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Graham EL, Bove R, Costello K, Crayton H, Jacobs DA, Shah S, Sorrell F, Stoll SS, Houtchens MK. Practical Considerations for Managing Pregnancy in Patients With Multiple Sclerosis: Dispelling the Myths. Neurol Clin Pract 2024; 14:e200253. [PMID: 38585436 PMCID: PMC10996912 DOI: 10.1212/cpj.0000000000200253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 11/27/2023] [Indexed: 04/09/2024]
Abstract
Purpose of Review Lack of consistent data and guidance have led to variations between clinicians in the management of pregnancy in women with multiple sclerosis (MS). Pregnant and/or lactating women are often excluded from clinical trials conducted in MS, and thus, the labeling for most disease-modifying therapies (DMTs) excludes use during pregnancy. This has led to heterogeneity in interpretation and labeling regarding the safety of DMTs during pregnancy and lactation and the required preconception washout periods. This review identifies key themes where there is conflicting information surrounding family planning and pregnancy in MS, focusing on the most common discussion points between physicians and patients during preconception planning, pregnancy, postpartum, and lactation. The goal was to inform the patient-physician conversation and provide best practice recommendations based on expert clinical expertise and experience. Recent Findings We outline the latest evidence-based data for DMT use during pregnancy and lactation, the effect of MS on fertility and fertility treatments, the risk of adverse pregnancy and delivery outcomes, the risk of postpartum relapse, and immunization and clinical imaging safety during pregnancy and breastfeeding. Summary Management of family planning and pregnancy in patients with MS requires the most current information. Health care providers should discuss family planning early and frequently with patients with MS, and partners where practicable. Because management of pregnant people with MS will often require a risk/benefit analysis of their needs, shared decision-making in family planning discussions is emphasized. Additional data are needed for specific and underrepresented populations with MS (e.g., single parents or those from the LGBTQ+ community) and those at risk of racial and socioeconomic disparities in care. Pregnancy registries and the design and conduct of clinical trials focused on pregnant and lactating patients should provide additional data to guide the ongoing management of patients with MS.
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Affiliation(s)
- Edith L Graham
- Department of Neurology (ELG), Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Neurology (RB), UCSF Weill Institute for Neurosciences, University of California, San Francisco; Can Do Multiple Sclerosis (KC), Avon, CO; Multiple Sclerosis Center of Greater Washington (HC), Vienna, VA; Department of Neurology (DAJ), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Neurology (SS), Duke University School of Medicine, Durham, NC; Envision Pharma Group (FS), Glasgow, UK; Stoll Medical Group (SSS), Philadelphia, PA; and Brigham Multiple Sclerosis Center (MKH), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Riley Bove
- Department of Neurology (ELG), Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Neurology (RB), UCSF Weill Institute for Neurosciences, University of California, San Francisco; Can Do Multiple Sclerosis (KC), Avon, CO; Multiple Sclerosis Center of Greater Washington (HC), Vienna, VA; Department of Neurology (DAJ), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Neurology (SS), Duke University School of Medicine, Durham, NC; Envision Pharma Group (FS), Glasgow, UK; Stoll Medical Group (SSS), Philadelphia, PA; and Brigham Multiple Sclerosis Center (MKH), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Kathleen Costello
- Department of Neurology (ELG), Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Neurology (RB), UCSF Weill Institute for Neurosciences, University of California, San Francisco; Can Do Multiple Sclerosis (KC), Avon, CO; Multiple Sclerosis Center of Greater Washington (HC), Vienna, VA; Department of Neurology (DAJ), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Neurology (SS), Duke University School of Medicine, Durham, NC; Envision Pharma Group (FS), Glasgow, UK; Stoll Medical Group (SSS), Philadelphia, PA; and Brigham Multiple Sclerosis Center (MKH), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Heidi Crayton
- Department of Neurology (ELG), Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Neurology (RB), UCSF Weill Institute for Neurosciences, University of California, San Francisco; Can Do Multiple Sclerosis (KC), Avon, CO; Multiple Sclerosis Center of Greater Washington (HC), Vienna, VA; Department of Neurology (DAJ), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Neurology (SS), Duke University School of Medicine, Durham, NC; Envision Pharma Group (FS), Glasgow, UK; Stoll Medical Group (SSS), Philadelphia, PA; and Brigham Multiple Sclerosis Center (MKH), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Dina A Jacobs
- Department of Neurology (ELG), Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Neurology (RB), UCSF Weill Institute for Neurosciences, University of California, San Francisco; Can Do Multiple Sclerosis (KC), Avon, CO; Multiple Sclerosis Center of Greater Washington (HC), Vienna, VA; Department of Neurology (DAJ), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Neurology (SS), Duke University School of Medicine, Durham, NC; Envision Pharma Group (FS), Glasgow, UK; Stoll Medical Group (SSS), Philadelphia, PA; and Brigham Multiple Sclerosis Center (MKH), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Suma Shah
- Department of Neurology (ELG), Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Neurology (RB), UCSF Weill Institute for Neurosciences, University of California, San Francisco; Can Do Multiple Sclerosis (KC), Avon, CO; Multiple Sclerosis Center of Greater Washington (HC), Vienna, VA; Department of Neurology (DAJ), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Neurology (SS), Duke University School of Medicine, Durham, NC; Envision Pharma Group (FS), Glasgow, UK; Stoll Medical Group (SSS), Philadelphia, PA; and Brigham Multiple Sclerosis Center (MKH), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Francesca Sorrell
- Department of Neurology (ELG), Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Neurology (RB), UCSF Weill Institute for Neurosciences, University of California, San Francisco; Can Do Multiple Sclerosis (KC), Avon, CO; Multiple Sclerosis Center of Greater Washington (HC), Vienna, VA; Department of Neurology (DAJ), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Neurology (SS), Duke University School of Medicine, Durham, NC; Envision Pharma Group (FS), Glasgow, UK; Stoll Medical Group (SSS), Philadelphia, PA; and Brigham Multiple Sclerosis Center (MKH), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Sharon S Stoll
- Department of Neurology (ELG), Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Neurology (RB), UCSF Weill Institute for Neurosciences, University of California, San Francisco; Can Do Multiple Sclerosis (KC), Avon, CO; Multiple Sclerosis Center of Greater Washington (HC), Vienna, VA; Department of Neurology (DAJ), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Neurology (SS), Duke University School of Medicine, Durham, NC; Envision Pharma Group (FS), Glasgow, UK; Stoll Medical Group (SSS), Philadelphia, PA; and Brigham Multiple Sclerosis Center (MKH), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Maria K Houtchens
- Department of Neurology (ELG), Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Neurology (RB), UCSF Weill Institute for Neurosciences, University of California, San Francisco; Can Do Multiple Sclerosis (KC), Avon, CO; Multiple Sclerosis Center of Greater Washington (HC), Vienna, VA; Department of Neurology (DAJ), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Neurology (SS), Duke University School of Medicine, Durham, NC; Envision Pharma Group (FS), Glasgow, UK; Stoll Medical Group (SSS), Philadelphia, PA; and Brigham Multiple Sclerosis Center (MKH), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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2
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Sparaco M, Carbone L, Landi D, Ingrasciotta Y, Di Girolamo R, Vitturi G, Marfia GA, Alviggi C, Bonavita S. Assisted Reproductive Technology and Disease Management in Infertile Women with Multiple Sclerosis. CNS Drugs 2023; 37:849-866. [PMID: 37679579 PMCID: PMC10570169 DOI: 10.1007/s40263-023-01036-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/24/2023] [Indexed: 09/09/2023]
Abstract
Multiple sclerosis (MS) predominantly affects women of fertile age. Various aspects of MS could impact on fertility, such as sexual dysfunction, endocrine alterations, autoimmune imbalances, and disease-modifying therapies (DMTs). The proportion of women with MS (wMS) requesting infertility management and assisted reproductive technology (ART) is increasing over time. In this review, we report on data regarding ART in wMS and address safety issues. We also discuss the clinical aspects to consider when planning a course of treatment for infertility, and provide updated recommendations to guide neurologists in the management of wMS undergoing ART, with the goal of reducing the risk of disease activation after this procedure. According to most studies, there is an increase in relapse rate and magnetic resonance imaging activity after ART. Therefore, to reduce the risk of relapse, ART should be considered in wMS with stable disease. In wMS, especially those with high disease activity, fertility issues should be discussed early as the choice of DMT, and fertility preservation strategies might be proposed in selected cases to ensure both disease control and a safe pregnancy. For patients with stable disease taking DMTs compatible with pregnancy, treatment should not be interrupted before ART. If the ongoing therapy is contraindicated in pregnancy, then it should be switched to a compatible therapy. Prior to beginning fertility treatments in wMS, it would be reasonable to assess vitamin D serum levels, thyroid function and its antibody serum levels; start folic acid supplementation; and ensure smoking and alcohol cessation, adequate sleep, and food hygiene. Cervico-vaginal swabs for Ureaplasma urealyticum, Mycoplasma hominis, and Chlamydia trachomatis, as well as serology for viral hepatitis, HIV, syphilis, and cytomegalovirus, should be performed. Steroids could be administered under specific indications. Although the available data do not clearly show a definite raised relapse risk associated with a specific ART protocol, it seems reasonably safe to prefer the use of gonadotropin-releasing hormone (GnRH) antagonists for ovarian stimulation. Close clinical and radiological monitoring is reasonably recommended, particularly after hormonal stimulation and in case of pregnancy failure.
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Affiliation(s)
- Maddalena Sparaco
- Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Piazza Miraglia, 2, 80138, Naples, Italy
| | - Luigi Carbone
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, Federico II University of Naples, Naples, Italy
| | - Doriana Landi
- Multiple Sclerosis Clinical and Research Unit, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Ylenia Ingrasciotta
- Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Raffaella Di Girolamo
- Department of Public Health, School of Medicine, Federico II University of Naples, Naples, Italy
| | - Giacomo Vitturi
- Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Girolama Alessandra Marfia
- Multiple Sclerosis Clinical and Research Unit, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Carlo Alviggi
- Department of Public Health, School of Medicine, Federico II University of Naples, Naples, Italy
| | - Simona Bonavita
- Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Piazza Miraglia, 2, 80138, Naples, Italy.
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Sokou R, Parastatidou S, Iliodromiti Z, Lampropoulou K, Vrachnis D, Boutsikou T, Konstantinidi A, Iacovidou N. Knowledge Gaps and Current Evidence Regarding Breastfeeding Issues in Mothers with Chronic Diseases. Nutrients 2023; 15:2822. [PMID: 37447149 DOI: 10.3390/nu15132822] [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: 05/24/2023] [Revised: 06/16/2023] [Accepted: 06/19/2023] [Indexed: 07/15/2023] Open
Abstract
The prevalence of chronic maternal disease is rising in the last decades in the developed world. Recent evidence indicated that the incidence of chronic maternal disease ranges from 10 to 30% of pregnancies worldwide. Several epidemiological studies in mothers with chronic diseases have mainly focused on the risk for adverse obstetric outcomes. Evidence from these studies supports a correlation between maternal chronic conditions and adverse perinatal outcomes, including increased risk for preeclampsia, cesarean section, preterm birth, and admission in the Neonatal Intensive Care Unit (NICU). However, there is a knowledge gap pertaining to the management of these women during lactation. This review aimed at summarizing the available research literature regarding breastfeeding in mothers with chronic diseases. Adjusted and evidence-based support may be required to promote breastfeeding in women with chronic diseases; however, our comprehension of breastfeeding in this subpopulation is still unclear. The literature related to breastfeeding extends in various scientific areas and multidisciplinary effort is necessary to compile an overview of current evidence and knowledge regarding breastfeeding issues in mothers with chronic diseases.
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Affiliation(s)
- Rozeta Sokou
- Neonatal Intensive Care Unit, "Agios Panteleimon" General Hospital of Nikea, 3 D.Mantouvalou Str., Nikea, 18454 Piraeus, Greece
- Neonatal Department, School of Medicine, National and Kapodistrian University of Athens, Aretaieio Hospital, 11528 Athens, Greece
| | - Stavroula Parastatidou
- Neonatal Intensive Care Unit, "Elena Venizelou" Maternity Hospital, 11521 Athens, Greece
| | - Zoi Iliodromiti
- Neonatal Department, School of Medicine, National and Kapodistrian University of Athens, Aretaieio Hospital, 11528 Athens, Greece
| | - Katerina Lampropoulou
- Neonatal Intensive Care Unit, School of Medicine, University of Ioannina, 45110 Ioannina, Greece
| | - Dionysios Vrachnis
- Endocrinology Unit, 2nd Department of Obstetrics and Gynecology, School of Medicine, National and Kapodistrian University of Athens, Aretaieio Hospital, 11528 Athens, Greece
| | - Theodora Boutsikou
- Neonatal Department, School of Medicine, National and Kapodistrian University of Athens, Aretaieio Hospital, 11528 Athens, Greece
| | - Aikaterini Konstantinidi
- Neonatal Intensive Care Unit, "Agios Panteleimon" General Hospital of Nikea, 3 D.Mantouvalou Str., Nikea, 18454 Piraeus, Greece
| | - Nicoletta Iacovidou
- Neonatal Department, School of Medicine, National and Kapodistrian University of Athens, Aretaieio Hospital, 11528 Athens, Greece
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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: 18] [Impact Index Per Article: 18.0] [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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Menascu S, Siegel-Kirshenbaum M, Dreyer-Alster S, Warszawer Y, Magalashvili D, Dolev M, Mandel M, Harari G, Achiron A. Intravenous immunoglobulin treatment during pregnancy and the post-partum period in women with multiple sclerosis: A prospective analysis. Mult Scler J Exp Transl Clin 2023; 9:20552173221151127. [PMID: 36687367 PMCID: PMC9853871 DOI: 10.1177/20552173221151127] [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: 10/10/2022] [Accepted: 12/30/2022] [Indexed: 01/19/2023] Open
Abstract
Background Relapsing-remitting multiple sclerosis (RRMS) affects predominantly young women within reproductive years. As an increased risk of relapses is known to occur during the post-partum period, it is important to consider treatment options. Aim Evaluate the effects of intravenous immunoglobulins (IVIg) to prevent post-partum relapses. Methods We prospectively followed 198 pregnant female RRMS patients, 67 treated with IVIg during pregnancy and the three months post-partum, and 131 untreated patients that served as controls. Results During the pre-gestation year, 41.4% were treated with immunomodulatory drugs, and 28.3% experienced a relapse. During pregnancy and the post-partum period, the number of relapsing patients significantly decreased in the IVIg group (37.3%, 10.4%, 8.9%, respectively, p = 0.0003), while no significant change was observed in the untreated group (23.7%, 17.6%, and 22.1%). During the three-month post-partum period, there were only mild and moderate relapses in the IVIg group, while in the untreated group, there were also severe relapses. Stepwise logistic regression that assessed the relation between three-month post-partum relapse and explanatory variables demonstrated that untreated patients had increased risk for post-partum relapse (odds ratio = 4.6, 95% CI [1.69, 12.78], p = 0.033). Conclusions IVIg treatment proved efficient to reduce the rate and severity of relapses during pregnancy and the three-month post-partum.
