - Jiwon Oh
- St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Melinda Magyari
- Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Celia Oreja-Guevara
- Hospital Clínico San Carlos, Universidad Complutense de Madrid, IdISSC, Madrid, Spain
| | - Maria Houtchens
- Brigham and Women's Hospital, Harvard Medical School, Brookline, MA, USA
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27
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Portaccio E, Amato MP. Breastfeeding and post-partum relapses in multiple sclerosis patients. Mult Scler 2019; 25:1211-1216. [PMID: 30793658 DOI: 10.1177/1352458519830588] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
While it is acknowledged that exclusive breastfeeding has well-established benefits for both infant/child and mother health, evidence on the relationships between breastfeeding and disease course in women with multiple sclerosis (MS) is still controversial. On one hand, in the post-partum period, a disease worsening is possible, particularly in women with more active MS. On the other hand, the use of disease modifying drugs is currently contraindicated during lactation. In this topical review, we describe available evidence on the relationship between breastfeeding and disease activity in MS. In some studies, a possible protective role for exclusive breastfeeding against the risk of post-partum relapse has been suggested, while, in others, its impact was neutral. Waiting for definitive evidence on this topic, we propose a pragmatic approach to breastfeeding choice, on a case-by-case basis, considering the disease characteristics before and during pregnancy and the patient therapeutic history.
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Affiliation(s)
- Emilio Portaccio
- SOC Neurologia - Firenze, Azienda USL Toscana Centro, Florence, Italy
| | - Maria Pia Amato
- Section of Neurosciences, Department of NEUROFARBA, University of Florence, Florence, Italy/IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy
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28
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Fragoso YD, Adoni T, Brooks JBB, Finkelsztejn A, da Gama PD, Grzesiuk AK, Marques VD, Parolin MFK, Sato HK, Varela DL, Vasconcelos CCF. Practical Evidence-Based Recommendations for Patients with Multiple Sclerosis Who Want to Have Children. Neurol Ther 2018; 7:207-232. [PMID: 30167914 PMCID: PMC6283793 DOI: 10.1007/s40120-018-0110-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Indexed: 12/14/2022] Open
Abstract
Multiple sclerosis (MS) management presently aims to reach a state of no (or minimal) evidence of disease activity. The development and commercialization of new drugs has led to a renewed interest in family planning, since patients with MS may face a future with reduced (or no) disease-related neurological disability. The advice of neurologists is often sought by patients who want to have children and need to know more about disease control at conception and during pregnancy and the puerperium. When MS is well controlled, the simple withdrawal of drugs for patients who intend to conceive is not an option. On the other hand, not all treatments presently recommended for MS are considered safe during conception, pregnancy and/or breastfeeding. The objective of the present study was to summarize the practical and evidence-based recommendations for family planning when our patients (women and men) have MS.Funding TEVA Pharmaceutical Brazil.
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Affiliation(s)
| | - Tarso Adoni
- Hospital Sirio-Libanes de Sao Paulo, São Paulo, SP, Brazil
| | | | | | | | | | | | | | - Henry K Sato
- Instituto de Neurologia de Curitiba, Curitiba, PR, Brazil
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Abstract
PURPOSE OF REVIEW Caring for women with multiple sclerosis (MS), whose first symptoms typically begin during the childbearing years, requires a comprehensive approach to management across a range of reproductive exposures, and beyond through menopause. RECENT FINDINGS This article summarizes what is known about the disease course in women with MS, how it differs from men, and the current state of knowledge regarding effects of reproductive exposures (menarche, childbearing, menopause) on MS-related inflammation and neurodegeneration. Recent findings regarding pregnancy-associated relapses in the treatment era, protective effects of breastfeeding, and care for women during the menopausal transition are reviewed. Then, updated recommendations to guiding women during childbearing-including pre-conception counseling, discontinuation of MS therapies, and management of postpartum relapses-are provided. Whenever possible, areas of uncertainty and avenues for future research are highlighted. From childhood through the postreproductive life stages, gender and hormonal exposures appear to shape an individual's risk for MS, as well as the experience of living with MS.
