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Bove R, Applebee A, Bawden K, Fine C, Shah A, Avila RL, Belviso N, Branco F, Fong K, Lewin JB, Liu J, England SM, Vignos M. Patterns of disease-modifying therapy utilization before, during, and after pregnancy and postpartum relapses in women with multiple sclerosis. Mult Scler Relat Disord 2024; 88:105738. [PMID: 38959591 DOI: 10.1016/j.msard.2024.105738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 05/13/2024] [Accepted: 06/19/2024] [Indexed: 07/05/2024]
Abstract
BACKGROUND Pregnancy is a common consideration for people with multiple sclerosis (pwMS); MS onset is typically between 20 and 45 years of age, during potential child-bearing years. Pregnancy and postpartum care are a significant factor influencing disease-modifying therapy (DMT) selection for many pwMS. To date, few DMTs are considered safe to continue during pregnancy and real-world treatment patterns before, during, and after pregnancy remain uncharacterized. Evolving guidance is needed regarding how to optimize management of the pregnancy and postpartum periods considering the changing DMT landscape. This analysis in two large claims databases describes DMT utilization for the treatment of MS before, during, and after pregnancy and relapse patterns during pregnancy and postpartum. METHODS In this retrospective, observational study, the US MarketScan Commercial and Medicaid claims database was assessed for female patients aged 18-55 years with ≥1 insurance claim submitted under the diagnosis code of MS from 01 January 2016-30 April 2021 and continuous enrollment eligibility from ≥6 months prior to pregnancy date (preconception) through 6 months of follow-up following delivery (postpartum period). Comorbid conditions were examined preconception and postpartum, including anxiety and depression. Moderate/severe relapse was defined as MS-related hospitalization, or an outpatient visit and one claim within 7 days of the visit with steroids or total plasma exchange. RESULTS A total of 944 patients (mean [standard deviation] age, 32.4 [5.0] years) were eligible; 688 (73%) were commercially insured and 256 (27%) received Medicaid. Compared with commercially-insured patients, use of DMTs was lower among Medicaid patients at 6 months preconception (25.4% vs 40.4%; p < 0.001), with similar patterns observed both during pregnancy and postpartum. Overall, prevalence of DMT use declined sharply during pregnancy, from 36.3% of patients in the 6 months preconception to 17.9%, 5.3%, and 5.8% in trimesters 1, 2 and 3, respectively. Postpartum DMT utilization increased to 20.9% at 0-3 months and 24.4% at 4-6 months. Of all patients in the preconception period, the most frequently used DMTs were glatiramer acetate (14.3%), dimethyl fumarate (6.0%), interferon (5.2%), and natalizumab (4.9%). Due to small sample size, information was limited for anti-CD20s and alemtuzumab. The proportion of patients with any moderate/severe relapse declined over pregnancy (preconception, n = 82 [8.7%]; pregnancy, n = 25 [2.6%]), but increased postpartum (n = 94 [10.0%]). Of the 889 patients who stopped DMT during pregnancy, the risk of postpartum relapses was lower in the patients who resumed DMT postpartum (10/192) than in patients who did not (76/697) (5.2% vs 10.9%; odds ratio, 0.455 [95% confidence interval 0.216-0.860], p = 0.018). Cases of postpartum depression and anxiety were significantly lower in commercially-insured patients vs Medicaid patients (postpartum depression, 13.7% vs 27.0%, p < 0.01; postpartum anxiety, 16.3% vs 30.5%, p < 0.01). CONCLUSION DMT utilization declined sharply during pregnancy; it gradually increased postpartum but remained below pre-pregnancy use. The proportion of pwMS experiencing a moderate/severe relapse and number of relapses declined over pregnancy but increased postpartum. Reinitiation of DMT during the postpartum period was associated with lower risk of relapses, supporting a role for early reinitiation of DMT postpartum. STUDY SUPPORTED BY Biogen.