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Affiliation(s)
- Shay Menascu
- Multiple Sclerosis Center, Sheba Medical Center, Ramat-Gann, Israel,Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Michal Siegel-Kirshenbaum
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel,Fertility Unit, Department of Obstetrics and Gynecology, Sheba Medical Center, Ramat Gann, Israel
| | | | - Yehuda Warszawer
- Multiple Sclerosis Center, Sheba Medical Center, Ramat-Gann, Israel
| | | | - Mark Dolev
- Multiple Sclerosis Center, Sheba Medical Center, Ramat-Gann, Israel
| | - Mathilda Mandel
- Multiple Sclerosis Center, Sheba Medical Center, Ramat-Gann, Israel
| | - Gil Harari
- Multiple Sclerosis Center, Sheba Medical Center, Ramat-Gann, Israel
| | - Anat Achiron
- Multiple Sclerosis Center, Sheba Medical Center, Ramat-Gann, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
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6
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Lescot L, Lefort M, Leguy S, Le Page E, Vukusic S, Edan G, Kerbrat A, Lebrun-Frenay C, De Sèze J, Laplaud DA, Wiertlewski S, Leray E, Michel L. Disease modifying therapies and disease activity during pregnancy and postpartum in a contemporary cohort of relapsing Multiple Sclerosis patients. Mult Scler Relat Disord 2022; 68:104122. [PMID: 36037756 DOI: 10.1016/j.msard.2022.104122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 08/14/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND In Multiple Sclerosis (MS) women, therapeutic management for pregnancy planning and during pregnancy still represents a challenge regarding timing of disease-modifying therapies (DMT) stop, risk of disease reactivation and potential fetal toxicity. The objective of this study was to describe disease activity during pregnancy and postpartum depending on treatment status before conception in women with MS. METHODS 339 MS patients who have achieved a pregnancy between 2007 and 2017 were included. Women were classified according to their exposure to DMT in the 18 months period prior to pregnancy (untreated / first- / second/third-line treatment). RESULTS 122 women were not exposed to DMT prior to conception, whereas 147 were exposed to first-line DMT and 70 to second/third line DMT (73% to natalizumab and 23% to fingolimod) before conception. In the first-line group, the ARR decreased from 0.39 during the year before conception to 0.21 during pregnancy, whereas it increased in the second/third-line group from 0.59 to 0.78. 47.1% of the second/third-line group faced at least one relapse during pregnancy and the time from conception to first relapse was significantly shorter in this group (p < 10-4). The risk of relapse during pregnancy and postpartum was associated with occurrence of pre-conception relapses and second/third line DMT exposure before pregnancy. CONCLUSION Careful consideration should be given to natalizumab and fingolimod exposed patients before conception as they are at higher risk of reactivation of MS during pregnancy.
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Affiliation(s)
- Lucile Lescot
- Neurology Department, CRCSEP, Rennes Clinical Investigation Centre CIC-P 1414, Service de Neurologie, CHU Pontchaillou, Rennes University Hospital Rennes University INSERM, Rennes 35033, France
| | - Mathilde Lefort
- EHESP, CNRS, Inserm, Arènes - UMR 6051, RSMS (Recherche sur les Services et Management en Santé) - U 1309, University Rennes, Rennes F-35000, France
| | - Soizic Leguy
- Neurology Department, CRCSEP, Rennes Clinical Investigation Centre CIC-P 1414, Service de Neurologie, CHU Pontchaillou, Rennes University Hospital Rennes University INSERM, Rennes 35033, France
| | - Emmanuelle Le Page
- Neurology Department, CRCSEP, Rennes Clinical Investigation Centre CIC-P 1414, Service de Neurologie, CHU Pontchaillou, Rennes University Hospital Rennes University INSERM, Rennes 35033, France
| | - Sandra Vukusic
- Service de neurologie, Sclérose en plaques, Pathologies de la myéline et neuro-inflammation et centre de recherche, Ressources et compétences sur la sclérose en plaques, Hospices civils de Lyon, Bron 69677, France; Inserm 1028 et CNRS UMR 5292, Observatoire français de la sclérose en plaques, Centre de recherche en neurosciences de Lyon, Lyon 69003, France; Université de Lyon, Université Claude-Bernard Lyon 1, Lyon 69000, France; Eugène Devic EDMUS Foundation against multiple sclerosis, State-approved foundation, Bron 69677, France
| | - Gilles Edan
- Neurology Department, CRCSEP, Rennes Clinical Investigation Centre CIC-P 1414, Service de Neurologie, CHU Pontchaillou, Rennes University Hospital Rennes University INSERM, Rennes 35033, France
| | - Anne Kerbrat
- Neurology Department, CRCSEP, Rennes Clinical Investigation Centre CIC-P 1414, Service de Neurologie, CHU Pontchaillou, Rennes University Hospital Rennes University INSERM, Rennes 35033, France
| | | | - Jérome De Sèze
- Centre d'investigation clinique, INSERM U1434, Centre Hospitalier Universitaire de Strasbourg, 1 Place de l'Hôpital, Strasbourg 67000, France
| | - David Axel Laplaud
- Centre de Recherche en Transplantation et Immunologie UMR1064, INSERM, Université de Nantes, Nantes, France
| | - Sandrine Wiertlewski
- Centre de Recherche en Transplantation et Immunologie UMR1064, INSERM, Université de Nantes, Nantes, France
| | - Emmanuelle Leray
- EHESP, CNRS, Inserm, Arènes - UMR 6051, RSMS (Recherche sur les Services et Management en Santé) - U 1309, University Rennes, Rennes F-35000, France
| | - Laure Michel
- Neurology Department, CRCSEP, Rennes Clinical Investigation Centre CIC-P 1414, Service de Neurologie, CHU Pontchaillou, Rennes University Hospital Rennes University INSERM, Rennes 35033, France; Microenvironment, Cell Differentiation, Immunology and Cancer unit, INSERM, Rennes I University, French Blood Agency, Rennes, France.
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7
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Nytrova P, Dolezal O. Sex bias in multiple sclerosis and neuromyelitis optica spectrum disorders: How it influences clinical course, MRI parameters and prognosis. Front Immunol 2022; 13:933415. [PMID: 36016923 PMCID: PMC9396644 DOI: 10.3389/fimmu.2022.933415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 07/19/2022] [Indexed: 11/13/2022] Open
Abstract
This review is a condensed summary of representative articles addressing the sex/gender bias in multiple sclerosis (MS) and neuromyelitis optica spectrum disorders (NMOSD). The strong effects of sex on the incidence and possibly also the activity and progression of these disorders should be implemented in the evaluation of any phase of clinical research and also in treatment choice consideration in clinical practice and evaluation of MRI parameters. Some relationships between clinical variables and gender still remain elusive but with further understanding of sex/gender-related differences, we should be able to provide appropriate patient-centered care and research.
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Affiliation(s)
- Petra Nytrova
- Department of Neurology and Centre of Clinical Neuroscience, First Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czechia
- *Correspondence: Petra Nytrova,
| | - Ondrej Dolezal
- Department of Neurology, Dumfries and Galloway Royal Infirmary, NHS Scotland, Dumfries, United Kingdom
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Valero-López G, Millán-Pascual J, Iniesta-Martínez F, Delgado-Marín JL, Jimenez-Veiga J, Tejero-Martín AB, León-Hernández A, Zamarro-Parra J, Morales-Ortiz A, Meca-Lallana JE. Treatment with natalizumab during pregnancy in multiple sclerosis: The experience of implementing a clinical practice protocol (NAP-30). Mult Scler Relat Disord 2022; 66:104038. [PMID: 35870370 DOI: 10.1016/j.msard.2022.104038] [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: 05/03/2022] [Revised: 06/24/2022] [Accepted: 07/05/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Pregnancy planning in women with highly active multiple sclerosis (HAMS) who need a high-efficacy disease-modifying therapy (heDMT) currently requires a careful risk-benefit evaluation. This includes minimizing fetal drug toxicity and preventing MS reactivation. We describe our experience with natalizumab in women with HAMS and unplanned pregnancy by implementing a clinical practice protocol (NAP-30) designed to maintain the effectiveness of natalizumab during pregnancy, reduce fetal exposure and prevent complications. METHODS This was an observational retrospective study including women with HAMS on active treatment with natalizumab who became unexpectedly pregnant in the period 2018-2021 and continued this treatment during pregnancy according to the NAP-30 protocol. MS clinical and radiological variables were analyzed before and during pregnancy and in the postpartum period, along with maternal and fetal toxicity during pregnancy and safety findings in newborns. We also describe the NAP-30 protocol, which includes the use of a bridging dose to adjust and maintain natalizumab infusions every 6 weeks during pregnancy up to week 30 and scheduled delivery at week 40. RESULTS Six women (one in her first gestation) with a median age of 31.5 years at the onset of pregnancy (min-max: 24-37 years) were included. All were negative for anti-John Cunningham virus (JCV) antibodies and were on treatment with intravenous natalizumab 300 mg every 4 weeks. At the time of conception, three patients had received 12, 17 and 53 infusions of natalizumab, respectively, while for the remaining three patients natalizumab was their first DMT (two patients had received 6 infusions and one patient had received 3 infusions of natalizumab). All six patients received 6 doses of natalizumab during pregnancy according to the NAP-30 protocol. After delivery, all six patients restarted natalizumab every 4 weeks (median: 3 days; range: 2-4 days). No patients had relapses during pregnancy or at 6 months postpartum, nor did they develop any general health or laboratory abnormalities. The MRI scan performed at 4-6 months postpartum showed no new T2 lesions or gadolinium-enhancing lesions. No miscarriages or threatened miscarriages were reported. One of the patients underwent elective preterm delivery at week 35 after mild-to-moderate anemia was detected by fetal Doppler scan. The newborn had low birth weight (2080 g) and mild anemia, which resolved within two months with oral iron supplementation. The other infants were born with normal birth weight and showed no blood count abnormalities. After a median follow-up of 10 months, all six babies showed normal development with no complications detected. CONCLUSIONS Based on our experience, the implementation of the NAP-30 protocol in women with HAMS and unplanned pregnancy undergoing treatment with natalizumab allows the continuation of natalizumab during pregnancy, with a very favorable clinical and radiological effectiveness and maternal-fetal safety profile during pregnancy and postpartum. Both in pregnancy with HAMS and in general, and particularly for successful implementation of the NAP-30 protocol, obstetric support and monitoring is essential for adequate pregnancy management.
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Affiliation(s)
- Gabriel Valero-López
- CSUR Multiple Sclerosis and Clinical Neuroimmunology Unit, Neurology Department. "Virgen de la Arrixaca" Clinical University Hospital, IMIB-Arrixaca. Murcia, Spain; Clinical Neuroimmunology and Multiple Sclerosis Cathedra. UCAM. Universidad Católica San Antonio, Murcia, Spain
| | - Jorge Millán-Pascual
- CSUR Multiple Sclerosis and Clinical Neuroimmunology Unit, Neurology Department. "Virgen de la Arrixaca" Clinical University Hospital, IMIB-Arrixaca. Murcia, Spain; Clinical Neuroimmunology and Multiple Sclerosis Cathedra. UCAM. Universidad Católica San Antonio, Murcia, Spain
| | - Francisca Iniesta-Martínez
- CSUR Multiple Sclerosis and Clinical Neuroimmunology Unit, Neurology Department. "Virgen de la Arrixaca" Clinical University Hospital, IMIB-Arrixaca. Murcia, Spain; Clinical Neuroimmunology and Multiple Sclerosis Cathedra. UCAM. Universidad Católica San Antonio, Murcia, Spain.
| | - Juan L Delgado-Marín
- Fetal Medicine Unit, Obstetrics Department, "Virgen de la Arrixaca" Clinical University Hospital, IMIB-Arrixaca, Murcia, Spain.
| | - Judith Jimenez-Veiga
- CSUR Multiple Sclerosis and Clinical Neuroimmunology Unit, Neurology Department. "Virgen de la Arrixaca" Clinical University Hospital, IMIB-Arrixaca. Murcia, Spain; Clinical Neuroimmunology and Multiple Sclerosis Cathedra. UCAM. Universidad Católica San Antonio, Murcia, Spain
| | - Ana B Tejero-Martín
- CSUR Multiple Sclerosis and Clinical Neuroimmunology Unit, Neurology Department. "Virgen de la Arrixaca" Clinical University Hospital, IMIB-Arrixaca. Murcia, Spain.
| | - Adelaida León-Hernández
- Neurorradiology Unit, Radiodiagnostic Department, "Virgen de la Arrixaca" Clinical University Hospital. IMIB-Arrixaca, Murcia, Spain
| | - Joaquín Zamarro-Parra
- Neurorradiology Unit, Radiodiagnostic Department, "Virgen de la Arrixaca" Clinical University Hospital. IMIB-Arrixaca, Murcia, Spain
| | - Ana Morales-Ortiz
- CSUR Multiple Sclerosis and Clinical Neuroimmunology Unit, Neurology Department. "Virgen de la Arrixaca" Clinical University Hospital, IMIB-Arrixaca. Murcia, Spain
| | - José E Meca-Lallana
- CSUR Multiple Sclerosis and Clinical Neuroimmunology Unit, Neurology Department. "Virgen de la Arrixaca" Clinical University Hospital, IMIB-Arrixaca. Murcia, Spain; Clinical Neuroimmunology and Multiple Sclerosis Cathedra. UCAM. Universidad Católica San Antonio, Murcia, Spain.
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9
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Leguy S, Lefort M, Lescot L, Michaud A, Vukusic S, Le Page E, Edan G, Kerbrat A, Lebrun-Frenay C, De Sèze J, Laplaud DA, Wiertlewski S, Leray E, Michel L. COPP-MS: COrticosteroids during the Post-Partum in relapsing Multiple Sclerosis patients. J Neurol 2022; 269:5571-5581. [PMID: 35737108 DOI: 10.1007/s00415-022-11215-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 06/02/2022] [Accepted: 06/03/2022] [Indexed: 10/17/2022]
Abstract
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.