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Affiliation(s)
- Kelsey Rankin
- Weill Institute for the Neurosciences, Department of Neurology, University of California, San Francisco, 675 Nelson Rising Lane, San Francisco, CA, USA
| | - Riley Bove
- Weill Institute for the Neurosciences, Department of Neurology, University of California, San Francisco, 675 Nelson Rising Lane, San Francisco, CA, USA.
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30
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Dumitrescu L, Constantinescu CS, Tanasescu R. Recent developments in interferon-based therapies for multiple sclerosis. Expert Opin Biol Ther 2018; 18:665-680. [PMID: 29624084 DOI: 10.1080/14712598.2018.1462793] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Multiple sclerosis (MS) is a chronic and disabling immune-mediated disease of the central nervous system. Beta-interferons are the first approved and still the most widely used first-line disease-modifying treatment in MS. AREAS COVERED Here we focus on recent developments in pharmacology and delivery systems of beta-interferons, and discuss their place within current state of the art therapeutic approaches. We briefly review the clinical trials for classical and PEGylated formulations, emphasizing effectiveness, safety concerns, and tolerability. The mechanisms of action of IFN-β in view of MS pathogenesis are also debated EXPERT OPINION Though only modestly efficient in reducing the annualized relapse rate, beta-interferons remain a valid first-line option due to their good long-term safety profile and cost-efficacy. Moreover, they are endogenous class II cytokines essential for mounting an effective antiviral response, and they may interact with putative MS triggering factors such as Epstein-Barr virus infection and human endogenous retroviruses. Recent improvements in formulations, delivery devices and drug regimens tackle the tolerability and adherence issues frequently seen with these drugs, and scientific advances may offer means for a better selection of patients. Although a well-established immunomodulatory treatment, beta-interferons have not said their last word in the management of MS.
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Affiliation(s)
- Laura Dumitrescu
- a Department of Clinical Neurosciences , University of Medicine and Pharmacy Carol Davila , Bucharest , Romania.,b Department of Neurology , Colentina Hospital , Bucharest , Romania
| | - Cris S Constantinescu
- c Academic Clinical Neurology, Division of Clinical Neuroscience , University of Nottingham , UK
| | - Radu Tanasescu
- a Department of Clinical Neurosciences , University of Medicine and Pharmacy Carol Davila , Bucharest , Romania.,b Department of Neurology , Colentina Hospital , Bucharest , Romania.,c Academic Clinical Neurology, Division of Clinical Neuroscience , University of Nottingham , UK
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31
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Abstract
PURPOSE OF REVIEW This article provides a review of the available data on reproductive issues that arise in patients with multiple sclerosis (MS). RECENT FINDINGS Recent findings have replicated earlier findings that pregnancy and possibly breast-feeding bring about a favorable immunomodulatory effect in patients with MS. Use of disease-modifying therapies prior to pregnancy may further decrease a patient's risk for postpartum disease activity. SUMMARY The annualized relapse rate in MS decreases during pregnancy, with a nadir in the third trimester, and rebounds significantly in the 3-month postpartum period. Exclusive breast-feeding may exert a beneficial effect in decreasing the postpartum risk for relapse. Certain assisted reproductive technology methods are thought to increase the risk for relapse. Disease-modifying therapies are generally discontinued during pregnancy and lactation with a few exceptions. The pregnancy course is usually routine without significant obstetric complications, and babies, although slightly smaller, are typically healthy.
