Intravenous immunoglobulin treatment in multiple sclerosis: A prospective, rater-blinded analysis of relapse rates during pregnancy and the postnatal period

Multiple Sclerosis: An Emergency Medicine-Focused Narrative Review

BACKGROUND

Multiple sclerosis (MS) is a rare but serious condition associated with significant morbidity.

OBJECTIVE

This review provides a focused assessment of MS for emergency clinicians, including the presentation, evaluation, and emergency department (ED) management based on current evidence.

DISCUSSION

MS is an autoimmune disorder targeting the central nervous system (CNS), characterized by clinical relapses and radiological lesions disseminated in time and location. Patients with MS most commonly present with long tract signs (e.g., myelopathy, asymmetric spastic paraplegia, urinary dysfunction, Lhermitte's sign), optic neuritis, or brainstem syndromes (bilateral internuclear ophthalmoplegia). Cortical syndromes or multifocal presentations are less common. Radiologically isolated syndrome and clinically isolated syndrome (CIS) may or may not progress to chronic forms of MS, including relapsing remitting MS, primary progressive MS, and secondary progressive MS. The foundation of outpatient management involves disease-modifying therapy, which is typically initiated with the first signs of disease onset. Management of CIS and acute flares of MS in the ED includes corticosteroid therapy, ideally after diagnostic testing with imaging and lumbar puncture for cerebrospinal fluid analysis. Emergency clinicians should evaluate whether patients with MS are presenting with new-onset debilitating neurological symptoms to avoid unnecessary testing and admissions, but failure to appropriately diagnose CIS or MS flare is associated with increased morbidity.

CONCLUSIONS

An understanding of MS can assist emergency clinicians in better diagnosing and managing this neurologically devastating disease.

Multiple sclerosis and pregnancy: Pathogenesis, influencing factors, and treatment options

Multiple sclerosis (MS) is an autoimmune-mediated degenerative disease of the central nervous system, characterized by inflammatory demyelination. It is primarily found in women of childbearing age, making pregnancy a significant concern for both patients with MS and clinicians. To assist these patients in achieving their desire for pregnancy, reducing MS relapses during all stages of pregnancy, preventing the progression of MS, mitigating the impact of MS treatment on the course and outcome of pregnancy, and a thorough understanding of the relationship between pregnancy and MS, as well as specific management and the application of relevant medications for MS patients at each stage of pregnancy, are essential. This article provides an update on pregnancy-related issues in women with MS, including the general recommendations for management at each stage of pregnancy.

Pregnancy and multiple sclerosis: 2022 recommendations from the French multiple sclerosis society

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.

COPP-MS: COrticosteroids during the Post-Partum in relapsing Multiple Sclerosis patients

BACKGROUND

No specific treatment has demonstrated its effectiveness to prevent post-partum relapses for multiple sclerosis (MS) women.

OBJECTIVE

To assess the effectiveness of preventive high-dose corticosteroids in the post-partum period by comparing two strategies: (1) no preventive treatment and (2) standardized preventive treatment.

METHODS

We selected five French Multiple Sclerosis centers using the same post-partum strategy for their patients-either high-dose steroids (treating centers TC) or no treatment (non-treating centers NTC). We included relapsing-remitting multiple sclerosis women who delivered between January 2007 and January 2017. Our primary outcomes were the time from delivery to first relapse, EDSS progression and MRI activity between patients of treating centers and non-treating centers, after propensity-score weighting.

RESULTS

350 patients were included (116 from treating centers, 234 from non-treating centers). For both groups, the annualized relapse rate decreased during pregnancy (0.28 in treating centers and 0.34 in non-treating centers during the third trimester) and increased during the first post-partum trimester (0.45 and 0.69, respectively) with 11% and 14% (NS) of patients facing at least one relapse, respectively. Our primary outcomes were not statistically different between both groups.

CONCLUSION

This study provides class III evidence that systematic high-dose corticosteroids are not associated with a reduced inflammatory activity during the post-partum period in multiple sclerosis patients.