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Affiliation(s)
- Riley Bove
- Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
| | - Angela Applebee
- Department of Neurology, St. Peter's Multiple Sclerosis and Headache Center, Albany, NY, USA
| | - Katrina Bawden
- Rocky Mountain Multiple Sclerosis Clinic and Research Group, Salt Lake City, UT, USA
| | | | - Anna Shah
- Rocky Mountain Multiple Sclerosis Center, University of Colorado, Aurora, CO, USA
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Perillan C, Coto A, Arguelles J, Nuñez P. Study of the impact of multiple sclerosis on the reproductive life of Spanish women: An online survey. Mult Scler Relat Disord 2024; 90:105789. [PMID: 39096667 DOI: 10.1016/j.msard.2024.105789] [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: 04/12/2024] [Revised: 06/29/2024] [Accepted: 07/25/2024] [Indexed: 08/05/2024]
Abstract
BACKGROUND Women have a higher risk of developing multiple sclerosis (MS) than men. The natural reproductive period from menarche to menopause corresponds to the period of active inflammatory disease in MS. Mothers and pregnant women with MS need information about how their disease may affect pregnancy and breastfeeding. AIM The aim was to explore the reproductive factors in an MS-diagnosed population and to identify ways to support patients and their decision-making process. METHODS We conducted a cross-sectional, Web-based survey of women living with MS in Asturias (Spain) using a community-based participatory approach. FINDINGS Early menarche may predict the onset of MS. Pregnancy improves the general health of patients and reduces the number of relapses. Breastfeeding is often not practised and may cause concern in women. MS does not affect the age of menopause, but it can worsen symptoms. However, menopause does not increase the number of MS relapses. CONCLUSIONS MS is increasingly diagnosed at an earlier age, which increases the number of women who become pregnant after being diagnosed with MS. The decrease in MS relapses during pregnancy and the increase during the postpartum period are consistent with previous reports. Women who choose to breastfeed are in the minority due to treatment incompatibility, although some currently used treatments are compatible with breastfeeding. However, there is a lack of information on this which should be investigated.
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Affiliation(s)
- Carmen Perillan
- Department of Functional Biology, Physiology, Faculty of Medicine and Health Sciences, University of Oviedo, Oviedo, Spain
| | - Aroa Coto
- Department of Functional Biology, Physiology, Faculty of Medicine and Health Sciences, University of Oviedo, Oviedo, Spain
| | - Juan Arguelles
- Department of Functional Biology, Physiology, Faculty of Medicine and Health Sciences, University of Oviedo, Oviedo, Spain
| | - Paula Nuñez
- Department of Functional Biology, Physiology, Faculty of Medicine and Health Sciences, University of Oviedo, Oviedo, Spain.
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Saito S, Ikeguchi R, Kitagawa K, Shimizu Y. Clinical Experience with Dimethyl Fumarate and Natalizumab in Pregnant Women with Multiple Sclerosis: A Four-Patient Case Series. Case Rep Neurol Med 2024; 2024:7808140. [PMID: 39044765 PMCID: PMC11265946 DOI: 10.1155/2024/7808140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Revised: 05/12/2024] [Accepted: 07/04/2024] [Indexed: 07/25/2024] Open
Abstract
Interferon β and glatiramer acetate are the disease-modifying drugs (DMDs) considered relatively safe for use in pregnant women with multiple sclerosis (MS); however, the safety profile of dimethyl fumarate (DMF) and natalizumab (NTZ) in this population remains inconclusive. Here, we present four cases of pregnant women with MS who were treated with DMF and NTZ (n = 2 patients, each) during their pregnancy and discuss our observations with the use of these drugs and the clinical courses of the patients. We retrospectively examined relapse of MS during pregnancy and after delivery; duration of exposure to DMDs; maternal, fetal, and neonatal adverse events; breastfeeding; and timing of resumption of DMDs. The two patients treated with DMF discontinued treatment 5 or 6 weeks after the discovery of pregnancy. DMF was resumed 1 week postpartum, and mixed breastfeeding was initiated. Brain magnetic resonance imaging in one patient 9 months after delivery revealed a new lesion; however, it was not classified as a clinical relapse. In two patients treated with NTZ, the dosing interval was extended to 6 weeks after the discovery of pregnancy. One patient discontinued NTZ at 30 weeks and the other at 25 weeks of gestation, as a slight restriction in fetal growth was observed owing to hyperemesis gravidarum. Both patients opted for formula feeding, and no relapse was observed within 1 year postpartum. Additionally, no abnormalities were observed in any of the patients during the perinatal period, and their development was normal. Investigation of drug safety in pregnant and parturient women primarily relies on registries, postmarketing surveillance, and case reports due to ethical limitations on conducting randomized controlled trials. Our findings demonstrated that DMF and NTZ were not contraindicated during pregnancy or the perinatal period in women with MS; nevertheless, vigilant monitoring is essential to ensure the safety of these drugs.