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32
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Voskuhl R, Momtazee C. Pregnancy: Effect on Multiple Sclerosis, Treatment Considerations, and Breastfeeding. Neurotherapeutics 2017; 14:974-984. [PMID: 28766273 PMCID: PMC5722767 DOI: 10.1007/s13311-017-0562-7] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Multiple sclerosis (MS) commonly affects women in childbearing years making pregnancy issues important for patients with MS and their families. Pregnancy is a naturally occurring disease modifier of MS associated with a 70% reduction in relapse rates in the third trimester. This relapse rate reduction during the last trimester is roughly equal to the most effective disease-modifying treatments for MS. Given this efficacy, various pregnancy factors have been tested to determine which play a part in pregnancy's protection, and some have been translated to completed and ongoing phase II clinical trials. In contrast to protective effects during pregnancy, the postpartum period entails increased relapse risk, which may be due to either abrupt removal of protective pregnancy factors after delivery or to unique deleterious factors inherent to the postpartum period. The effect of breastfeeding on MS remains unclear. The best predictor for whether a patient will have a postpartum relapse is the incidence of her having active relapsing MS prior to pregnancy. The medical management of MS during pregnancy and the postpartum period is challenging given the risks of medication exposure to the fetus in utero and to the infant through breast milk. This review will focus on clinical aspects of pregnancy, including the effects of pregnancy on MS disease activity, as well as the medical management of MS during pregnancy and postpartum.
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Affiliation(s)
- Rhonda Voskuhl
- Multiple Sclerosis Program, UCLA Department of Neurology, David Geffen School of Medicine, University of Los Angeles, Los Angeles, CA, 90095, USA.
| | - Callene Momtazee
- Multiple Sclerosis Program, UCLA Department of Neurology, David Geffen School of Medicine, University of Los Angeles, Los Angeles, CA, 90095, USA
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Thöne J, Thiel S, Gold R, Hellwig K. Treatment of multiple sclerosis during pregnancy - safety considerations. Expert Opin Drug Saf 2017; 16:523-534. [PMID: 28333552 DOI: 10.1080/14740338.2017.1311321] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Women with multiple sclerosis (MS) are treated early in the disease course with disease modifying therapies (DMT). Updated information is needed on pregnancy outcomes of DMT-exposed pregnancies and the effect of the drug withdrawal on MS disease activity. Areas covered: In this review, we will cover the most important updated management strategies in planning a pregnancy when having MS. Expert opinion: MS itself does not increase the risk of adverse pregnancy outcomes and does not negatively influence the long-term course of the disease. As MS became a treatable disease, management of DMTs before, during and after pregnancy is important. This requires updated knowledge on safety of DMTs as well as data of the effect on disease activity after drug withdrawal. A special challenge is the handling of women with highly active MS, as pregnancy might not be powerful enough to suppress the risk of rebound relapses. Exclusive breastfeeding is an option for many women who want to do so, but in cases of high disease activity and those women who do not want to breastfeed, early reintroduction of MS therapies should be considered.
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Affiliation(s)
- Jan Thöne
- a Department of Neurology , University Hospital Essen , Essen , Germany
| | - Sandra Thiel
- b Department of Neurology, St. Josef-Hospital , Ruhr-University Bochum , Bochum , Germany
| | - Ralf Gold
- b Department of Neurology, St. Josef-Hospital , Ruhr-University Bochum , Bochum , Germany
| | - Kerstin Hellwig
- b Department of Neurology, St. Josef-Hospital , Ruhr-University Bochum , Bochum , Germany
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Holmøy T, Torkildsen Ø. Family planning, pregnancy and breastfeeding in multiple sclerosis. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2016; 136:1726-1729. [PMID: 27830907 DOI: 10.4045/tidsskr.16.0563] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Multiple sclerosis often affects women of childbearing age. The availability of more effective immunomodulatory therapy may increase the number of afflicted women wanting to fulfil their desire to have children. The purpose of this article is to provide an up-to-date review of medical issues and dilemmas related to family planning and pregnancy in multiple sclerosis.
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Affiliation(s)
- Trygve Holmøy
- Nevroklinikken Akershus universitetssykehus og Institutt for klinisk medisin Universitetet i Oslo
| | - Øivind Torkildsen
- Nevrologisk avdeling Haukeland universitetssykehus og KG Jebsen senter for MS-forskning Klinisk institutt 1 Universitetet i Bergen
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Coyle PK. Management of women with multiple sclerosis through pregnancy and after childbirth. Ther Adv Neurol Disord 2016; 9:198-210. [PMID: 27134675 DOI: 10.1177/1756285616631897] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Multiple sclerosis (MS) is a major acquired neurologic disease of young adults. The prototypic patient is a young woman of reproductive age. Gender preference is becoming more pronounced, since MS is increasing specifically among women. Any healthcare provider who deals with MS must be prepared to discuss pregnancy issues, and provide appropriate counseling. This is now complicated by the availability of multiple treatment options. There is growing literature on which to base recommendations, particularly regarding washout periods. After a brief background introduction, this review will discuss state-of-the-art family planning counseling in the treatment era, divided into prepregnancy, pregnancy, and postpartum MS issues.