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Affiliation(s)
- Soizic Leguy
- Neurology Department, CRC-SEP Rennes, Rennes Clinical Investigation Center, Rennes University Hospital Rennes University INSERM, CHU Pontchaillou, 35033, Rennes, France
| | - Mathilde Lefort
- EHESP, CNRS, Inserm, Arènes, UMR 6051, RSMS (Recherche sur les Services et Management en Santé), University Rennes, U 1309, 35000, Rennes, France.,CHU Rennes, Inserm, CIC 1414 [(Centre d'Investigation Clinique de Rennes)], University Rennes, 35000, Rennes, France
| | - Lucile Lescot
- Neurology Department, CRC-SEP Rennes, Rennes Clinical Investigation Center, Rennes University Hospital Rennes University INSERM, CHU Pontchaillou, 35033, Rennes, France
| | - Audrey Michaud
- EHESP, CNRS, Inserm, Arènes, UMR 6051, RSMS (Recherche sur les Services et Management en Santé), University Rennes, U 1309, 35000, Rennes, France
| | - Sandra Vukusic
- Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro-Inflammation et Centre de Recherche, Ressources et Compétences sur la Sclérose en Plaques, Hospices Civils de Lyon, 69677, Bron, France.,Inserm 1028 et CNRS UMR 5292, Observatoire Français de la Sclérose en Plaques, Centre de Recherche en Neurosciences de Lyon, 69003, Lyon, France.,Université de Lyon, université Claude-Bernard Lyon 1, 69000, Lyon, France.,Eugène Devic EDMUS Foundation Against Multiple Sclerosis, state-approved foundation, 69677, Bron, France
| | - Emmanuelle Le Page
- Neurology Department, CRC-SEP Rennes, Rennes Clinical Investigation Center, Rennes University Hospital Rennes University INSERM, CHU Pontchaillou, 35033, Rennes, France.,CHU Rennes, Inserm, CIC 1414 [(Centre d'Investigation Clinique de Rennes)], University Rennes, 35000, Rennes, France
| | - Gilles Edan
- Neurology Department, CRC-SEP Rennes, Rennes Clinical Investigation Center, Rennes University Hospital Rennes University INSERM, CHU Pontchaillou, 35033, Rennes, France.,CHU Rennes, Inserm, CIC 1414 [(Centre d'Investigation Clinique de Rennes)], University Rennes, 35000, Rennes, France
| | - Anne Kerbrat
- Neurology Department, CRC-SEP Rennes, Rennes Clinical Investigation Center, Rennes University Hospital Rennes University INSERM, CHU Pontchaillou, 35033, Rennes, France.,CHU Rennes, Inserm, CIC 1414 [(Centre d'Investigation Clinique de Rennes)], University Rennes, 35000, Rennes, France
| | | | - Jérôme De Sèze
- CRCSEP, CHU de Nice Pasteur 2, Université Nice Côte d'Azur UR2CA URRIS, Nice, France.,Centre d'investigation Clinique, INSERM U1434, Centre Hospitalier Universitaire de Strasbourg, 1 Place de l'Hôpital, 67000, Strasbourg, France
| | - David-Axel Laplaud
- Centre de Recherche en Transplantation et Immunologie UMR1064, INSERM; Université de Nantes, CHU de Nantes France, Nantes, France
| | - Sandrine Wiertlewski
- Centre de Recherche en Transplantation et Immunologie UMR1064, INSERM; Université de Nantes, CHU de Nantes France, Nantes, France
| | - Emmanuelle Leray
- EHESP, CNRS, Inserm, Arènes, UMR 6051, RSMS (Recherche sur les Services et Management en Santé), University Rennes, U 1309, 35000, Rennes, France.,CHU Rennes, Inserm, CIC 1414 [(Centre d'Investigation Clinique de Rennes)], University Rennes, 35000, Rennes, France
| | - Laure Michel
- Neurology Department, CRC-SEP Rennes, Rennes Clinical Investigation Center, Rennes University Hospital Rennes University INSERM, CHU Pontchaillou, 35033, Rennes, France. .,CHU Rennes, Inserm, CIC 1414 [(Centre d'Investigation Clinique de Rennes)], University Rennes, 35000, Rennes, France. .,Microenvironment, Cell Differentiation, Immunology and Cancer Unit, INSERM, Rennes I University, French Blood Agency, Rennes, France.
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10
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Pregnancy and Family Planning Considerations in Multiple Sclerosis. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2022. [DOI: 10.1007/s13669-022-00329-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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11
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Krajnc N, Bsteh G, Berger T, Mares J, Hartung HP. Monoclonal Antibodies in the Treatment of Relapsing Multiple Sclerosis: an Overview with Emphasis on Pregnancy, Vaccination, and Risk Management. Neurotherapeutics 2022; 19:753-773. [PMID: 35378683 PMCID: PMC8978776 DOI: 10.1007/s13311-022-01224-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2022] [Indexed: 01/10/2023] Open
Abstract
Monoclonal antibodies have become a mainstay in the treatment of patients with relapsing multiple sclerosis (RMS) and provide some benefit to patients with primary progressive MS. They are highly precise by specifically targeting molecules displayed on cells involved in distinct immune mechanisms of MS pathophysiology. They not only differ in the target antigen they recognize but also by the mode of action that generates their therapeutic effect. Natalizumab, an [Formula: see text]4[Formula: see text]1 integrin antagonist, works via binding to cell surface receptors, blocking the interaction with their ligands and, in that way, preventing the migration of leukocytes across the blood-brain barrier. On the other hand, the anti-CD52 monoclonal antibody alemtuzumab and the anti-CD20 monoclonal antibodies rituximab, ocrelizumab, ofatumumab, and ublituximab work via eliminating selected pathogenic cell populations. However, potential adverse effects may be serious and can necessitate treatment discontinuation. Most importantly, those are the risk for (opportunistic) infections, but also secondary autoimmune diseases or malignancies. Monoclonal antibodies also carry the risk of infusion/injection-related reactions, primarily in early phases of treatment. By careful patient selection and monitoring during therapy, the occurrence of these potentially serious adverse effects can be minimized. Monoclonal antibodies are characterized by a relatively long pharmacologic half-life and pharmacodynamic effects, which provides advantages such as permitting infrequent dosing, but also creates disadvantages regarding vaccination and family planning. This review presents an overview of currently available monoclonal antibodies for the treatment of RMS, including their mechanism of action, efficacy and safety profile. Furthermore, we provide practical recommendations for risk management, vaccination, and family planning.
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Affiliation(s)
- Nik Krajnc
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Gabriel Bsteh
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Thomas Berger
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Jan Mares
- Department of Neurology, Palacky University Olomouc, Olomouc, Czech Republic
| | - Hans-Peter Hartung
- Department of Neurology, Medical University of Vienna, Vienna, Austria.
- Department of Neurology, Palacky University Olomouc, Olomouc, Czech Republic.
- Department of Neurology, Medical Faculty, Heinrich-Heine University, Moorenstrasse 5, 40225, Düsseldorf, Germany.
- Brain and Mind Center, University of Sydney, Sydney, Australia.
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12
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Ostrem BL, Anderson A, Conway S, Healy BC, Oh J, Jacobs D, Dobson R, Graham EL, Sadovnick AD, Zimmerman V, Liu Y, Bove R, Houtchens M. Peripartum disease activity in moderately and severely disabled women with multiple sclerosis. Mult Scler J Exp Transl Clin 2022; 8:20552173221104918. [PMID: 35734229 PMCID: PMC9208060 DOI: 10.1177/20552173221104918] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 05/16/2022] [Indexed: 11/16/2022] Open
Abstract
Background The effects of pregnancy on multiple sclerosis (MS) inflammatory activity are not well described in women with moderate to severe disabilities. Objective To quantify the peripartum annualized relapse rate (ARR) in women with MS with an Expanded Disability Status Scale (EDSS) ≥ 3. Methods We performed a retrospective cohort study of 85 pregnancies in 74 subjects with preconception EDSS ≥ 3. We quantified peripartum ARR and tested for risk factors predictive of peripartum relapses, postpartum brain magnetic resonance imaging activity (new T2 or gadolinium-enhancing lesions), and disability worsening. Results There were 74 live births, with a 56% operative delivery rate. In subjects with relapsing-remitting MS, ARR decreased to 0.11 during the third trimester of pregnancy compared to 0.59 in the year preconception and increased to 1.22 in the 3 months postpartum. Women with a higher preconception EDSS had higher odds of postpartum relapses and clinically significant worsening of disability as compared to subjects with a lower EDSS. Conclusions Moderately to severely disabled women with MS have a lower risk of relapse during pregnancy as compared to preconception, followed by a marked increase postpartum. Further studies are needed to identify ways to reduce peripartum inflammatory activity and disability progression in women with MS with moderate to severe disability.
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Affiliation(s)
- Bridget LaMonica Ostrem
- Department of Neurology, Brigham and Women’s Hospital, Boston, MA, USA
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Annika Anderson
- Department of Neurology, University of California, San Francisco, CA, USA
| | | | - Brian C Healy
- Department of Neurology, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Jiwon Oh
- Division of Neurology, Department of Medicine, St. Michaels Hospital, University of Toronto, Toronto, Canada
| | - Dina Jacobs
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Center for Neuroinflammation and Experimental Therapeutics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Ruth Dobson
- Preventive Neurology Unit, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
- Department of Neurology, Royal London Hospital, Barts Health NHS Trust, London, UK
| | | | - A Dessa Sadovnick
- Departments of Neurology and Medical Genetics, University of British Columbia, Vancouver, BC, Canada
| | - Vanessa Zimmerman
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Center for Neuroinflammation and Experimental Therapeutics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Yanqing Liu
- Department of Neurology, Brigham and Women’s Hospital, Boston, MA, USA
| | - Riley Bove
- Department of Neurology, University of California, San Francisco, CA, USA
| | - Maria Houtchens
- Department of Neurology, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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13
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Berek K, Paganini C, Hegen H, Bsteh G, Grams A, Auer M, Berger T, Deisenhammer F, Di Pauli F. Natalizumab treatment during pregnancy in multiple sclerosis-clinical and bioethical aspects of an ongoing debate. Wien Med Wochenschr 2022; 172:373-378. [PMID: 35142953 DOI: 10.1007/s10354-022-00913-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 01/03/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Natalizumab is an approved treatment for relapsing remitting multiple sclerosis; however, its safety during pregnancy is not formally proven. CASE PRESENTATION We report a woman with multiple sclerosis being treated with natalizumab before pregnancy. After withdrawal of natalizumab, she suffered a severe, disabling rebound. In agreement with the patient, natalizumab was restarted during pregnancy. Our patient improved substantially and gave birth to a healthy boy. CONCLUSION Use of natalizumab during pregnancy may be an option in highly active multiple sclerosis.
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Affiliation(s)
- Klaus Berek
- Departmentof Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Claudia Paganini
- Department of Christian Philosophy, University of Innsbruck, Innsbruck, Austria
| | - Harald Hegen
- Departmentof Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Gabriel Bsteh
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Astrid Grams
- Department of Neuroradiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Michael Auer
- Departmentof Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Thomas Berger
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | | | - Franziska Di Pauli
- Departmentof Neurology, Medical University of Innsbruck, Innsbruck, Austria.
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14
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Bsteh G, Hegen H, Riedl K, Altmann P, Di Pauli F, Ehling R, Zulehner G, Rommer P, Leutmezer F, Deisenhammer F, Berger T. Estimating Risk of Multiple Sclerosis Disease Reactivation in Pregnancy and Postpartum: The VIPRiMS Score. Front Neurol 2022; 12:766956. [PMID: 35111123 PMCID: PMC8801570 DOI: 10.3389/fneur.2021.766956] [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: 08/30/2021] [Accepted: 12/15/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Evidence guiding personalized decision-making with respect to disease-modifying therapy (DMT) around pregnancy in relapsing multiple sclerosis (RMS) is lacking. Objective: To generate and validate a risk score for disease reactivation intrapartum and postpartum in RMS. Methods: From the Vienna Innsbruck MS database (VIMSD), we included 343 pregnancies in patients with RMS. Primary endpoint was disease reactivation. Patients were randomly assigned 2:1 in a generation and validation dataset. A predictive score was calculated using the Cox regression and validated. Results: In the generation dataset, occurrence of relapse and type of DMT in the year before conception, DMT washout duration, the Expanded Disability Status Scale (EDSS) at conception, and time until DMT restart postpartum were identified as independent predictors of disease reactivation (p < 0.001). The resulting 10-point risk score robustly predicted reactivation (explaining 75% of variance, p < 0.001) identifying patients at high [≥6 points; mean risk 65%; range 50–100%; hazard ratio (HR) 14.5], intermediate (3–5 points; mean risk 24%; range 15–35%; HR 4.3), and low risk (≤2 points; mean risk 6%; range 0–8%) of disease reactivation in pregnancy and up to 6 months postpartum. Conclusion: The composite Vienna Innsbruck Pregnancy Risk in Multiple Sclerosis (VIPRiMS) score is a valuable clinical tool to support patients and neurologists in anticipating risk and, thus, individualizing treatment decision-making around pregnancy.
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Affiliation(s)
- Gabriel Bsteh
- Department of Neurology, Medical University of Vienna, Vienna, Austria
- *Correspondence: Gabriel Bsteh
| | - Harald Hegen
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Katharina Riedl
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Patrick Altmann
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Franziska Di Pauli
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Rainer Ehling
- Department of Neurology, Clinic for Rehabilitation Münster, Münster, Austria
| | - Gudrun Zulehner
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Paulus Rommer
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Fritz Leutmezer
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | | | - Thomas Berger
- Department of Neurology, Medical University of Vienna, Vienna, Austria
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15
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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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16
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Uher T, Kubala Havrdova E, Vodehnalova K, Krasensky J, Capek V, Vaneckova M, Horakova D. Pregnancy-induced brain MRI changes in women with multiple sclerosis. Eur J Neurol 2022; 29:1446-1456. [PMID: 35015921 DOI: 10.1111/ene.15245] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 11/30/2021] [Accepted: 12/23/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND The effect of pregnancy on brain changes and radiological disease activity in women with multiple sclerosis (MS) is not well understood. AIMS To describe the dynamic of lesion activity and brain volume changes during the pregnancy and postpartum periods. METHODS This observational study of 62 women with relapsing-remitting MS included MRI (221 scans) as well as clinical visits at baseline (<24 and >6 months before), prepregnancy (<6 months before), postpartum (<3 months after), and the follow-up (>12 and <24 months after delivery) period. RESULTS The majority of women had a mild disability and a short disease duration (median 5.5 years). Eighteen (29.0%) women had a relapse during the year preceding pregnancy onset, 9 (14.5%) during pregnancy, and 20 (32.3%) in the year following delivery. Disability status remained unchanged during follow-up. Women in the postpartum period (n=62) had higher T2 lesion volume (median: 0.94 ml vs. 1.18 ml), greater annualized T2 lesion volume increase (0.0 ml vs. 0.23 ml), lower brain parenchymal fraction (86.4% vs. 85.6%) and greater annualized brain volume loss (-0.16% vs. -1.74%) compared with the prepregnancy period (all p<0.001). At 12-24 months after delivery women (n=41) had higher T2 lesion volume (1.0 ml vs. 1.16 ml) and lower brain parenchymal fraction (86.5% vs. 86.0%) compared to the prepregnancy period (both p<0.001). CONCLUSIONS The postpartum period was associated with an increase in T2 lesion volume and accelerated brain volume loss in a considerable proportion of women. This should be considered in treatment decision-making and designing clinical trials.