Multiple Sclerosis in Pregnancy and its Role in Female Fertility: A Systematic Review

Multiple sclerosis (MS) is a neurological disease that typically affects young women of reproductive age. There are still many questions and heterogeneous clinical approaches partly due to the lack of consensus and guidelines. For many years, women with MS have been discouraged from getting pregnant for fears that the disease might negatively affect the fetus or increase their obstetric risk or for claims that the disease might decrease fertility. However, fertility does not seem to be impaired to a larger extent in women with MS. Therefore, all healthcare providers involved in the follow-up of multiple sclerosis patients must be prepared to discuss future fertility, pregnancy, and others matters, in addition to providing them with the best possible counseling. This study presents data based on updated evidence and discusses fertility and pregnancy in patients with MS with respect to the impacts of pregnancy on the risk and prognostic factors tied to MS, and the impact of MS on pregnancy outcomes and fertility treatments administered to females with MS. In conclusion, a clear relationship between infertility and MS has not been established. There seems to exist a link between disease aggressiveness and progression with several processes that might impair fertility. However, MS does not stand as a contraindication to assisted reproductive technology. From the several studies analyzed, it is possible to conclude that pregnancy is possible in women with MS. It is important to discuss and plan the ideal moment to start treatment and managing pregnancy and contraception aiming at better results.

Immune-Mediated Myelopathies: A Review of Etiologies, Diagnostic Approach, and Therapeutic Management

Myelopathy is a broad term used to describe a heterogeneous group of disorders that affects the spinal cord; the focus of this article will be a subgroup of these disorders with an autoimmune and inflammatory-based pathology. Symptoms typically develop over hours or days and then worsen over a matter of days to weeks, but sometimes can have a more insidious or subacute presentation, which can make the diagnosis more puzzling. Despite relatively low incidence rates, almost a third of affected patients are left with severely disabling symptoms. Prompt recognition of the underlying etiology is essential so that a specific targeted therapy can be implemented for optimal outcomes. The authors discuss a systematic approach to immune-mediated myelopathies, with a focus on the unique characteristics of each that may aid in diagnosis.

Relapsing and progressive MS: the sex-specific perspective

Background:

Multiple sclerosis (MS) is an inflammatory and neurodegenerative disease whose aetiology is not fully understood. The female sex is clearly predominant, with a sex ratio between 2 and 3. In primary progressive MS the sex ratio almost balances out. Since the age at onset is higher for patients with progressive onset (POMS) than for relapsing onset (ROMS), it can be hypothesized that the age at onset is a decisive factor for the sex ratio.

Methods:

To address this aspect, we compare clinical and demographic data between females and males for the different disease courses within the population of the German MS Register by the German MS Society. Only patients with complete details in mandatory data items and a follow-up visit since 01. Jan 2018 were included.

Results:

A total of 18,728 patients were included in our analyses, revealing a female-to-male ratio of 2.6 (2.7 for patients with ROMS and 1.3 for POMS). The age at diagnosis is higher in patients with POMS (43.3 and 42.3 years for females and males versus 32.1 and 33.2 years, respectively). Females irrespective of disease course are statistically significantly more often affected by cognitive impairment (POMS: p = 0.013, ROMS: p = 0.001) and depression (POMS: p = 0.002, ROMS: 0.001) and suffer more often from pain (POMS and ROMS: p < 0.001). Fatigue is significantly more often seen in females with ROMS (p < 0.001) but not in POMS. Females with ROMS retire significantly (p < 0.001) earlier (42.8 versus 44.2 years) and to a greater extent than males (28 versus 24%). Disease progression was similar for women and men.

Conclusion:

Our analysis shows that clinical and demographic data differ more between disease courses than between men and women. For pain, depression and cognitive impairment the female sex is the decisive factor. Whether these factors are responsible for the earlier retirement of females with ROMS is not clear. Appropriate measures for optimization of symptomatic treatment as well as to promote employment should be taken.

Treatment Optimization in Multiple Sclerosis: Canadian MS Working Group Recommendations

The Canadian Multiple Sclerosis Working Group has updated its treatment optimization recommendations (TORs) on the optimal use of disease-modifying therapies for patients with all forms of multiple sclerosis (MS). Recommendations provide guidance on initiating effective treatment early in the course of disease, monitoring response to therapy, and modifying or switching therapies to optimize disease control. The current TORs also address the treatment of pediatric MS, progressive MS and the identification and treatment of aggressive forms of the disease. Newer therapies offer improved efficacy, but also have potential safety concerns that must be adequately balanced, notably when treatment sequencing is considered. There are added discussions regarding the management of pregnancy, the future potential of biomarkers and consideration as to when it may be prudent to stop therapy. These TORs are meant to be used and interpreted by all neurologists with a special interest in the management of MS.