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Affiliation(s)
- Patricia K Coyle
- Dept. of Neurology HSC, T12 Stony Brook University Medical Center Stony Brook, NY 11794, USA
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Almas S, Vance J, Baker T, Hale T. Management of Multiple Sclerosis in the Breastfeeding Mother. Mult Scler Int 2016; 2016:6527458. [PMID: 26966579 PMCID: PMC4757692 DOI: 10.1155/2016/6527458] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 12/30/2015] [Accepted: 12/31/2015] [Indexed: 12/12/2022] Open
Abstract
Multiple Sclerosis (MS) is an autoimmune neurological disease characterized by inflammation of the brain and spinal cord. Relapsing-Remitting MS is characterized by acute attacks followed by remission. Treatment is aimed at halting these attacks; therapy may last for months to years. Because MS disproportionately affects females and commonly begins during the childbearing years, clinicians treat pregnant or nursing MS patients. The intent of this review is to perform an in-depth analysis into the safety of drugs used in breastfeeding women with MS. This paper is composed of several drugs used in the treatment of MS and current research regarding their safety in breastfeeding including immunomodulators, immunosuppressants, monoclonal antibodies, corticosteroids, and drugs used for symptomatic treatment. Typically, some medications are large polar molecules which often do not pass into the milk in clinically relevant amounts. For this reason, interferon beta is likely safe for the infant when given to a breastfeeding mother. However, other drugs with particularly dangerous side effects may not be recommended. While treatment options are available and some data from clinical studies does exist, there continues to be a need for investigation and ongoing review of the medications used in breastfeeding mothers.
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Affiliation(s)
- Saneea Almas
- Department of Pediatrics, School of Medicine, Texas Tech University Health Sciences Center, 1400 Wallace Boulevard, Amarillo, TX 79106, USA
| | - Jesse Vance
- Infant Risk Center, Texas Tech University Health Sciences Center, 1400 Wallace Boulevard, Amarillo, TX 79106, USA
| | - Teresa Baker
- Department of Obstetrics & Gynecology, School of Medicine, Texas Tech University Health Sciences Center, 1400 Coulter Street, Amarillo, TX 79106, USA
| | - Thomas Hale
- Department of Pediatrics, School of Medicine, Texas Tech University Health Sciences Center, 1400 Wallace Boulevard, Amarillo, TX 79106, USA
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Hegen H, Auer M, Deisenhammer F. Pharmacokinetic considerations in the treatment of multiple sclerosis with interferon-β. Expert Opin Drug Metab Toxicol 2015; 11:1803-19. [PMID: 26419922 DOI: 10.1517/17425255.2015.1094055] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Interferon-β (IFNβ) is well established as a disease-modifying treatment for patients with multiple sclerosis. Several preparations of the biopharmaceutical are available differing in protein structure, formulation, dose as well as frequency and route of administration. Recently, a pegylated form of IFNβ has been marketed. AREAS COVERED Following a PubMed database search, we provide an overview of what is presently known about the pharmacokinetics (PK) of IFNβ including its absorption, distribution, metabolism and elimination. Also, we discuss the association with clinically relevant issues such as treatment efficacy, adverse events and anti-drug antibodies. EXPERT OPINION IFNβ has a bioavailability of ∼ 30% after subcutaneous or intramuscular administration, shows peak serum concentrations within several hours, has a half-life of < 1 day and is eliminated by a renal and hepatic pathway. PK parameters do not substantially differ between the types of IFNβ and routes of administration; only pegylation of IFNβ results in substantially increased and prolonged PK. Although no clinical dose-effect relationship could be established, there is an association of IFNβ dose with magnetic resonance imaging outcome parameters. Furthermore, there is an association of IFNβ serum levels with the occurrence of adverse events and anti-drug antibodies.