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Affiliation(s)
- Tomas Uher
- Department of Neurology and Center of Clinical Neuroscience, Charles University in Prague, 1st Faculty of Medicine and General University Hospital, Prague, Czech Republic
| | - Eva Kubala Havrdova
- Department of Neurology and Center of Clinical Neuroscience, Charles University in Prague, 1st Faculty of Medicine and General University Hospital, Prague, Czech Republic
| | - Karolina Vodehnalova
- Department of Neurology and Center of Clinical Neuroscience, Charles University in Prague, 1st Faculty of Medicine and General University Hospital, Prague, Czech Republic
| | - Jan Krasensky
- Department of Radiology, Charles University in Prague, First Faculty of Medicine and General University Hospital in Prague, Czech Republic
| | - Vaclav Capek
- Department of Neurology and Center of Clinical Neuroscience, Charles University in Prague, 1st Faculty of Medicine and General University Hospital, Prague, Czech Republic
| | - Manuela Vaneckova
- Department of Radiology, Charles University in Prague, First Faculty of Medicine and General University Hospital in Prague, Czech Republic
| | - Dana Horakova
- Department of Neurology and Center of Clinical Neuroscience, Charles University in Prague, 1st Faculty of Medicine and General University Hospital, Prague, Czech Republic
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Hellwig K, Verdun di Cantogno E, Sabidó M. A systematic review of relapse rates during pregnancy and postpartum in patients with relapsing multiple sclerosis. Ther Adv Neurol Disord 2021; 14:17562864211051012. [PMID: 34876925 PMCID: PMC8645312 DOI: 10.1177/17562864211051012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 09/16/2021] [Indexed: 11/21/2022] Open
Abstract
Introduction: Pregnancy is widely accepted as a period when relapses of
multiple sclerosis (MS) are decreased, with an increased risk of relapse in
the first months postpartum. This systematic review evaluated relapses
during pregnancy and postpartum, according to disease-modifying therapy
(DMT) exposure before, during, and after pregnancy, and the influence of DMT
on these outcomes. Methods: We searched Medline and EMBASE to identify relevant
publications from November 2009 to 2019 along with references lists of
selected articles. Publications were filtered and assessed by two
independent reviewers to ensure appropriate data extraction. Results: Of 469 articles identified, 28 were included for analysis
including 4739 pregnancies in 5324 patients. All five studies comparing
natalizumab or fingolimod (high-efficacy DMTs) use preconception versus
interferon beta, glatiramer acetate, or dimethyl fumarate, or no DMT
suggested that there was a greater risk of relapse during pregnancy
following withdrawal of the high-efficacy DMTs. Of 10 studies evaluating
relapses during pregnancy, five studies found that continuing DMTs into
early pregnancy reduced relapses compared to discontinuing treatment. DMT
exposure preconception generally had no effect on postpartum relapses versus
no DMT; however, natalizumab or fingolimod use preconception was associated
with postpartum relapse versus no high-efficacy DMT in one study. DMT
exposure during pregnancy was associated with fewer postpartum relapses
versus no DMT exposure in four of seven studies, while three found no
difference between groups. Conclusion: Results of this systematic review concerning women with
relapsing MS show a complex and often conflicting picture regarding DMT
exposure and relapses during and after pregnancy. Although our data are
limited by variability between studies, there is some evidence suggesting
the use of natalizumab or fingolimod preconception is associated with
increased risk of relapses during pregnancy, highlighting the need for
effective disease-management strategies in these especially high-risk
patients.
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Affiliation(s)
- Kerstin Hellwig
- Department of Neurology, St. Josef Hospital, Ruhr-University Bochum, Gudrunstrasse 56, 44791 Bochum, Germany
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Ahmed AM, Reda MABMG, Elsheshiny AH. Outcomes of pregnancy in Egyptian women with multiple sclerosis in the new treatment era: a multi-center retrospective observational study. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2021. [DOI: 10.1186/s41983-021-00386-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Pregnancy is a recent growing issue in multiple sclerosis (MS) and the update in the diagnostic criteria of MS and introduction of many disease-modifying therapies (DMTs) may cause changes in the relationship between MS, pregnancy, and breastfeeding. This study aimed to investigate the effect of pregnancy and breastfeeding on MS and vice versa. A retrospective observational study was conducted to include MS women with a history of at least one pregnancy during the last 7 years. Data were collected from the archived files in addition to a self-administrating questionnaire. The annualized relapsing rate (ARR) was calculated before, during, and after pregnancy.
Results
We included 116 successful pregnancies from 93 MS women with mean age 32.74 ± 5.12 years. Interferon-beta was the commonly used DMT during and after pregnancy. Despite the ARR during the two years preceding the conception was 0.36 (95% CI 0.32–0.41), this rate was significantly decreased during first, second, and third trimester (0.07; 95% CI 0.04–0.15, 0.10; 95% CI 0.03–0.17, and 0.15; 95% CI 0.08–0.24, respectively; P-value < 0.001 in all). Furthermore, this ARR was significantly decreased during the first and last three months after delivery (0.27; 95% CI 0.16–0.39; P-value = 0.037, and 0.24; 95% CI 0.17–0.38; P-value = 0.023). Exclusive breastfeeding was associated with deceased risk of postpartum relapse, with HR 0.31 (95% CI 0.12–0.67; P = 0.002).
Conclusions
Pregnancy is protective from MS relapse, with a significant decrease of ARR from the pre-pregnancy period. Postpartum reactivation of the disease occurs from the third month after labor, rather than the early postpartum period. Exclusive breastfeeding for at least 2 months decreased the risk of postpartum relapse.
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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: 13] [Impact Index Per Article: 4.3] [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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Portaccio E, Tudisco L, Pastò L, Razzolini L, Fonderico M, Bellinvia A, Ghezzi A, Annovazzi P, Zaffaroni M, Moiola L, Martinelli V, Chisari CG, Patti F, Mancardi G, Pozzilli C, De Giglio L, Totaro R, Lugaresi A, Di Tommaso V, Paolicelli D, Cocco E, Marrosu MG, Comi G, Filippi M, Trojano M, Amato MP. Pregnancy in multiple sclerosis women with relapses in the year before conception increases the risk of long-term disability worsening. Mult Scler 2021; 28:472-479. [PMID: 34132146 DOI: 10.1177/13524585211023365] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The influence of pregnancy on long-term disability in multiple sclerosis (MS) is still controversial. OBJECTIVE To assess the risk of long-term disability worsening after pregnancy in MS women as compared with a propensity-score (PS) matched group of MS women without pregnancy. METHODS In the setting of the Italian Pregnancy Dataset, MS patients with (pregnancy group (PG)) and without pregnancy (control group (CG)) were recruited. Time to disability worsening on the Expanded Disability Status Scale (EDSS) was assessed through a multivariable Cox regression model. RESULTS The PS-matching retained 230 PG and 102 CG patients. After a follow-up of 6.5 +/- 3.1 years, disability worsening occurred in 87 (26.2%) women. In the multivariable analysis, disability worsening was associated with pregnancy in women with relapses in the year before conception (adjusted hazard ratio (aHR) = 1.74; 95% confidence interval (CI) 1.06-2.84; p = 0.027), higher EDSS (aHR = 1.39; 95% CI 1.12-1.74; p = 0.003), younger age (aHR = 0.95; 95% CI 0.91-0.99; p = 0.022) and shorter DMD exposure over the follow-up (p < 0.008). CONCLUSION Pregnancy in MS women with relapses in the year before conception increases the risk of long-term disability worsening. Our findings underscore the importance of counselling in MS women facing a pregnancy that should be planned after a period of clinical stability, favouring treatment optimization in patients with recent disease activity.
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Affiliation(s)
- Emilio Portaccio
- Division Neurological Rehabilitation, Department of NEUROFARBA, University of Florence, Florence, Italy/IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy
| | - Laura Tudisco
- Division Neurological Rehabilitation, Department of NEUROFARBA, University of Florence, Florence, Italy
| | - Luisa Pastò
- Division Neurological Rehabilitation, Careggi University Hospital, Florence, Italy
| | - Lorenzo Razzolini
- Division Neurological Rehabilitation, Department of NEUROFARBA, University of Florence, Florence, Italy
| | - Mattia Fonderico
- Division Neurological Rehabilitation, Department of NEUROFARBA, University of Florence, Florence, Italy
| | - Angelo Bellinvia
- Division Neurological Rehabilitation, Department of NEUROFARBA, University of Florence, Florence, Italy
| | - Angelo Ghezzi
- Multiple Sclerosis Center, ASST Valle Olona, Gallarate Hospital (VA), Gallarate, Italy
| | - Pietro Annovazzi
- Multiple Sclerosis Center, ASST Valle Olona, Gallarate Hospital (VA), Gallarate, Italy
| | - Mauro Zaffaroni
- Multiple Sclerosis Center, ASST Valle Olona, Gallarate Hospital (VA), Gallarate, Italy
| | - Lucia Moiola
- Neurology Unit and MS Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Vittorio Martinelli
- Neurology Unit and MS Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Francesco Patti
- Department of Neurology, University of Catania, Catania, Italy
| | | | - Carlo Pozzilli
- Department of Neurology and Psychiatry, 'La Sapienza' University, Rome, Italy
| | - Laura De Giglio
- Department of Neurology and Psychiatry, 'La Sapienza' University, Rome, Italy
| | - Rocco Totaro
- Demyelinating Disease Center, Department of Neurology, San Salvatore Hospital, L'Aquila, Italy
| | - Alessandra Lugaresi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy/Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Valeria Di Tommaso
- Department of Neuroscience and Imaging, University 'G. d'Annunzio' of Chieti, Chieti, Italy
| | - Damiano Paolicelli
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari, Bari, Italy
| | - Eleonora Cocco
- Department of Public Health, Clinical and Molecular Medicine, University of Cagliari, Cagliari, Italy
| | - Maria Giovanna Marrosu
- Department of Public Health, Clinical and Molecular Medicine, University of Cagliari, Cagliari, Italy
| | - Giancarlo Comi
- Institute of Experimental Neurology, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Massimo Filippi
- Neurology Unit and MS Center, IRCCS San Raffaele Scientific Institute, Milan, Italy/Vita-Salute San Raffaele University, Milan, Italy/Neuroimaging Research Unit, Institute of Experimental Neurology, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy/Neurophysiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Maria Trojano
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari, Bari, Italy
| | - Maria Pia Amato
- Division Neurological Rehabilitation, Department of NEUROFARBA, University of Florence, Florence, Italy/IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy
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Yeh WZ, Widyastuti PA, Van der Walt A, Stankovich J, Havrdova E, Horakova D, Vodehnalova K, Ozakbas S, Eichau S, Duquette P, Kalincik T, Patti F, Boz C, Terzi M, Yamout BI, Lechner-Scott J, Sola P, Skibina OG, Barnett M, Onofrj M, Sá MJ, McCombe PA, Grammond P, Ampapa R, Grand'Maison F, Bergamaschi R, Spitaleri DLA, Van Pesch V, Cartechini E, Hodgkinson S, Soysal A, Saiz A, Gresle M, Uher T, Maimone D, Turkoglu R, Hupperts RM, Amato MP, Granella F, Oreja-Guevara C, Altintas A, Macdonell RA, Castillo-Trivino T, Butzkueven H, Alroughani R, Jokubaitis VG. Natalizumab, Fingolimod and Dimethyl Fumarate Use and Pregnancy-Related Relapse and Disability in Women With Multiple Sclerosis. Neurology 2021; 96:e2989-e3002. [PMID: 33879599 PMCID: PMC8253565 DOI: 10.1212/wnl.0000000000012084] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 03/17/2021] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE To investigate pregnancy-related disease activity in a contemporary multiple sclerosis (MS) cohort. METHODS Using data from the MSBase Registry, we included pregnancies conceived after 31 Dec 2010 from women with relapsing-remitting MS or clinically isolated syndrome. Predictors of intrapartum relapse, and postpartum relapse and disability progression were determined by clustered logistic regression or Cox regression analyses. RESULTS We included 1998 pregnancies from 1619 women with MS. Preconception annualized relapse rate (ARR) was 0.29 (95% CI 0.27-0.32), fell to 0.19 (0.14-0.24) in third trimester, and increased to 0.59 (0.51-0.67) in early postpartum. Among women who used fingolimod or natalizumab, ARR before pregnancy was 0.37 (0.28-0.49) and 0.29 (0.22-0.37), respectively, and increased during pregnancy. Intrapartum ARR decreased with preconception dimethyl fumarate use. ARR spiked after delivery across all DMT groups. Natalizumab continuation into pregnancy reduced the odds of relapse during pregnancy (OR 0.76 per month [0.60-0.95], p=0.017). DMT re-initiation with natalizumab protected against postpartum relapse (HR 0.11 [0.04-0.32], p<0.0001). Breastfeeding women were less likely to relapse (HR 0.61 [0.41-0.91], p=0.016). 5.6% of pregnancies were followed by confirmed disability progression, predicted by higher relapse activity in pregnancy and postpartum. CONCLUSION Intrapartum and postpartum relapse probabilities increased among women with MS after natalizumab or fingolimod cessation. In women considered to be at high relapse risk, use of natalizumab before pregnancy and continued up to 34 weeks gestation, with early re-initiation after delivery is an effective option to minimize relapse risks. Strategies of DMT use have to be balanced against potential fetal/neonatal complications.
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Affiliation(s)
- Wei Zhen Yeh
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
| | - Putu Ayu Widyastuti
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Anneke Van der Walt
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
| | - Jim Stankovich
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Eva Havrdova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Dana Horakova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Karolina Vodehnalova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | | | - Sara Eichau
- Hospital Universitario Virgen Macarena, Spain
| | | | - Tomas Kalincik
- CORe, Department of Medicine, University of Melbourne, Australia
- Melbourne MS Centre, Royal Melbourne Hospital, Australia
| | - Francesco Patti
- Department of Medical and Surgical Sciences and Advanced Technologies
- GF Ingrassia, University of Catania - AOU Policlinico-San Marco, University of Catania
| | - Cavit Boz
- KTU Medical Faculty Farabi Hospital, Turkey
| | | | - Bassem I Yamout
- American University of Beirut, Faculty of Medicine, Nehme and Therese Multiple Sclerosis Center, Beirut, Lebanon
| | | | - Patrizia Sola
- Neurology Unit, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy
| | - Olga G Skibina
- Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
| | | | | | - Maria José Sá
- Department of Neurology, São João Universitary Hospital Center, Porto, Portugal
| | - Pamela Ann McCombe
- St Andrews Place, Australia, & Royal Brisbane and Women's Hospital, Australia
| | - Pierre Grammond
- Centre de réadaptation déficience physique Chaudière-Appalache, Canada
| | | | | | | | | | - Vincent Van Pesch
- Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Belgium
| | | | | | - Aysun Soysal
- Bakirkoy Education and Research Hospital for Psychiatric and Neurological Diseases, Turkey
| | - Albert Saiz
- Service of Neurology, Hospital Clinic, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS)
- Institut de Neurociències, Universitat de Barcelona, Barcelona, Spain
| | - Melissa Gresle
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
| | - Tomas Uher
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Davide Maimone
- Centro Sclerosi Multipla, UOC Neurologia, ARNAS Garibaldi, Catania, Italy
| | - Recai Turkoglu
- Haydarpasa Numune Training and Research Hospital, Turkey
| | | | - Maria Pia Amato
- Department NEUROFARBA, University of Florence, Italy
- IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy
| | | | - Celia Oreja-Guevara
- Department of Neurology, Hospital Clínico San Carlos, Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid (UCM)
- IdISSC, Madrid, Spain
| | - Ayse Altintas
- Department of Neurology, Koc University School of Medicine, Turkey
| | | | | | - Helmut Butzkueven
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
- Box Hill Hospital, Australia
| | | | - Vilija G Jokubaitis
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
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Colaceci S, Zambri F, Marchetti F, Trivelli G, Rossi E, Petruzzo A, Vanacore N, Giusti A. 'A sleeping volcano that could erupt sooner or later'. Lived experiences of women with multiple sclerosis during childbearing age and motherhood: A phenomenological qualitative study. Mult Scler Relat Disord 2021; 51:102938. [PMID: 33882427 DOI: 10.1016/j.msard.2021.102938] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 03/30/2021] [Accepted: 04/03/2021] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Multiple Sclerosis (MS) mainly involves women, impacting many aspects related to childbearing age and maternity. Women with MS can have healthy pregnancies and infants. Needs, challenges and concerns of women with MS should be considered in order to improve care pathway, ensuring a patient-centred approach. Therefore, the aim of this study was to explore personal experiences, expectations, fears in women with MS. METHODS A descriptive phenomenological study, including women with MS during childbearing age, pregnancy and motherhood, carried out from January to April 2019. Women, enrolled in a MS centre with snowball sampling through healthcare network, were invited for a face-to-face or phone interview, digitally audio-recorded and fully transcribed. Two different sets of semi-structured interviews were developed (woman seeking pregnancy / pregnant woman and mother), together with an anonymous form, to collect some main sociodemographic data. Categorical data analysis, inductively and deductively, was processed by 3 different researchers, using Creswell extension to reduce subjective influences. QDA Miner qualitative text analysis software was used. RESULTS The following 6 deductive themes emerged: 1) experience with diagnosis of MS; 2) relationship with the partner, children, and family; 3) pregnancy; 4) delivery; 5) puerperium; 6) care pathway. Experiences with diagnosis can be very different between women. Communication of MS diagnosis appears as an opportunity to strengthen emotional ties, despite sorrow and concerns. Reasons for quarrels and disagreements, both in couple and parents, were due to an overly protective and supportive attitude. Some participants reported difficulty of conceiving. Pregnancy is described as a state of wellbeing, not devoid by fears and worries. Women experienced fatigue and exhaustion especially during the second stage of labour, but spontaneous delivery is described as an empowering experience. Findings about breastfeeding confirm that healthcare professionals have a crucial role regarding initiation, duration and type of breastfeeding and often scarce education and training on the topic, together with lack of reliable scientific sources, lead to a conservative approach. Healthcare providers communication and consulting emerge as indispensable skills. CONCLUSION The study provides a better understanding of how MS impacts women' life during childbearing age, pregnancy and motherhood. Findings support the importance of provide quality and tailored care for women with MS, according to an empathetic and patient-centred approach. Further research should be more comprehensive explorations of mothers' experiences in different cultural contexts, but also partners and offspring of women with MS.