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Affiliation(s)
- Satoshi Saito
- Department of NeurologyTokyo Women's Medical University School of Medicine, 8-1, Kawadacho, Shinjukuku, Tokyo, Japan
| | - Ryotaro Ikeguchi
- Department of NeurologyTokyo Women's Medical University School of Medicine, 8-1, Kawadacho, Shinjukuku, Tokyo, Japan
| | - Kazuo Kitagawa
- Department of NeurologyTokyo Women's Medical University School of Medicine, 8-1, Kawadacho, Shinjukuku, Tokyo, Japan
| | - Yuko Shimizu
- Department of NeurologyTokyo Women's Medical University School of Medicine, 8-1, Kawadacho, Shinjukuku, Tokyo, Japan
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Zveik O, Rechtman A, Ganz T, Vaknin-Dembinsky A. The interplay of inflammation and remyelination: rethinking MS treatment with a focus on oligodendrocyte progenitor cells. Mol Neurodegener 2024; 19:53. [PMID: 38997755 PMCID: PMC11245841 DOI: 10.1186/s13024-024-00742-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Accepted: 07/01/2024] [Indexed: 07/14/2024] Open
Abstract
BACKGROUND Multiple sclerosis (MS) therapeutic goals have traditionally been dichotomized into two distinct avenues: immune-modulatory-centric interventions and pro-regenerative strategies. Oligodendrocyte progenitor cells (OPCs) were regarded for many years solely in concern to their potential to generate oligodendrocytes and myelin in the central nervous system (CNS). However, accumulating data elucidate the multifaceted roles of OPCs, including their immunomodulatory functions, positioning them as cardinal constituents of the CNS's immune landscape. MAIN BODY In this review, we will discuss how the two therapeutic approaches converge. We present a model by which (1) an inflammation is required for the appropriate pro-myelinating immune function of OPCs in the chronically inflamed CNS, and (2) the immune function of OPCs is crucial for their ability to differentiate and promote remyelination. This model highlights the reciprocal interactions between OPCs' pro-myelinating and immune-modulating functions. Additionally, we review the specific effects of anti- and pro-inflammatory interventions on OPCs, suggesting that immunosuppression adversely affects OPCs' differentiation and immune functions. CONCLUSION We suggest a multi-systemic therapeutic approach, which necessitates not a unidimensional focus but a harmonious balance between OPCs' pro-myelinating and immune-modulatory functions.
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Affiliation(s)
- Omri Zveik
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, 91120, Israel
- The Department of Neurology and Laboratory of Neuroimmunology, The Agnes-Ginges Center for Human Neurogenetics, Hadassah-Hebrew University Medical Center, Ein-Kerem P.O.B. 12000, Jerusalem, 91120, Israel
| | - Ariel Rechtman
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, 91120, Israel
- The Department of Neurology and Laboratory of Neuroimmunology, The Agnes-Ginges Center for Human Neurogenetics, Hadassah-Hebrew University Medical Center, Ein-Kerem P.O.B. 12000, Jerusalem, 91120, Israel
| | - Tal Ganz
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, 91120, Israel
- The Department of Neurology and Laboratory of Neuroimmunology, The Agnes-Ginges Center for Human Neurogenetics, Hadassah-Hebrew University Medical Center, Ein-Kerem P.O.B. 12000, Jerusalem, 91120, Israel
| | - Adi Vaknin-Dembinsky
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, 91120, Israel.
- The Department of Neurology and Laboratory of Neuroimmunology, The Agnes-Ginges Center for Human Neurogenetics, Hadassah-Hebrew University Medical Center, Ein-Kerem P.O.B. 12000, Jerusalem, 91120, Israel.
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Houtchens MK. Pregnancy and reproductive health in women with multiple sclerosis: an update. Curr Opin Neurol 2024; 37:202-211. [PMID: 38587068 DOI: 10.1097/wco.0000000000001275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
PURPOSE OF REVIEW Multiple sclerosis (MS) is a chronic immune-mediated, inflammatory, neuro-degenerative disease of the central nervous system, prevalent in women of reproductive age. Today, many women want to start a family after MS diagnosis. There are over 20 treatments for MS, and safely navigating family planning is important. We review updated information on family planning, preconception, and peri-partum considerations, and reproductive concerns in special populations with MS. RECENT FINDINGS There are no MS-related restrictions on any available and appropriate contraceptive method in women with MS. The question of MS and pregnancy outcomes following assisted reproduction, remains somewhat unsettled. In many studies, no elevated relapse risk is confirmed regardless of the type of fertility treatment. MRI status may offer better assessment of postpartum disease stability than relapse rate alone. Ongoing effective MS treatments during fertility assistance and before pregnancy, can further reduce the relapse risk. B-cell depleting therapies are emerging as safe and effective treatments for peripartum MS patients. SUMMARY Patients with MS should receive accurate support and counseling related to their reproductive options. The general outlook on pregnancy and MS remains positive. The ever-increasing therapeutic complexity of MS calls for ongoing education and updated guidance for neuroimmunology and obstetrics healthcare providers.