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Affiliation(s)
- Harald Hegen
- a 1 Innsbruck Medical University, Department of Neurology , Innsbruck, Austria
| | - Michael Auer
- a 1 Innsbruck Medical University, Department of Neurology , Innsbruck, Austria
| | - Florian Deisenhammer
- b 2 Innsbruck Medical University, Department of Neurology, Neuroimmunology Laboratory , Innsbruck, Austria +43 5 12 50 42 42 64 ; +43 5 12 50 42 42 66 ;
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Fertility, pregnancy and childbirth in patients with multiple sclerosis: impact of disease-modifying drugs. CNS Drugs 2015; 29:207-20. [PMID: 25773609 DOI: 10.1007/s40263-015-0238-y] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
In recent decades, pregnancy-related issues in multiple sclerosis (MS) have received growing interest. MS is more frequent in women than in men and typically starts during child-bearing age. An increasing number of disease-modifying drugs (DMDs) for the treatment of MS are becoming available. Gathering information on their influences on pregnancy-related issues is of crucial importance for the counselling of MS patients. As for the immunomodulatory drugs (interferons and glatiramer acetate), accumulating evidence points to the relative safety of pregnancy exposure in terms of maternal and foetal outcomes. In case of higher clinical disease activity before pregnancy, these drugs could be continued until conception. As for the 'newer' drugs (fingolimod, natalizumab, teriflunomide, dimethyl fumarate and alemtuzumab), the information is more limited. Whereas fingolimod and teriflunomide are likely associated with an increased risk of foetal malformations, the effects of natalizumab, dimethyl fumarate and alemtuzumab still need to be ascertained. This article provides a review of the available information on the use of DMDs during pregnancy, with a specific focus on fertility, foetal development, delivery and breast-feeding.
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Management of multiple sclerosis during pregnancy and the reproductive years: a systematic review. Obstet Gynecol 2015; 124:1157-1168. [PMID: 25415167 DOI: 10.1097/aog.0000000000000541] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To examine the evidence guiding management of multiple sclerosis (MS) in reproductive-aged women. DATA SOURCES We conducted an electronic literature search using PubMed, ClinicalTrials.gov, and other available resources. The following keywords were used: "multiple sclerosis" and "pregnancy." We manually searched the reference lists of identified studies. METHODS OF STUDY SELECTION Two reviewers categorized all studies identified in the search by management topic, including effect of pregnancy on MS course, fetal risks associated with disease-modifying treatments during pregnancy, and management of patients off disease-modifying treatment. We categorized studies by strength of evidence and included prior meta-analyses and systematic studies. These studies were then summarized and discussed by an expert multidisciplinary team. TABULATION, INTEGRATION, AND RESULTS The risk of MS relapses is decreased during pregnancy and increased postpartum. Data are lacking regarding the risks of disease-modifying treatments during pregnancy. There may be an increased risk of MS relapses after use of assisted reproductive techniques. There does not appear to be a major increase in adverse outcomes in newborns of mothers with MS. CONCLUSION Although there are many unmet research needs, the reviewed data support the conclusion that in the majority of cases, women with MS can safely choose to become pregnant, give birth, and breastfeed children. Clinical management should be individualized to optimize both the mother's reproductive outcomes and MS course.