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Affiliation(s)
- Sofia Colaceci
- Departmental faculty of Medicine and Surgery, Saint Camillus International University of Rome and Medical Sciences (UniCamillus), Rome, Italy.
| | - Francesca Zambri
- National Centre for Diseases Prevention and Health Promotion, National Institute of Health, Rome, Italy
| | - Francesca Marchetti
- National Centre for Diseases Prevention and Health Promotion, National Institute of Health, Rome, Italy; Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Gessica Trivelli
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Elisa Rossi
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | | | - Nicola Vanacore
- National Centre for Diseases Prevention and Health Promotion, National Institute of Health, Rome, Italy
| | - Angela Giusti
- National Centre for Diseases Prevention and Health Promotion, National Institute of Health, Rome, Italy
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23
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Alhomoud MA, Khan AS, Alhomoud I. The Potential Preventive Effect of Pregnancy and Breastfeeding on Multiple Sclerosis. Eur Neurol 2021; 84:71-84. [PMID: 33744881 DOI: 10.1159/000514432] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 01/09/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Multiple sclerosis (MS) is an inflammatory demyelinating chronic neurological disease that affects the central nervous system of young adults and their quality of life. Several studies have investigated the effects of pregnancy and breastfeeding on MS. However, the evidence regarding the influence of pregnancy and breastfeeding on MS is still accumulating. This review aimed to summarize the current evidence regarding the effects of pregnancy and breastfeeding on MS. SUMMARY A systematic electronic literature search of the PubMed and Embase databases was conducted to determine relevant published articles. The eligible studies were summarized and evaluated in tables. Key Messages: The majority of the studies indicated that pregnancy appears to lower the rate of MS relapses, particularly in the third trimester. The evidence regarding the effect of breastfeeding on MS remains inconsistent. Despite reports of negative obstetric outcomes in some pregnant women with MS, pregnancies in women with MS should not be categorized as high-risk pregnancies.
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Affiliation(s)
- Mohsen Ali Alhomoud
- Department of Public Health, Ministry of Health, Eastern Province, Al Qatif, Saudi Arabia,
| | - Abdul Sattar Khan
- Family and Community Medicine Department, King Faisal University, Eastern Province, Al Ahsa, Saudi Arabia
| | - Iftetah Alhomoud
- Neurosciences Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
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Abstract
PURPOSE OF REVIEW The fact that multiple sclerosis (MS) predominantly affects women has been recognized for many years. As the age at diagnosis is decreasing, and treatment options are becoming more complex, increasing numbers of women are facing decisions about the use of disease modifying therapy (DMT) in and around pregnancy. RECENT FINDINGS New data are rapidly becoming available, particularly regarding the safety of therapies in both pregnancy and breastfeeding. Effective treatment and suppression of relapses is key to ensuring good outcomes in the longer term for the woman, however this must be balanced against individual risk of relapse and risks to the fetus. Women should be advised that it is possible to breastfeed while taking selected DMT. SUMMARY In this review, we discuss evidence surrounding the safety of DMTs in both pregnancy and breastfeeding, and use this knowledge to suggest approaches to pregnancy and family planning in women with MS.
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Anderson A, Krysko KM, Rutatangwa A, Krishnakumar T, Chen C, Rowles W, Zhao C, Houtchens MK, Bove R. Clinical and Radiologic Disease Activity in Pregnancy and Postpartum in MS. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2021; 8:8/2/e959. [PMID: 33608303 PMCID: PMC8105896 DOI: 10.1212/nxi.0000000000000959] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 12/14/2020] [Indexed: 11/23/2022]
Abstract
Objective To evaluate radiologic and clinical inflammatory activity in women with MS during pregnancy and postpartum. Methods We performed a retrospective analysis of prospectively collected clinical and MRI reports for women who became pregnant while followed at the University of California, San Francisco MS Center between 2005 and 2018. Proportion of brain MRIs with new T2-hyperintense or gadolinium enhancing (Gd+) lesions (primary outcome) and annualized relapse rate (ARR; secondary) were compared before and after pregnancy. Results We identified 155 pregnancies in 119 women (median Expanded Disability Status Scale [EDSS] 2.0). For the 146 live birth pregnancies, prepregnancy ARR was 0.33; ARR decreased during pregnancy, particularly the third trimester (ARR 0.10, p = 0.017) and increased in the 3 months postpartum (ARR 0.61, p = 0.012); and 16% of women experienced a clinically meaningful increase in EDSS. Among 70 pregnancies with paired brain MRIs available, 53% had new T2 and/or Gd+ lesions postpartum compared with 32% prepregnancy (p < 0.001). Postpartum clinical relapses were associated with Gd+ lesions (p < 0.001). However, even for patients without postpartum relapses, surveillance brain MRIs revealed new T2 and/or Gd+ lesions in 31%. Protective effects of exclusive breastfeeding for ≥3 months (odds ratio = 0.3, 95% confidence interval 0.1–0.9) were observed for relapses. Conclusions Building on previous reports of increased relapse rate in the first 3 months postpartum, we report a significant association between inflammation on MRI and this clinical activity. We also detected postpartum radiologic activity in the absence of relapses. Both clinical and radiologic reassessment may inform optimal treatment decision-making during the high-risk early postpartum period.
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Affiliation(s)
- Annika Anderson
- From the Weill Institute for Neurosciences (A.A., K.M.K.), Department of Neurology, University of California San Francisco, San Francisco, CA; Department of Neurology (K.M.K., R.B.), School of Medicine, University of California San Francisco, San Francisco, CA; Weill Institute for Neurosciences (A.R., T.K., C.C., W.R., C.Z., R.B.), Department of Neurology, University of California San Francisco, San Francisco, CA; Department of Neurology (M.H.), Brigham and Womens Hospital, Harvard Medical School, Boston MA
| | - Kristen M Krysko
- From the Weill Institute for Neurosciences (A.A., K.M.K.), Department of Neurology, University of California San Francisco, San Francisco, CA; Department of Neurology (K.M.K., R.B.), School of Medicine, University of California San Francisco, San Francisco, CA; Weill Institute for Neurosciences (A.R., T.K., C.C., W.R., C.Z., R.B.), Department of Neurology, University of California San Francisco, San Francisco, CA; Department of Neurology (M.H.), Brigham and Womens Hospital, Harvard Medical School, Boston MA
| | - Alice Rutatangwa
- From the Weill Institute for Neurosciences (A.A., K.M.K.), Department of Neurology, University of California San Francisco, San Francisco, CA; Department of Neurology (K.M.K., R.B.), School of Medicine, University of California San Francisco, San Francisco, CA; Weill Institute for Neurosciences (A.R., T.K., C.C., W.R., C.Z., R.B.), Department of Neurology, University of California San Francisco, San Francisco, CA; Department of Neurology (M.H.), Brigham and Womens Hospital, Harvard Medical School, Boston MA
| | - Tanya Krishnakumar
- From the Weill Institute for Neurosciences (A.A., K.M.K.), Department of Neurology, University of California San Francisco, San Francisco, CA; Department of Neurology (K.M.K., R.B.), School of Medicine, University of California San Francisco, San Francisco, CA; Weill Institute for Neurosciences (A.R., T.K., C.C., W.R., C.Z., R.B.), Department of Neurology, University of California San Francisco, San Francisco, CA; Department of Neurology (M.H.), Brigham and Womens Hospital, Harvard Medical School, Boston MA
| | - Chelsea Chen
- From the Weill Institute for Neurosciences (A.A., K.M.K.), Department of Neurology, University of California San Francisco, San Francisco, CA; Department of Neurology (K.M.K., R.B.), School of Medicine, University of California San Francisco, San Francisco, CA; Weill Institute for Neurosciences (A.R., T.K., C.C., W.R., C.Z., R.B.), Department of Neurology, University of California San Francisco, San Francisco, CA; Department of Neurology (M.H.), Brigham and Womens Hospital, Harvard Medical School, Boston MA
| | - William Rowles
- From the Weill Institute for Neurosciences (A.A., K.M.K.), Department of Neurology, University of California San Francisco, San Francisco, CA; Department of Neurology (K.M.K., R.B.), School of Medicine, University of California San Francisco, San Francisco, CA; Weill Institute for Neurosciences (A.R., T.K., C.C., W.R., C.Z., R.B.), Department of Neurology, University of California San Francisco, San Francisco, CA; Department of Neurology (M.H.), Brigham and Womens Hospital, Harvard Medical School, Boston MA
| | - Chao Zhao
- From the Weill Institute for Neurosciences (A.A., K.M.K.), Department of Neurology, University of California San Francisco, San Francisco, CA; Department of Neurology (K.M.K., R.B.), School of Medicine, University of California San Francisco, San Francisco, CA; Weill Institute for Neurosciences (A.R., T.K., C.C., W.R., C.Z., R.B.), Department of Neurology, University of California San Francisco, San Francisco, CA; Department of Neurology (M.H.), Brigham and Womens Hospital, Harvard Medical School, Boston MA
| | - Maria K Houtchens
- From the Weill Institute for Neurosciences (A.A., K.M.K.), Department of Neurology, University of California San Francisco, San Francisco, CA; Department of Neurology (K.M.K., R.B.), School of Medicine, University of California San Francisco, San Francisco, CA; Weill Institute for Neurosciences (A.R., T.K., C.C., W.R., C.Z., R.B.), Department of Neurology, University of California San Francisco, San Francisco, CA; Department of Neurology (M.H.), Brigham and Womens Hospital, Harvard Medical School, Boston MA
| | - Riley Bove
- From the Weill Institute for Neurosciences (A.A., K.M.K.), Department of Neurology, University of California San Francisco, San Francisco, CA; Department of Neurology (K.M.K., R.B.), School of Medicine, University of California San Francisco, San Francisco, CA; Weill Institute for Neurosciences (A.R., T.K., C.C., W.R., C.Z., R.B.), Department of Neurology, University of California San Francisco, San Francisco, CA; Department of Neurology (M.H.), Brigham and Womens Hospital, Harvard Medical School, Boston MA.
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Krysko KM, Rutatangwa A, Graves J, Lazar A, Waubant E. Association Between Breastfeeding and Postpartum Multiple Sclerosis Relapses: A Systematic Review and Meta-analysis. JAMA Neurol 2021; 77:327-338. [PMID: 31816024 DOI: 10.1001/jamaneurol.2019.4173] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Importance Multiple sclerosis (MS) relapses may be increased in the postpartum period, and whether breastfeeding is associated with reduction in the risk of postpartum relapses remains controversial. Objective To perform a systematic review and meta-analysis to evaluate whether breastfeeding is associated with reduction in postpartum MS relapses compared with not breastfeeding. Data Sources PubMed and Embase were searched for studies assessing the association between breastfeeding and MS disease activity published between January 1, 1980, and July 11, 2018, as well as reference lists of selected articles. Study Selection All study designs assessing the association between breastfeeding and postpartum relapses in MS relative to a comparator group were included. Data Extraction and Synthesis Study eligibility assessment and extraction of study characteristics, methods, and outcomes, were performed independently by 2 reviewers following PRISMA guidelines. Risk of bias was evaluated by 2 independent reviewers with the ROBINS-I tool for nonrandomized, interventional studies. Findings from studies with data available for the number of women with postpartum relapses in the breastfeeding and nonbreastfeeding groups were combined with a random-effects model. Main Outcomes and Measures Postpartum MS relapse. Results The search identified 462 unique citations, and 24 (2974 women) satisfied eligibility criteria and were included, of which 16 were included in the quantitative meta-analysis. The pooled summary odds ratio for the association of breastfeeding with postpartum relapses was 0.63 (95% CI, 0.45-0.88; P = .006) compared with a reference of nonbreastfeeding. Pooled adjusted hazard ratio across 4 studies that reported this finding was 0.57 (95% CI, 0.38-0.85; P = .006). There was moderate heterogeneity (I2 = 48%), which was explained by variable prepregnancy relapse rate, postpartum follow-up duration, and the publication year. A stronger association was seen in studies of exclusive rather than nonexclusive breastfeeding, although both demonstrated an association. Studies were rated at moderate and serious risk of bias, with concern for residual confounding, although sensitivity analysis including only moderate quality studies was consistent with a protective outcome of breastfeeding. Conclusions and Relevance These findings suggest that breastfeeding is protective against postpartum relapses in MS, although high-quality prospective studies to date are limited and well-designed observational studies that aim to emulate a randomized trial would be of benefit.
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Affiliation(s)
- Kristen M Krysko
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco
| | - Alice Rutatangwa
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco
| | - Jennifer Graves
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco.,Department of Neurology, University of California, San Diego
| | - Ann Lazar
- Preventive & Restorative Dental Sciences, University of California, San Francisco
| | - Emmanuelle Waubant
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco
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Modrego PJ, Urrea MA, de Cerio LD. The effects of pregnancy on relapse rates, disability and peripartum outcomes in women with multiple sclerosis: a systematic review and meta-analysis. J Comp Eff Res 2021; 10:175-186. [PMID: 33565886 DOI: 10.2217/cer-2020-0211] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background: Although previous cohort studies of women with multiple sclerosis (MS) yielded a reduction in relapse rate during pregnancy, the effect size has not been quantified in a comprehensive manner. In addition, the effects on disability progression and peripartum outcomes have been controversial. The purpose of this work is to assess the effect of pregnancy on disease activity, and to assess the effects of MS on pregnancy as well. Materials & methods: We searched in PubMed, Cochrane Library and EMBASE for cohort studies dealing with the effects of pregnancy on relapse rates, disability progression and peripartum outcomes in women with MS. The evaluated outcomes were: changes in the annualized relapse rate (ARR) in pregnancy and puerperium, disability worsening compared with the year before pregnancy, and peripartum outcomes, which were compared with the ones of non-MS women. In the majority of cohorts included here, the women were not under disease modifying therapies during pregnancy. Results: We found 23 cohort studies measuring changes in the ARR during pregnancy and puerperium; 12 were prospective and 11 retrospective. In 17 cohorts there was significant reduction in the ARR during pregnancy compared with prepregnancy period. The pooled mean reduction in the ARR was -0.5 (95% CI: 0.67-0.38), p < 0.001, from 15 cohorts included in meta-analysis. In 18 cohorts the ARR increased in the 3-month puerperium relative to prepregnancy year period; the pooled mean increase in the ARR was 0.22 (95% CI: 0.11-0.33), p < 0.001, from 14 cohorts included in meta-analysis. Disability worsening was addressed in 18 cohorts, and in 14 of them there were no significant changes. Peripartum complications and obstetrical outcomes were assessed in 16 cohorts, of whom 13 were retrospective, without finding significant differences. Conclusion: Pregnancy is associated with lower disease activity, and puerperium with higher disease activity. Disability does not change significantly after pregnancy. The obstetrical outcomes are not very different from those of non-MS women in most cohorts.