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Affiliation(s)
- Maria K Houtchens
- Brigham Multiple Sclerosis Center, Building for Transformative Medicine, 1set Floor, 60 Fenwood Road, Boston, Massachusetts, USA
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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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Yamout B, Al-Jumah M, Sahraian MA, Almalik Y, Khaburi JA, Shalaby N, Aljarallah S, Bohlega S, Dahdaleh M, Almahdawi A, Khoury SJ, Koussa S, Slassi E, Daoudi S, Aref H, Mrabet S, Zeineddine M, Zakaria M, Inshasi J, Gouider R, Alroughani R. Consensus recommendations for diagnosis and treatment of Multiple Sclerosis: 2023 revision of the MENACTRIMS guidelines. Mult Scler Relat Disord 2024; 83:105435. [PMID: 38245998 DOI: 10.1016/j.msard.2024.105435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 12/21/2023] [Accepted: 01/06/2024] [Indexed: 01/23/2024]
Abstract
With evolving diagnostic criteria and the advent of new oral and parenteral therapies for Multiple Sclerosis (MS), most current diagnostic and treatment algorithms need revision and updating. The diagnosis of MS relies on incorporating clinical and paraclinical findings to prove dissemination in space and time and exclude alternative diseases that can explain the findings at hand. The differential diagnostic workup should be guided by clinical and laboratory red flags to avoid unnecessary tests. Appropriate selection of MS therapies is critical to maximize patient benefit. The current guidelines review the current diagnostic criteria for MS and the scientific evidence supporting treatment of acute relapses, radiologically isolated syndrome, clinically isolated syndrome, relapsing remitting MS, progressive MS, pediatric cases and pregnant women. The purpose of these guidelines is to provide practical recommendations and algorithms for the diagnosis and treatment of MS based on current scientific evidence and clinical experience.
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Affiliation(s)
- B Yamout
- Neurology Institute and Multiple Sclerosis Center, Harley Street Medical Center, Abu Dhabi, United Arab Emirates.
| | - M Al-Jumah
- InterHealth hospital, Multiple Sclerosis Center, Riyadh, Saudi Arabia
| | - M A Sahraian
- Multiple Sclerosis Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Y Almalik
- Division of Neurology, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, National Guard Health Affairs, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - J Al Khaburi
- Department of Neurology, The Royal Hospital, Sultanate of Oman
| | - N Shalaby
- Neurology Department, Kasr Al-Ainy School of Medicine, Cairo University, Cairo, Egypt
| | | | - S Bohlega
- King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | | | - A Almahdawi
- Consultant Neurologist, Neurology Unit, Baghdad Teaching Hospital, Medical City Complex, Iraq
| | - S J Khoury
- Nehme and Therese Tohme Multiple Sclerosis Center, American University of Beirut Medical Center, Beirut, Lebanon
| | - S Koussa
- Multiple Sclerosis Center, Geitaoui Lebanese University Hospital, Beirut, Lebanon
| | - E Slassi
- Hôpital Cheikh Khalifa Ibn Zaid, Casablanca, Morocco
| | - S Daoudi
- Hospital Center Nedir Mohamed, Faculty of Medicine, University Mouloud Mammeri Tizi-Ouzou, Algeria
| | - H Aref
- Neurology Department, Ain Shams University, Cairo, Egypt
| | - S Mrabet
- Department of Neurology, CIC, Razi Universitary Hospital, University of Tunis El Manar, Tunis, Tunisia
| | - M Zeineddine
- Middle East and North Africa Committee for Treatment and Research in Multiple Sclerosis (MENACTRIMS), Beirut, Lebanon
| | | | - J Inshasi
- Department of Neurology, Rashid Hospital and Dubai Medical College, Dubai Health Authority, Dubai, United Arab Emirates
| | - R Gouider
- Department of Neurology, CIC, Razi Universitary Hospital, University of Tunis El Manar, Tunis, Tunisia
| | - R Alroughani
- Amiri Hospital, Arabian Gulf Street, Sharq, Kuwait
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Faissner S, Bongert M, Trendelenburg P, Thiel S, Yamamura T, Hellwig K, Gold R. Eomesodermin-expressing CD4+ Th cells and association with pregnancy in multiple sclerosis. Ther Adv Neurol Disord 2024; 17:17562864241229321. [PMID: 38371384 PMCID: PMC10874138 DOI: 10.1177/17562864241229321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 01/09/2024] [Indexed: 02/20/2024] Open
Abstract