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Borisow N, Paul F, Dörr J. Optimal management of multiple sclerosis during pregnancy: current perspectives. Degener Neurol Neuromuscul Dis 2014; 4:111-120. [PMID: 32669905 PMCID: PMC7337198 DOI: 10.2147/dnnd.s48618] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 03/06/2014] [Indexed: 11/23/2022] Open
Abstract
Multiple sclerosis (MS) is a common inflammatory demyelinating disorder of the central nervous system. It frequently affects females in their reproductive phase of life. Therefore, family planning, pregnancy, and breastfeeding are important issues in the management of MS, particularly with respect to counseling and drug treatment. This paper reviews currently available data on the outcome of pregnancies in MS patients and the influence of pregnancy on the course of the disease. We give an update on the use of various disease-modifying MS drugs during pregnancy and breastfeeding. In addition to established therapies such as interferon-β, glatiramer acetate, natalizumab, and fingolimod, we also discuss the state of knowledge about new agents such as dimethyl fumarate, teriflunomide, and alemtuzumab in the context of pregnancy and breastfeeding.
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Affiliation(s)
- Nadja Borisow
- NeuroCure Clinical Research Center and Clinical and Experimental Research Center for Multiple Sclerosis, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Friedemann Paul
- NeuroCure Clinical Research Center and Clinical and Experimental Research Center for Multiple Sclerosis, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Jan Dörr
- NeuroCure Clinical Research Center and Clinical and Experimental Research Center for Multiple Sclerosis, Charité – Universitätsmedizin Berlin, Berlin, Germany
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Ghezzi A, Annovazzi P, Portaccio E, Cesari E, Amato MP. Current recommendations for multiple sclerosis treatment in pregnancy and puerperium. Expert Rev Clin Immunol 2014; 9:683-91; quiz 692. [PMID: 23899239 DOI: 10.1586/1744666x.2013.811046] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
As multiple sclerosis (MS) typically starts at about 30 years of age, and is twice more frequent in females than in males, women with MS frequently face issues related to pregnancy and to the effects of medications commonly used in MS treatment. In this review, the authors provide and summarize literature data addressing the effect of MS and its treatments on pregnancy, delivery, postpartum and conception. There is a strong evidence that relapses are fewer during pregnancy but more frequent during postpartum, and that IFN-β and glatiramer acetate do not expose patients and their babies to relevant adverse events; nevertheless, these drugs should be discontinued during pregnancy and before conception. However, if their preventive withdrawal exposes patients to a high risk of disease activity, these medications could be continued until proven conception. Little information is available on the effect of natalizumab and fingolimod.
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Affiliation(s)
- Angelo Ghezzi
- UO Neurologia 2 - Centro Studi Sclerosi Multipla, Ospedale di Gallarate, Via Pastori 4, 21013 Gallarate, Italy.
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Abstract
PURPOSE OF REVIEW This article reviews the current understanding of the interactions between multiple sclerosis (MS) and pregnancy, and implications for reproductive counseling. This is a key topic in MS because the typical patient is a young woman of childbearing age. RECENT FINDINGS It has been known for some time that MS disease activity markedly reduces during the last trimester of pregnancy, then markedly increases in the 3 months postpartum before returning to the prepregnancy baseline. High relapse rate or disability before pregnancy, as well as relapse during pregnancy, have been associated with increased risk for postpartum attacks. Recent data continue to support the conclusion that long-term disease progression is not worsened (and may actually be lessened) with pregnancy in patients with relapsing MS; the data are not so clear for those with progressive MS. Among the MS disease-modifying therapies, the only one that requires contraception use by men is the new oral agent teriflunomide, because the drug is present in semen. It is reassuring that, to date, no human teratogenic effects have been documented for any of the MS disease-modifying therapies. SUMMARY Pregnancy has a profound effect on MS disease activity. Identification of the responsible mechanisms for this effect should lead to new disease insights and therapeutic strategies.