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Affiliation(s)
- Pedro J Modrego
- Department of Neurology, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | | | - Leyre Diaz de Cerio
- Department of Neurology, Hospital Universitario Miguel Servet, Zaragoza, Spain
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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: 40] [Impact Index Per Article: 13.3] [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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Lechner-Scott J, Hawkes CH, Giovannoni G, Levy M, Maltby V. Why should Neurologists get involved in family planning? Mult Scler Relat Disord 2020; 46:102598. [DOI: 10.1016/j.msard.2020.102598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Smith JB, Hellwig K, Fink K, Lyell DJ, Piehl F, Langer-Gould A. Rituximab, MS, and pregnancy. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2020; 7:e734. [PMID: 32358226 PMCID: PMC7217660 DOI: 10.1212/nxi.0000000000000734] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Accepted: 03/24/2020] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To describe the safety and efficacy of rituximab (RTX) in MS and pregnancy, we conducted a retrospective cohort study of 74 pregnancies among 55 women treated with RTX for MS and their offspring. METHODS We used prospectively collected information from the electronic health record at Kaiser Permanente Southern California between 2012 and 2019 of mother and baby to identify treatment history, pregnancy outcomes, and relapses. RESULTS Last RTX exposure before conception occurred between 1.8 and 5.2 months in 32 (49%) of 65 pregnancies and accidentally during the first trimester in 9 (12%). Among 38 live births, adverse pregnancy outcomes were as follows: 3 preterm deliveries (including 1 set of twins), 1 neonatal death (preterm twin), and 1 perinatal stroke (full-term). No stillbirths, chorioamnionitis, or major malformations were found. Fifteen (27%) women had at least one first-trimester miscarriage, of whom 8 (53%) had a history of infertility. Cumulative dose or timing of last RTX infusion was not associated with an increased risk of miscarriage. Only 2 (5.4%) women experienced relapses, one during pregnancy and the other postpartum. CONCLUSION We observed no increase in adverse pregnancy outcomes compared with expected national incidence rates and remarkably little disease activity in RTX-treated women with MS, particularly when compared with periconceptional natalizumab-treated cohorts. However, larger studies are needed to fully assess the safety of RTX use before pregnancy, especially risks associated with prolonged B-cell depletion and hypogammaglobulinemia. Until these data are available, we recommend restricting RTX use before pregnancy to women who require highly effective MS treatments. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that for pregnant women with MS, RTX controls disease activity and does not increase adverse pregnancy outcomes.
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Affiliation(s)
- Jessica B Smith
- From the Department of Research & Evaluation (J.B.S.), Kaiser Permanente Southern California; Department of Neurology (K.H.), St. Josef Hospital, Bochum, Germany; Department of Clinical Neuroscience (K.F., F.P.), Karolinska Institute; Center for Neurology (K.F.), Academic Specialist Center, Stockholm, Sweden; Department of Obstetrics & Gynecology - Maternal Fetal Medicine (D.J.L.), Stanford University School of Medicine, Stanford, CA; Department of Neurology (F.P.), Karolinska University Hospital, Stockholm, Sweden; and Department of Neurology (A.L.-G.), Los Angeles Medical Center, Southern California Permanente Medical Group, Los Angeles, CA
| | - Kerstin Hellwig
- From the Department of Research & Evaluation (J.B.S.), Kaiser Permanente Southern California; Department of Neurology (K.H.), St. Josef Hospital, Bochum, Germany; Department of Clinical Neuroscience (K.F., F.P.), Karolinska Institute; Center for Neurology (K.F.), Academic Specialist Center, Stockholm, Sweden; Department of Obstetrics & Gynecology - Maternal Fetal Medicine (D.J.L.), Stanford University School of Medicine, Stanford, CA; Department of Neurology (F.P.), Karolinska University Hospital, Stockholm, Sweden; and Department of Neurology (A.L.-G.), Los Angeles Medical Center, Southern California Permanente Medical Group, Los Angeles, CA
| | - Katharina Fink
- From the Department of Research & Evaluation (J.B.S.), Kaiser Permanente Southern California; Department of Neurology (K.H.), St. Josef Hospital, Bochum, Germany; Department of Clinical Neuroscience (K.F., F.P.), Karolinska Institute; Center for Neurology (K.F.), Academic Specialist Center, Stockholm, Sweden; Department of Obstetrics & Gynecology - Maternal Fetal Medicine (D.J.L.), Stanford University School of Medicine, Stanford, CA; Department of Neurology (F.P.), Karolinska University Hospital, Stockholm, Sweden; and Department of Neurology (A.L.-G.), Los Angeles Medical Center, Southern California Permanente Medical Group, Los Angeles, CA
| | - Deirdre J Lyell
- From the Department of Research & Evaluation (J.B.S.), Kaiser Permanente Southern California; Department of Neurology (K.H.), St. Josef Hospital, Bochum, Germany; Department of Clinical Neuroscience (K.F., F.P.), Karolinska Institute; Center for Neurology (K.F.), Academic Specialist Center, Stockholm, Sweden; Department of Obstetrics & Gynecology - Maternal Fetal Medicine (D.J.L.), Stanford University School of Medicine, Stanford, CA; Department of Neurology (F.P.), Karolinska University Hospital, Stockholm, Sweden; and Department of Neurology (A.L.-G.), Los Angeles Medical Center, Southern California Permanente Medical Group, Los Angeles, CA
| | - Fredrik Piehl
- From the Department of Research & Evaluation (J.B.S.), Kaiser Permanente Southern California; Department of Neurology (K.H.), St. Josef Hospital, Bochum, Germany; Department of Clinical Neuroscience (K.F., F.P.), Karolinska Institute; Center for Neurology (K.F.), Academic Specialist Center, Stockholm, Sweden; Department of Obstetrics & Gynecology - Maternal Fetal Medicine (D.J.L.), Stanford University School of Medicine, Stanford, CA; Department of Neurology (F.P.), Karolinska University Hospital, Stockholm, Sweden; and Department of Neurology (A.L.-G.), Los Angeles Medical Center, Southern California Permanente Medical Group, Los Angeles, CA
| | - Annette Langer-Gould
- From the Department of Research & Evaluation (J.B.S.), Kaiser Permanente Southern California; Department of Neurology (K.H.), St. Josef Hospital, Bochum, Germany; Department of Clinical Neuroscience (K.F., F.P.), Karolinska Institute; Center for Neurology (K.F.), Academic Specialist Center, Stockholm, Sweden; Department of Obstetrics & Gynecology - Maternal Fetal Medicine (D.J.L.), Stanford University School of Medicine, Stanford, CA; Department of Neurology (F.P.), Karolinska University Hospital, Stockholm, Sweden; and Department of Neurology (A.L.-G.), Los Angeles Medical Center, Southern California Permanente Medical Group, Los Angeles, CA.
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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: 52] [Impact Index Per Article: 13.0] [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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Langer-Gould A, Smith JB, Albers KB, Xiang AH, Wu J, Kerezsi EH, McClearnen K, Gonzales EG, Leimpeter AD, Van Den Eeden SK. Pregnancy-related relapses and breastfeeding in a contemporary multiple sclerosis cohort. Neurology 2020; 94:e1939-e1949. [PMID: 32284359 DOI: 10.1212/wnl.0000000000009374] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 11/27/2019] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine whether women with multiple sclerosis (MS) diagnosed according to current criteria are at an increased risk of postpartum relapses and to assess whether this risk is modified by breastfeeding or MS disease-modifying therapies (DMTs), we examined the electronic health records (EHRs) of 466 pregnancies among 375 women with MS and their infants. METHODS We used prospectively collected information from the EHR at Kaiser Permanente Southern and Northern California between 2008 and 2016 of the mother and infant to identify treatment history, breastfeeding, and relapses. Multivariable models accounting for measures of disease severity were used. RESULTS In the postpartum year, 26.4% relapsed, 87% breastfed, 36% breastfed exclusively for at least 2 months, and 58.8% did not use DMTs. At pregnancy onset, 67.2% had suboptimally controlled disease. Annualized relapse rates (ARRs) declined from 0.37 before pregnancy to 0.14-0.07 (p < 0.0001) during pregnancy, but in the postpartum period, we did not observe any rebound disease activity. The ARR was 0.27 in the first 3 months postpartum, returning to prepregnancy rates at 4-6 months (0.37). Exclusive breastfeeding reduced the risk of early postpartum relapses (adjusted hazard ratio = 0.37, p = 0.009), measures of disease severity increased the risk, and resuming modestly effective DMTs had no effect (time-dependent covariate, p = 0.62). CONCLUSION Most women diagnosed with MS today can have children without incurring an increased risk of relapses. Women with suboptimal disease control before pregnancy may benefit from highly effective DMTs that are compatible with pregnancy and lactation. Women with MS should be encouraged to breastfeed exclusively.
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Affiliation(s)
- Annette Langer-Gould
- From the Department of Neurology (A.L.-G.), Southern California Permanente Medical Group, Los Angeles Medical Center; Department of Research & Evaluation (J.B.S., A.H.X., J.W., E.G.G.), Kaiser Permanente Southern California; and Division of Research (K.B.A., E.H.K., K.M., A.D.L., S.K.V.D.E.), Kaiser Permanente Northern California, Los Angeles, CA.
| | - Jessica B Smith
- From the Department of Neurology (A.L.-G.), Southern California Permanente Medical Group, Los Angeles Medical Center; Department of Research & Evaluation (J.B.S., A.H.X., J.W., E.G.G.), Kaiser Permanente Southern California; and Division of Research (K.B.A., E.H.K., K.M., A.D.L., S.K.V.D.E.), Kaiser Permanente Northern California, Los Angeles, CA
| | - Kathleen B Albers
- From the Department of Neurology (A.L.-G.), Southern California Permanente Medical Group, Los Angeles Medical Center; Department of Research & Evaluation (J.B.S., A.H.X., J.W., E.G.G.), Kaiser Permanente Southern California; and Division of Research (K.B.A., E.H.K., K.M., A.D.L., S.K.V.D.E.), Kaiser Permanente Northern California, Los Angeles, CA
| | - Anny H Xiang
- From the Department of Neurology (A.L.-G.), Southern California Permanente Medical Group, Los Angeles Medical Center; Department of Research & Evaluation (J.B.S., A.H.X., J.W., E.G.G.), Kaiser Permanente Southern California; and Division of Research (K.B.A., E.H.K., K.M., A.D.L., S.K.V.D.E.), Kaiser Permanente Northern California, Los Angeles, CA
| | - Jun Wu
- From the Department of Neurology (A.L.-G.), Southern California Permanente Medical Group, Los Angeles Medical Center; Department of Research & Evaluation (J.B.S., A.H.X., J.W., E.G.G.), Kaiser Permanente Southern California; and Division of Research (K.B.A., E.H.K., K.M., A.D.L., S.K.V.D.E.), Kaiser Permanente Northern California, Los Angeles, CA
| | - Erica H Kerezsi
- From the Department of Neurology (A.L.-G.), Southern California Permanente Medical Group, Los Angeles Medical Center; Department of Research & Evaluation (J.B.S., A.H.X., J.W., E.G.G.), Kaiser Permanente Southern California; and Division of Research (K.B.A., E.H.K., K.M., A.D.L., S.K.V.D.E.), Kaiser Permanente Northern California, Los Angeles, CA
| | - Keeli McClearnen
- From the Department of Neurology (A.L.-G.), Southern California Permanente Medical Group, Los Angeles Medical Center; Department of Research & Evaluation (J.B.S., A.H.X., J.W., E.G.G.), Kaiser Permanente Southern California; and Division of Research (K.B.A., E.H.K., K.M., A.D.L., S.K.V.D.E.), Kaiser Permanente Northern California, Los Angeles, CA
| | - Edlin G Gonzales
- From the Department of Neurology (A.L.-G.), Southern California Permanente Medical Group, Los Angeles Medical Center; Department of Research & Evaluation (J.B.S., A.H.X., J.W., E.G.G.), Kaiser Permanente Southern California; and Division of Research (K.B.A., E.H.K., K.M., A.D.L., S.K.V.D.E.), Kaiser Permanente Northern California, Los Angeles, CA
| | - Amethyst D Leimpeter
- From the Department of Neurology (A.L.-G.), Southern California Permanente Medical Group, Los Angeles Medical Center; Department of Research & Evaluation (J.B.S., A.H.X., J.W., E.G.G.), Kaiser Permanente Southern California; and Division of Research (K.B.A., E.H.K., K.M., A.D.L., S.K.V.D.E.), Kaiser Permanente Northern California, Los Angeles, CA
| | - Stephen K Van Den Eeden
- From the Department of Neurology (A.L.-G.), Southern California Permanente Medical Group, Los Angeles Medical Center; Department of Research & Evaluation (J.B.S., A.H.X., J.W., E.G.G.), Kaiser Permanente Southern California; and Division of Research (K.B.A., E.H.K., K.M., A.D.L., S.K.V.D.E.), Kaiser Permanente Northern California, Los Angeles, CA
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Hellwig K, Duarte Caron F, Wicklein EM, Bhatti A, Adamo A. Pregnancy outcomes from the global pharmacovigilance database on interferon beta-1b exposure. Ther Adv Neurol Disord 2020; 13:1756286420910310. [PMID: 32201504 PMCID: PMC7066586 DOI: 10.1177/1756286420910310] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 01/06/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The goal of the present cohort study was to review outcomes of patients exposed to interferon beta-1b during pregnancy. METHODS Pregnancy cases with exposure to interferon beta-1b reported to Bayer's pharmacovigilance (PV) database from worldwide sources from January 1995 through February 2018 were retrieved for evaluation. Only cases where pregnancy outcomes were unknown at the time of reporting (i.e. prospective cases) were included in the analysis of this retrospective cohort study. RESULTS As of February 2018, 2581 prospective pregnancies exposed to interferon beta-1b were retrieved from the database; 1348 pregnancies had documented outcomes. The majority of outcomes [1106 cases (82.0%)] were live births. Health status was known for 981 live births (no known health status for 125). Most of the prospective pregnancies with known outcomes corresponded to live births with no congenital anomalies [896 cases (91.3%)]. Spontaneous abortion occurred in 160 cases (11.9%). Congenital birth defects were observed in 14/981 live births with known health status [1.4%, 95% confidence interval (CI) 0.78-2.38]. No consistent pattern in the type of birth defect was identified. Rates of both spontaneous abortion and birth defects were not higher than the general population. CONCLUSIONS These PV data, the largest sample of interferon beta-1b-exposed patients reported to date, suggest no increase in risk of spontaneous abortion or congenital anomalies in women exposed during pregnancy.