Treatment Effectiveness for Resolution of Multiple Sclerosis Relapse in a US Health Plan Population

INTRODUCTION

Timely and effective resolution of multiple sclerosis (MS) relapse is critical to minimizing residual deficits, which can result in neurologic disability. Oral corticosteroids (OCS) and intravenous corticosteroids [intravenous methylprednisolone (IVMP)] are earlier line treatments; alternatives include repository corticotropin injection (RCI; H.P. Acthar® Gel), plasmapheresis (PMP), and intravenous immunoglobulin (IVIG). Contemporary insight into the use of relapse treatments and their effectiveness is needed.

OBJECTIVE

To evaluate relapse rates, frequency of treatments used, and treatment effectiveness (i.e., relapse resolution).

METHODS

A retrospective analysis of patients ages 18-89 years experiencing MS relapse from 1 January 2008 to 30 June 2015 was conducted using administrative claims data. MS relapse was defined based on established claims-based methodology. The first claim for relapse treatment (i.e., prescription or administration) was used to designate the treatment group and relapse date, respectively. Relapses occurring ≤ 30 days were considered an episode. The first relapse episode was identified for every patient. Treatment was deemed effective in resolving the relapse if no additional relapses followed within the episode; otherwise, the relapse was considered unresolved. A 5-day OCS taper following IVMP administration, designated IVMP ± OCS, was allowed. Relapse frequency, treatment use, and relapse resolution were quantified. Relapse resolution was likewise evaluated in patients continuously enrolled for 12 months before and after first treatment with RCI or PMP/IVIG, with PMP/IVIG administrations within 7 days of each other being considered a single course of therapy.

RESULTS

During the study period, 9574 patients experienced ≥ 1 relapse; 26.0% of patients had ≥ 2 relapses/year. The mean number of relapse episodes was 2.6 over a mean follow-up of 2.7 years for an annualized relapse rate of 1.0. Corticosteroids were the first treatment used in 90.4% of relapses (OCS = 51.8%, IVMP = 38.6%), followed by IVIG (6.0%), RCI (2.2%) and PMP (1.5%). The proportion of patients achieving relapse resolution with their first treatment was 90.5% with OCS (n = 5710), 47.8% with IVMP ± OCS (n = 3425), 96.9% with RCI (n = 195), 50.7% with PMP (n = 73), and 43.9% with IVIG (n = 171). Among continuously enrolled patients (n = 373), relapse resolution was 95.7% with RCI (n = 232) and 66.0% with PMP/IVIG (n = 141); significant cohort differences were observed.

CONCLUSIONS

As demonstrated in other studies, OCS were generally effective. However, real-world effectiveness varied with other treatments. Relapse resolution of the first treatment with OCS was higher than with IVMP ± OCS; similarly, relapse resolution was higher with RCI as the first treatment than with PMP/IVIG. Results demonstrate RCI's effectiveness in appropriate patients. Limitations pertaining to claims-based research apply.

FUNDING

Mallinckrodt Pharmaceuticals (Bedminster, NJ).

Intravenous immunoglobulin treatment in multiple sclerosis: A prospective, rater-blinded analysis of relapse rates during pregnancy and the postnatal period

BACKGROUND

Multiple sclerosis (MS) affects predominantly young women. Currently available disease-modifying drugs have neither been approved during pregnancy nor nursing.

AIMS

Evaluating the effect of treatment with intravenous immunoglobulin (IVIg) in MS patients with desire to have a baby.

METHODS

In all, 70 MS patients were either treated with IVIg before conception, during first trimester of pregnancy and 12 months postnatal (group I, n = 38) or started IVIg after delivery for 12 months (group II, n = 23) or were untreated (group III, n = 9). Relapse rates and disease progression were analyzed.

RESULTS

Pre-gestational relapse rates differed between groups. Lowest relapse rates were observed during late pregnancy, followed by an elevated relapse rate after delivery compared to the pre-pregnancy year and the first trimester. Only in group I, the postnatal relapse rate did not exceed the relapse rate before conception. IVIg treatment did not influence disease progression after delivery.

CONCLUSIONS

In MS patients, IVIg treatment during and/or after delivery is an option to reduce the incidence of relapses during pregnancy and the postnatal period. Surprisingly, untreated patients becoming pregnant showed an increase in the relapse rate in the first trimester compared with the pre-gestational period. How alterations of hormone status during pregnancy affect disease activity in MS has to be further investigated.