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Lu E, Wang BW, Guimond C, Synnes A, Sadovnick AD, Dahlgren L, Traboulsee A, Tremlett H. Safety of disease-modifying drugs for multiple sclerosis in pregnancy: current challenges and future considerations for effective pharmacovigilance. Expert Rev Neurother 2013; 13:251-60; quiz 261. [PMID: 23448215 DOI: 10.1586/ern.13.12] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
When contemplating a pregnancy, women treated for multiple sclerosis (MS) with a disease-modifying drug must decide to discontinue their medication before conception or risk exposing their unborn child to potential drug toxicity. Few studies exist as reference for patients and physicians, and of those available, the majority are less than ideal due to real-world constraints, ethical issues and methodological shortcomings. The authors provide a brief summary of existing animal and human data with current recommendations regarding the safety of IFN-β, glatiramer acetate, natalizumab, mitoxantrone, fingolimod and teriflunomide during pregnancy and lactation in women with MS. We also assess the quality, strengths and limitations of the existing studies including challenges with study design. The investigation of outcomes such as spontaneous abortion and congenital anomalies are highlighted with potential methodological improvements for future studies on drug safety in pregnancy suggested. The authors explore the pharmacokinetics and pharmacodynamics of the MS disease-modifying drugs for their possible mechanistic role in fetal harm and discuss the potential role of clinical trials. Future pharmacovigilance studies should continue to pursue multicenter collaboration with an emphasis on appropriate study design.
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Affiliation(s)
- Ellen Lu
- Department of Medicine, Division of Neurology, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
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Berlin CM, van den Anker JN. Safety during breastfeeding: drugs, foods, environmental chemicals, and maternal infections. Semin Fetal Neonatal Med 2013; 18:13-8. [PMID: 23131768 DOI: 10.1016/j.siny.2012.09.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The two ultimate goals of using maternal medications during breastfeeding are (i) to provide definitive therapy for maternal conditions for which the drugs have been prescribed, and (ii) to assure protection of the nursing infant from any adverse event related to his/her mother's treatment. Fortunately there are only a few drugs that have been identified as potentially causing harm to the infant. Analytic techniques exist to measure compounds in concentrations as small as nanograms per liter of milk. For nearly all compounds these very small amounts would not be able to exert pharmacological activity, even if absorbed by the infant via the oral route. For environmental chemicals, this ability to measure very small amounts exceeds our knowledge of any biological activity. Concern over any possible adverse event to the nursing infant should take into account the drug, its dose, the age of the infant, recognition of the interindividual variation in drug response and the role of pharmacogenetics. The latter two variables are closely linked.
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Affiliation(s)
- Cheston M Berlin
- Department of Pediatrics, Penn State Children's Hospital, Milton S. Hershey Medical Center, P.O. Box 850, MC HS83, Hershey, PA 17033, USA.
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Houtchens MK, Kolb CM. Multiple sclerosis and pregnancy: therapeutic considerations. J Neurol 2012; 260:1202-14. [PMID: 22926165 DOI: 10.1007/s00415-012-6653-9] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2012] [Revised: 08/07/2012] [Accepted: 08/08/2012] [Indexed: 12/15/2022]
Abstract
For women with multiple sclerosis (MS) who become pregnant, the risks and benefits of ongoing therapy for the health of both the mother and the fetus must be carefully considered. Based on a literature review and our MS center's standard practices, we provide guidance to aid clinical decision making in the absence of clear evidence-based clinical practice guidelines. Women seeking to achieve pregnancy should generally discontinue disease-modifying therapy use prior to attempting conception. For example, the immunosuppressant mitoxantrone is teratogenic and should be prescribed only with the assurance of effective contraception. Conception should be discouraged for patients on fingolimod, because of the limited information available on human pregnancy outcomes. Current evidence, including data from pregnancy registries for glatiramer acetate (GA), interferon beta-1a (IFNβ-1a), and natalizumab, has not shown specific patterns of malformations suggesting teratogenicity. Pregnancy registry data have not been published for IFNβ-1b. During breastfeeding, intravenous immunoglobulin and corticosteroids are generally safe and may be associated with a reduction in postpartum relapses; however, a washout period is recommended between corticosteroid administration and the resumption of breastfeeding. Clinical data on the use of IFNβ, GA, and natalizumab during lactation are limited. Mitoxantrone is contraindicated during breastfeeding, and fingolimod should be avoided in nursing mothers, because of a lack of data.
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Affiliation(s)
- Maria K Houtchens
- Department of Neurology, Partners Multiple Sclerosis Center, Brigham and Women's Hospital, Harvard Medical School, 1 Brookline Place #225, Brookline, MA 02445, USA.
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