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Affiliation(s)
- Kerstin Hellwig
- Department of Neurology, St. Joseph and St. Elisabeth Hospital, Ruhr University, Bleichstrasse 15, Bochum, 44787, Germany
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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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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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Krysko KM, LaHue SC, Anderson A, Rutatangwa A, Rowles W, Schubert RD, Marcus J, Riley CS, Bevan C, Hale TW, Bove R. Minimal breast milk transfer of rituximab, a monoclonal antibody used in neurological conditions. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2019; 7:7/1/e637. [PMID: 31719115 PMCID: PMC6857908 DOI: 10.1212/nxi.0000000000000637] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 10/01/2019] [Indexed: 12/31/2022]
Abstract
Objective To determine the transfer of rituximab, an anti-CD20 monoclonal antibody widely used for neurologic conditions, into mature breast milk. Methods Breast milk samples were collected from 9 women with MS who received rituximab 500 or 1,000 mg intravenous once or twice while breastfeeding from November 2017 to April 2019. Serial breast milk samples were collected before infusion and at 8 hours, 24 hours, 7 days, and 18–21 days after rituximab infusion in 4 patients. Five additional patients provided 1–2 samples at various times after rituximab infusion. Results The median average rituximab concentration in mature breast milk was low at 0.063 μg/mL (range 0.046–0.097) in the 4 patients with serial breast milk collection, with an estimated median absolute infant dose of 0.0094 mg/kg/d and a relative infant dose (RID) of 0.08% (range 0.06%–0.10%). Most patients had a maximum concentration at 1–7 days after infusion. The maximum concentration occurred in a woman with a single breast milk sample and was 0.29 μg/mL at 11 days postinfusion, which corresponds with an estimated RID of 0.33%. Rituximab concentration in milk was virtually undetectable by 90 days postinfusion. Conclusions We determined minimal transfer of rituximab into mature breast milk. The RID for rituximab was less than 0.4% and well below theoretically acceptable levels of less than 10%. Low oral bioavailability would probably also limit the absorption of rituximab by the newborn. In women with serious autoimmune neurologic conditions, monoclonal antibody therapy may afford an acceptable benefit to risk ratio, supporting both maternal treatment and breastfeeding.
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Affiliation(s)
- Kristen M Krysko
- From the Department of Neurology (K.M.K., S.C.L., A.A., A.R., W.R., R.D.S., R.B.), University of California, San Francisco; Weill Institute for Neurosciences (K.M.K., S.C.L., A.A., A.R., W.R., R.D.S., R.B.), Department of Neurology, University of California, San Francisco; Department of Neurology (J.M.), Kaiser Permanente, San Francisco; Department of Neurology (C.S.R.), Columbia University, New York, New York; Department of Neurology (C.B.), Northwestern University, Chicago, Illinois; and Department of Pediatrics (T.W.H.), Texas Tech University School of Medicine, Amarillo
| | - Sara C LaHue
- From the Department of Neurology (K.M.K., S.C.L., A.A., A.R., W.R., R.D.S., R.B.), University of California, San Francisco; Weill Institute for Neurosciences (K.M.K., S.C.L., A.A., A.R., W.R., R.D.S., R.B.), Department of Neurology, University of California, San Francisco; Department of Neurology (J.M.), Kaiser Permanente, San Francisco; Department of Neurology (C.S.R.), Columbia University, New York, New York; Department of Neurology (C.B.), Northwestern University, Chicago, Illinois; and Department of Pediatrics (T.W.H.), Texas Tech University School of Medicine, Amarillo
| | - Annika Anderson
- From the Department of Neurology (K.M.K., S.C.L., A.A., A.R., W.R., R.D.S., R.B.), University of California, San Francisco; Weill Institute for Neurosciences (K.M.K., S.C.L., A.A., A.R., W.R., R.D.S., R.B.), Department of Neurology, University of California, San Francisco; Department of Neurology (J.M.), Kaiser Permanente, San Francisco; Department of Neurology (C.S.R.), Columbia University, New York, New York; Department of Neurology (C.B.), Northwestern University, Chicago, Illinois; and Department of Pediatrics (T.W.H.), Texas Tech University School of Medicine, Amarillo
| | - Alice Rutatangwa
- From the Department of Neurology (K.M.K., S.C.L., A.A., A.R., W.R., R.D.S., R.B.), University of California, San Francisco; Weill Institute for Neurosciences (K.M.K., S.C.L., A.A., A.R., W.R., R.D.S., R.B.), Department of Neurology, University of California, San Francisco; Department of Neurology (J.M.), Kaiser Permanente, San Francisco; Department of Neurology (C.S.R.), Columbia University, New York, New York; Department of Neurology (C.B.), Northwestern University, Chicago, Illinois; and Department of Pediatrics (T.W.H.), Texas Tech University School of Medicine, Amarillo
| | - William Rowles
- From the Department of Neurology (K.M.K., S.C.L., A.A., A.R., W.R., R.D.S., R.B.), University of California, San Francisco; Weill Institute for Neurosciences (K.M.K., S.C.L., A.A., A.R., W.R., R.D.S., R.B.), Department of Neurology, University of California, San Francisco; Department of Neurology (J.M.), Kaiser Permanente, San Francisco; Department of Neurology (C.S.R.), Columbia University, New York, New York; Department of Neurology (C.B.), Northwestern University, Chicago, Illinois; and Department of Pediatrics (T.W.H.), Texas Tech University School of Medicine, Amarillo
| | - Ryan D Schubert
- From the Department of Neurology (K.M.K., S.C.L., A.A., A.R., W.R., R.D.S., R.B.), University of California, San Francisco; Weill Institute for Neurosciences (K.M.K., S.C.L., A.A., A.R., W.R., R.D.S., R.B.), Department of Neurology, University of California, San Francisco; Department of Neurology (J.M.), Kaiser Permanente, San Francisco; Department of Neurology (C.S.R.), Columbia University, New York, New York; Department of Neurology (C.B.), Northwestern University, Chicago, Illinois; and Department of Pediatrics (T.W.H.), Texas Tech University School of Medicine, Amarillo
| | - Jacqueline Marcus
- From the Department of Neurology (K.M.K., S.C.L., A.A., A.R., W.R., R.D.S., R.B.), University of California, San Francisco; Weill Institute for Neurosciences (K.M.K., S.C.L., A.A., A.R., W.R., R.D.S., R.B.), Department of Neurology, University of California, San Francisco; Department of Neurology (J.M.), Kaiser Permanente, San Francisco; Department of Neurology (C.S.R.), Columbia University, New York, New York; Department of Neurology (C.B.), Northwestern University, Chicago, Illinois; and Department of Pediatrics (T.W.H.), Texas Tech University School of Medicine, Amarillo
| | - Claire S Riley
- From the Department of Neurology (K.M.K., S.C.L., A.A., A.R., W.R., R.D.S., R.B.), University of California, San Francisco; Weill Institute for Neurosciences (K.M.K., S.C.L., A.A., A.R., W.R., R.D.S., R.B.), Department of Neurology, University of California, San Francisco; Department of Neurology (J.M.), Kaiser Permanente, San Francisco; Department of Neurology (C.S.R.), Columbia University, New York, New York; Department of Neurology (C.B.), Northwestern University, Chicago, Illinois; and Department of Pediatrics (T.W.H.), Texas Tech University School of Medicine, Amarillo.
| | - Carolyn Bevan
- From the Department of Neurology (K.M.K., S.C.L., A.A., A.R., W.R., R.D.S., R.B.), University of California, San Francisco; Weill Institute for Neurosciences (K.M.K., S.C.L., A.A., A.R., W.R., R.D.S., R.B.), Department of Neurology, University of California, San Francisco; Department of Neurology (J.M.), Kaiser Permanente, San Francisco; Department of Neurology (C.S.R.), Columbia University, New York, New York; Department of Neurology (C.B.), Northwestern University, Chicago, Illinois; and Department of Pediatrics (T.W.H.), Texas Tech University School of Medicine, Amarillo
| | - Thomas W Hale
- From the Department of Neurology (K.M.K., S.C.L., A.A., A.R., W.R., R.D.S., R.B.), University of California, San Francisco; Weill Institute for Neurosciences (K.M.K., S.C.L., A.A., A.R., W.R., R.D.S., R.B.), Department of Neurology, University of California, San Francisco; Department of Neurology (J.M.), Kaiser Permanente, San Francisco; Department of Neurology (C.S.R.), Columbia University, New York, New York; Department of Neurology (C.B.), Northwestern University, Chicago, Illinois; and Department of Pediatrics (T.W.H.), Texas Tech University School of Medicine, Amarillo
| | - Riley Bove
- From the Department of Neurology (K.M.K., S.C.L., A.A., A.R., W.R., R.D.S., R.B.), University of California, San Francisco; Weill Institute for Neurosciences (K.M.K., S.C.L., A.A., A.R., W.R., R.D.S., R.B.), Department of Neurology, University of California, San Francisco; Department of Neurology (J.M.), Kaiser Permanente, San Francisco; Department of Neurology (C.S.R.), Columbia University, New York, New York; Department of Neurology (C.B.), Northwestern University, Chicago, Illinois; and Department of Pediatrics (T.W.H.), Texas Tech University School of Medicine, Amarillo.
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LaHue SC, Gelfand AA, Bove RM. Navigating monoclonal antibody use in breastfeeding women: Do no harm or do little good? Neurology 2019; 93:668-672. [PMID: 31492717 DOI: 10.1212/wnl.0000000000008213] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Accepted: 07/05/2019] [Indexed: 11/15/2022] Open
Abstract
Many neurologic diseases disproportionately affect women, particularly during their reproductive years. For many of these diseases, monoclonal antibodies (mAbs) are becoming widely available as a treatment option, for example, in migraine, multiple sclerosis, and myasthenia gravis. Yet, despite how common pregnancy is (latest estimates suggest that 86% of US women ages 40-44 have given birth), there is a paucity of research on the safety of prescription medications, including mAbs, during the peripartum period. In this article, we focus on the safety of mAbs during breastfeeding. We summarize how pregnancy affects the trajectory of these diseases and explore the benefit derived from mAb therapies. We posit that as neurologists, we are uniquely poised to lead the study of peripartum safety for the mAbs now on the market and provide a framework for their future study.
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Affiliation(s)
- Sara C LaHue
- From the Department of Neurology, School of Medicine, and Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco
| | - Amy A Gelfand
- From the Department of Neurology, School of Medicine, and Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco
| | - Riley M Bove
- From the Department of Neurology, School of Medicine, and Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco.
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Nguyen AL, Eastaugh A, van der Walt A, Jokubaitis VG. Pregnancy and multiple sclerosis: Clinical effects across the lifespan. Autoimmun Rev 2019; 18:102360. [PMID: 31401345 DOI: 10.1016/j.autrev.2019.102360] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 04/17/2019] [Indexed: 01/10/2023]
Abstract
Multiple sclerosis (MS) is commonly diagnosed in women of childbearing age. Having a greater understanding of the effects of pregnancy on the course of MS will lead to improved family-planning counselling for women. We found well-established evidence for a protective effect of pregnancy on relapse occurrence in historical cohorts. More recent studies suggest that the protective effect of pregnancy against relapse may be lost in those women with more active disease treated with high efficacy therapies. Furthermore, a strong body of evidence suggests that gravidity after diagnosis of MS does not lead to worse long-term outcomes. More contentious however, is whether pregnancy can delay a first episode of demyelination or a confirmed diagnosis of MS. This review provides a detailed analysis of the literature relating to the clinical effects of pregnancy on MS outcomes across a woman's reproductive lifespan.
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Affiliation(s)
- Ai-Lan Nguyen
- Department of Medicine, University of Melbourne, Parkville, Australia; Department of Neurology, Royal Melbourne Hospital, Parkville, Australia.
| | - Alana Eastaugh
- Department of Neurology, Royal Melbourne Hospital, Parkville, Australia
| | - Anneke van der Walt
- Department of Medicine, University of Melbourne, Parkville, Australia; Department of Neurology, Royal Melbourne Hospital, Parkville, Australia; Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Australia; Department of Neurology, MSNI Service, Alfred Health, Melbourne, Australia
| | - Vilija G Jokubaitis
- Department of Medicine, University of Melbourne, Parkville, Australia; Department of Neurology, Royal Melbourne Hospital, Parkville, Australia; Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Australia; Department of Neurology, MSNI Service, Alfred Health, Melbourne, Australia
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Berenguer-Ruiz L, Gimenez-Martinez J, Palazón-Bru A, Sempere AP. Relapses and obstetric outcomes in women with multiple sclerosis planning pregnancy. J Neurol 2019; 266:2512-2517. [PMID: 31256279 DOI: 10.1007/s00415-019-09450-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Revised: 06/24/2019] [Accepted: 06/25/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To evaluate the effect of discontinuation of different disease-modifying therapies (DMTs) before pregnancy with respect to the occurrence of relapses and pregnancy outcomes. METHODS Women with multiple sclerosis who desire to bear children were followed prospectively. Demographic data, clinical characteristics, and the information on the use of DMTs were collected. A multivariate analysis was used to assess the relationship between relapses and the prior use of different DMTs. RESULTS The present study assessed 75 consecutive pregnancy plans (66 women), 65 of which resulted in pregnancy. The mean age of the participants was 32.1 ± 4.2 years, and the mean disease duration was 6.1 ± 4.2 years. No relapses before pregnancy were reported in the group of women who maintained their DMT until pregnancy confirmation, while 14 relapses were reported in 12/42 women (29%) who discontinued DMT before pregnancy. During pregnancy, patients on natalizumab or fingolimod before pregnancy had a higher rate of relapses. Most women restarted their previous DMT after delivery within the first trimester. The relapse rate in postpartum was 0.07. CONCLUSIONS Disease-modifying therapies received influences the risk of relapse and disease progression from women who are planning pregnancy. The risk of relapse during pregnancy was significantly higher in the group of women treated with natalizumab or fingolimod compared to the group of women treated with interferon beta or glatiramer acetate. The postpartum risk of relapses was lower than that found in previous reports.
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Affiliation(s)
| | | | - Antonio Palazón-Bru
- Department of Clinical Medicine, Miguel Hernández University, Sant Joan d'Alacant, Spain
| | - Angel Perez Sempere
- Neurology Service, Hospital General Universitario de Alicante, 03010, Alicante, Spain. .,Department of Clinical Medicine, Miguel Hernández University, Sant Joan d'Alacant, Spain.
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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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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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Bsteh G, Algrang L, Hegen H, Auer M, Wurth S, Di Pauli F, Deisenhammer F, Berger T. Pregnancy and multiple sclerosis in the DMT era: A cohort study in Western Austria. Mult Scler 2018; 26:69-78. [PMID: 30507345 DOI: 10.1177/1352458518816614] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Multiple sclerosis (MS) predominantly affects women of child-bearing potential. Pregnancy in MS is still a controversial issue lacking standardized treatment recommendations. OBJECTIVE To examine the reciprocal effects of pregnancy, MS, and disease-modifying treatment (DMT). METHODS We analyzed 387 pregnancies in 239 women with relapsing remitting multiple sclerosis (RRMS) and ⩾1 pregnancy, establishment of diagnosis >1 year before conception, and ⩾2 years of follow-up after delivery. Relapse rates and Expanded Disability Status Scale (EDSS) scores were compared in the year before conception, during pregnancy, and 2 years postpartum. Binary logistic regression was used to investigate predictors of risk for relapses and disability progression during pregnancy and postpartum. RESULTS Risk of relapse and disability progression during pregnancy was predicted by pre-conception relapse activity, higher EDSS score at conception, use of highly effective disease-modifying treatment (H-DMT) pre-conception, and prolonged washout period. Postpartum relapse and disability progression was associated with relapse activity pre-conception and during pregnancy and use of H-DMT pre-conception. Early restart of DMT reduced the risk of postpartum relapse. CONCLUSION A personalized approach in planning pregnancy in women with MS while on H-DMT needs to be adopted. It seems reasonable maintaining natalizumab closer to conception and restarting the drug early postpartum to reduce the considerable risk of disease reactivation during early pregnancy and after delivery.
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Affiliation(s)
- Gabriel Bsteh
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Laura Algrang
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Harald Hegen
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Michael Auer
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Sebastian Wurth
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Franziska Di Pauli
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Florian Deisenhammer
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Thomas Berger
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
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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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McCombe PA. The Short and Long-Term Effects of Pregnancy on Multiple Sclerosis and Experimental Autoimmune Encephalomyelitis. J Clin Med 2018; 7:jcm7120494. [PMID: 30486504 PMCID: PMC6306813 DOI: 10.3390/jcm7120494] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 11/21/2018] [Accepted: 11/21/2018] [Indexed: 02/07/2023] Open
Abstract
The role of pregnancy in multiple sclerosis (MS) is of importance because many patients with MS are young women in the childbearing age who require information to inform their reproductive decisions. Pregnancy is now well-known to be associated with fewer relapses of MS and reduced activity of autoimmune encephalomyelitis (EAE). However, in women with multiple sclerosis, this benefit is not always sufficient to protect against a rebound of disease activity if disease-modulating therapy is ceased for pregnancy. There is concern that use of assisted reproductive therapies can be associated with relapses of MS, but more data are required. It is thought that the beneficial effects of pregnancy are due to the pregnancy-associated changes in the maternal immune system. There is some evidence of this in human studies and studies of EAE. There is also evidence that having been pregnant leads to better long-term outcome of MS. The mechanism for this is not fully understood but it could result from epigenetic changes resulting from pregnancy or parenthood. Further studies of the mechanisms of the beneficial effects of pregnancy could provide information that might be used to produce new therapies.
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Affiliation(s)
- Pamela A McCombe
- The University of Queensland, Centre for Clinical Research, Brisbane, QLD 4029, Australia.
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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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Majdinasab N, Motl RW, Mokhtarzade M, Zimmer P, Ranjbar R, Keytsman C, Cullen T, Negaresh R, Baker JS. Acute responses of cytokines and adipokines to aerobic exercise in relapsing vs. remitting women with multiple sclerosis. Complement Ther Clin Pract 2018; 31:295-301. [DOI: 10.1016/j.ctcp.2018.03.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Revised: 03/04/2018] [Accepted: 03/13/2018] [Indexed: 01/28/2023]
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Marrie RA, Montalban X. Disease-modifying therapy in multiple sclerosis: Two guidelines (almost) passing in the night. Mult Scler 2018; 24:558-562. [DOI: 10.1177/1352458518767323] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Ruth Ann Marrie
- Departments of Internal Medicine and Community Health Sciences, Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Xavier Montalban
- Centre d’Esclerosi Múltiple de Catalunya (Cemcat), Vall d’Hebron University Hospital, Barcelona, Spain; Division of Neurology, University of Toronto, St Michael’s Hospital, Toronto, ON, Canada
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Portaccio E, Moiola L, Martinelli V, Annovazzi P, Ghezzi A, Zaffaroni M, Lanzillo R, Brescia Morra V, Rinaldi F, Gallo P, Tortorella C, Paolicelli D, Pozzilli C, De Giglio L, Cavalla P, Cocco E, Marrosu MG, Solaro C, Uccelli A, Laroni A, Pastò L, Giannini M, Trojano M, Comi G, Amato MP. Pregnancy decision-making in women with multiple sclerosis treated with natalizumab: II: Maternal risks. Neurology 2018; 90:e832-e839. [PMID: 29438041 DOI: 10.1212/wnl.0000000000005068] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 11/16/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To assess the risk of disease reactivation during pregnancy after natalizumab suspension in women with multiple sclerosis (MS). METHODS Data of all pregnancies occurring between 2009 and 2015 in patients with MS treated with natalizumab and referring to 19 participating sites were collected and compared with those of pregnancies in untreated patients and patients treated with injectable immunomodulatory agents through a 2-factor repeated measures analysis. Predictors of disease activity were assessed through stepwise multivariable logistic regression models. RESULTS A total of 92 pregnancies were tracked in 83 women receiving natalizumab. Among these pregnancies, 74 in 70 women resulted in live births, with a postpartum follow-up of at least 1 year, and were compared with 350 previously published pregnancies. Relapse rate during and after pregnancy was higher in women treated with natalizumab (p < 0.001). In multivariable analysis, longer natalizumab washout period was the only predictor of relapse occurrence during pregnancy (p = 0.001). Relapses in the postpartum year were related to relapses during pregnancy (p = 0.019) and early reintroduction of disease-modifying drugs (DMD; p = 0.021). Disability progression occurred in 16.2% of patients and was reduced by early reintroduction of DMD (p = 0.024). CONCLUSIONS Taken as a whole, our findings indicate that the combination of avoiding natalizumab washout and the early resumption of DMD after delivery could be the best option in the perspective of maternal risk. This approach must take into account possible fetal risks that need to be discussed with the mother and require further investigation. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that in women with MS, the risk of relapses during pregnancy is higher in those who had been using natalizumab as compared to those who had been using interferon-β or no treatment.
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Affiliation(s)
- Emilio Portaccio
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (C.S.), ASL3 Genovese; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy.
| | - Lucia Moiola
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (C.S.), ASL3 Genovese; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Vittorio Martinelli
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (C.S.), ASL3 Genovese; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Pietro Annovazzi
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (C.S.), ASL3 Genovese; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Angelo Ghezzi
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (C.S.), ASL3 Genovese; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Mauro Zaffaroni
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (C.S.), ASL3 Genovese; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Roberta Lanzillo
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (C.S.), ASL3 Genovese; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Vincenzo Brescia Morra
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (C.S.), ASL3 Genovese; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Francesca Rinaldi
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (C.S.), ASL3 Genovese; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Paolo Gallo
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (C.S.), ASL3 Genovese; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Carla Tortorella
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (C.S.), ASL3 Genovese; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Damiano Paolicelli
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (C.S.), ASL3 Genovese; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Carlo Pozzilli
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (C.S.), ASL3 Genovese; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Laura De Giglio
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (C.S.), ASL3 Genovese; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Paola Cavalla
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (C.S.), ASL3 Genovese; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Eleonora Cocco
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (C.S.), ASL3 Genovese; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Maria Giovanna Marrosu
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (C.S.), ASL3 Genovese; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Claudio Solaro
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (C.S.), ASL3 Genovese; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Antonio Uccelli
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (C.S.), ASL3 Genovese; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Alice Laroni
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (C.S.), ASL3 Genovese; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Luisa Pastò
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (C.S.), ASL3 Genovese; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Marta Giannini
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (C.S.), ASL3 Genovese; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Maria Trojano
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (C.S.), ASL3 Genovese; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Giancarlo Comi
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (C.S.), ASL3 Genovese; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Maria Pia Amato
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (C.S.), ASL3 Genovese; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
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Portaccio E, Annovazzi P, Ghezzi A, Zaffaroni M, Moiola L, Martinelli V, Lanzillo R, Brescia Morra V, Rinaldi F, Gallo P, Tortorella C, Paolicelli D, Pozzilli C, De Giglio L, Cavalla P, Cocco E, Marrosu MG, Patti F, Solaro C, Bellantonio P, Uccelli A, Laroni A, Pastò L, Giannini M, Trojano M, Comi G, Amato MP. Pregnancy decision-making in women with multiple sclerosis treated with natalizumab: I: Fetal risks. Neurology 2018; 90:e823-e831. [PMID: 29438046 DOI: 10.1212/wnl.0000000000005067] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 11/16/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To assess fetal risk after pregnancy exposure to natalizumab in women with multiple sclerosis (MS), with a specific focus on spontaneous abortion (SA) and congenital anomalies (CA). METHODS Data of all pregnancies occurring between 2009 and 2015 in patients with MS treated with natalizumab and referring to 19 participating sites were collected and compared with those of pregnancies in untreated patients and patients treated with injectable immunomodulatory agents. Rates of SA and CA were also compared with those reported in the Italian population. Multivariable logistic and linear regression models were performed. RESULTS A total of 92 pregnancies were tracked in 83 women. In the multivariable analysis, natalizumab exposure was associated with SA (odds ratio [OR] 3.9, 95% confidence interval [CI] 1.9-8.5, p < 0.001). However, the rate of SA (17.4%) was within the estimates for the general population, as well as the rate of major CA (3.7%). Moreover, exposure to natalizumab and interferon-β (IFN-β) was associated with lower length and weight of the babies (p < 0.001). CONCLUSION Our results showed that natalizumab exposure to up 12 weeks of gestation is associated with an increased risk of SA, although within the limits expected in the general population, whereas the risk of CA needs further investigation. Taking into account the high risk of disease reactivation after natalizumab suspension, pregnancy could be planned continuing natalizumab while strictly monitoring conception. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that in women with MS, natalizumab exposure increases the risk of spontaneous abortion as compared to IFN-β-exposed or untreated patients (OR 3.9, 95% CI 1.9-8.5).
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Affiliation(s)
- Emilio Portaccio
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (F.P.), University of Catania; Department of Neurology (C.S.), ASL3 Genovese; Multiple Sclerosis Center (P.B.), IRCCS Neuromed, Pozzilli; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy.
| | - Pietro Annovazzi
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (F.P.), University of Catania; Department of Neurology (C.S.), ASL3 Genovese; Multiple Sclerosis Center (P.B.), IRCCS Neuromed, Pozzilli; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Angelo Ghezzi
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (F.P.), University of Catania; Department of Neurology (C.S.), ASL3 Genovese; Multiple Sclerosis Center (P.B.), IRCCS Neuromed, Pozzilli; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Mauro Zaffaroni
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (F.P.), University of Catania; Department of Neurology (C.S.), ASL3 Genovese; Multiple Sclerosis Center (P.B.), IRCCS Neuromed, Pozzilli; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Lucia Moiola
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (F.P.), University of Catania; Department of Neurology (C.S.), ASL3 Genovese; Multiple Sclerosis Center (P.B.), IRCCS Neuromed, Pozzilli; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Vittorio Martinelli
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (F.P.), University of Catania; Department of Neurology (C.S.), ASL3 Genovese; Multiple Sclerosis Center (P.B.), IRCCS Neuromed, Pozzilli; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Roberta Lanzillo
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (F.P.), University of Catania; Department of Neurology (C.S.), ASL3 Genovese; Multiple Sclerosis Center (P.B.), IRCCS Neuromed, Pozzilli; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Vincenzo Brescia Morra
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (F.P.), University of Catania; Department of Neurology (C.S.), ASL3 Genovese; Multiple Sclerosis Center (P.B.), IRCCS Neuromed, Pozzilli; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Francesca Rinaldi
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (F.P.), University of Catania; Department of Neurology (C.S.), ASL3 Genovese; Multiple Sclerosis Center (P.B.), IRCCS Neuromed, Pozzilli; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Paolo Gallo
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (F.P.), University of Catania; Department of Neurology (C.S.), ASL3 Genovese; Multiple Sclerosis Center (P.B.), IRCCS Neuromed, Pozzilli; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Carla Tortorella
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (F.P.), University of Catania; Department of Neurology (C.S.), ASL3 Genovese; Multiple Sclerosis Center (P.B.), IRCCS Neuromed, Pozzilli; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Damiano Paolicelli
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (F.P.), University of Catania; Department of Neurology (C.S.), ASL3 Genovese; Multiple Sclerosis Center (P.B.), IRCCS Neuromed, Pozzilli; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Carlo Pozzilli
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (F.P.), University of Catania; Department of Neurology (C.S.), ASL3 Genovese; Multiple Sclerosis Center (P.B.), IRCCS Neuromed, Pozzilli; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Laura De Giglio
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (F.P.), University of Catania; Department of Neurology (C.S.), ASL3 Genovese; Multiple Sclerosis Center (P.B.), IRCCS Neuromed, Pozzilli; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Paola Cavalla
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (F.P.), University of Catania; Department of Neurology (C.S.), ASL3 Genovese; Multiple Sclerosis Center (P.B.), IRCCS Neuromed, Pozzilli; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Eleonora Cocco
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (F.P.), University of Catania; Department of Neurology (C.S.), ASL3 Genovese; Multiple Sclerosis Center (P.B.), IRCCS Neuromed, Pozzilli; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Maria Giovanna Marrosu
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (F.P.), University of Catania; Department of Neurology (C.S.), ASL3 Genovese; Multiple Sclerosis Center (P.B.), IRCCS Neuromed, Pozzilli; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Francesco Patti
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (F.P.), University of Catania; Department of Neurology (C.S.), ASL3 Genovese; Multiple Sclerosis Center (P.B.), IRCCS Neuromed, Pozzilli; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Claudio Solaro
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (F.P.), University of Catania; Department of Neurology (C.S.), ASL3 Genovese; Multiple Sclerosis Center (P.B.), IRCCS Neuromed, Pozzilli; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Paolo Bellantonio
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (F.P.), University of Catania; Department of Neurology (C.S.), ASL3 Genovese; Multiple Sclerosis Center (P.B.), IRCCS Neuromed, Pozzilli; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Antonio Uccelli
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (F.P.), University of Catania; Department of Neurology (C.S.), ASL3 Genovese; Multiple Sclerosis Center (P.B.), IRCCS Neuromed, Pozzilli; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Alice Laroni
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (F.P.), University of Catania; Department of Neurology (C.S.), ASL3 Genovese; Multiple Sclerosis Center (P.B.), IRCCS Neuromed, Pozzilli; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Luisa Pastò
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (F.P.), University of Catania; Department of Neurology (C.S.), ASL3 Genovese; Multiple Sclerosis Center (P.B.), IRCCS Neuromed, Pozzilli; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Marta Giannini
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (F.P.), University of Catania; Department of Neurology (C.S.), ASL3 Genovese; Multiple Sclerosis Center (P.B.), IRCCS Neuromed, Pozzilli; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Maria Trojano
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (F.P.), University of Catania; Department of Neurology (C.S.), ASL3 Genovese; Multiple Sclerosis Center (P.B.), IRCCS Neuromed, Pozzilli; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Giancarlo Comi
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (F.P.), University of Catania; Department of Neurology (C.S.), ASL3 Genovese; Multiple Sclerosis Center (P.B.), IRCCS Neuromed, Pozzilli; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Maria Pia Amato
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (F.P.), University of Catania; Department of Neurology (C.S.), ASL3 Genovese; Multiple Sclerosis Center (P.B.), IRCCS Neuromed, Pozzilli; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
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