Background Pregnancy in patients with multiple sclerosis (MS) is accompanied by a decline of relapse activity with increased risk of relapses 3 months post-partum, for unknown reasons. Eomesodermin+ T-helper cells (Eomes+ Th cells) are known to mediate neuroinflammation and disease progression in MS and are induced by prolactin-secreting cells. Objectives Here, investigated immune cell alterations and the pathophysiological role of Eomes+ Th cells for disease activity during pregnancy and post-partum in MS. Methods We enrolled n = 81 pregnant patients with relapsing-remitting MS (RRMS), n = 27 post-partum RRMS and n = 26 female RRMS control patients under the umbrella of the German Multiple Sclerosis and Pregnancy Registry. Clinical data were collected and immune cell alterations were analysed using flow cytometry. Results While CD3+CD4+ Th cells were unaffected, CD3+CD8+ cytotoxic T-cells were elevated post-partum (p = 0.02) with reduced B-cell frequencies (p = 0.01) compared to non-pregnant RRMS patients. NK cells were elevated during first trimester (p = 0.02) compared to the third trimester. Frequencies of Eomes+ Th and Eomes+ Tc cells did not differ. There was no correlation of prolactin release and expression of Eomes+ Th cells. However, Eomes+ Th cells correlated with lower frequencies of regulatory T-cells during second (r = -0.42; p < 0.05) and third trimester (r = -0.37; p < 0.05). Moreover, Eomes+ Th cells correlated with frequencies of B-cells during third trimester (r = 0.54; p = 0.02). Frequencies of Eomes+ Th cells were not associated with the number of relapses before pregnancy, during pregnancy or post-partum. However, Eomes+ Th cells strongly correlated with disability post-partum as assessed using the EDSS (r = 0.52; p = 0.009). Discussion Pregnancy in MS is associated with robust immunological alterations. Eomes+ Th cells are capable of inducing immune cell alterations during the course of pregnancy, most evident during the second and third trimester as shown with a correlation of reduced Treg cells and a significant increase of B-cells. Importantly, Eomes+ Th cells correlate with disability post-partum. In summary, during late pregnancy in MS an inflammatory, cytotoxic and dysregulated immunological environment is primed gaining function post-delivery. This may be responsible for post-partum disability accumulation.
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Affiliation(s)
- Simon Faissner
- Department of Neurology, Ruhr-University Bochum, St. Josef-Hospital, Gudrunstr. 56, Bochum 44791, Germany
| | - Marielena Bongert
- Department of Neurology, Ruhr-University Bochum, St. Josef-Hospital, Bochum, Germany
| | - Paulina Trendelenburg
- Department of Neurology, Ruhr-University Bochum, St. Josef-Hospital, Bochum, Germany
| | - Sandra Thiel
- Department of Neurology, Ruhr-University Bochum, St. Josef-Hospital, Bochum, Germany
| | - Takashi Yamamura
- Department of Immunology, National Institute of Neuroscience, National Center of Neurology and Psychiatry, Kodaira, Japan
| | - Kerstin Hellwig
- Department of Neurology, Ruhr-University Bochum, St. Josef-Hospital, Bochum, Germany
| | - Ralf Gold
- Department of Neurology, Ruhr-University Bochum, St. Josef-Hospital, Bochum, Germany
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9
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Bove R, Sutton P, Nicholas J. Women's Health and Pregnancy in Multiple Sclerosis. Neurol Clin 2024; 42:275-293. [PMID: 37980119 DOI: 10.1016/j.ncl.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2023]
Abstract
Multiple sclerosis has a 3:1 female-to-male predominance and commonly presents in young adult women. The hormonal changes in women throughout their lifetime do affect the underlying pathology of multiple sclerosis, and the needs of women therefore change with age. Although multiple sclerosis does not adversely affect fertility or pregnancy, there are many factors to consider when caring for women throughout family planning, pregnancy, and the postpartum period. The care of these women and complex decisions regarding disease-modifying therapy use in family planning should be individualized and comprehensive.
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Affiliation(s)
- Riley Bove
- UCSF Weill Institute for Neurosciences, 1651 Fourth Street, San Francisco, CA 94158, USA
| | - Paige Sutton
- OhioHealth Multiple Sclerosis Center, 3535 Olentangy River Road, Columbus, OH 43214, USA.
| | - Jacqueline Nicholas
- OhioHealth Multiple Sclerosis Center, 3535 Olentangy River Road, Columbus, OH 43214, USA
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10
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Kelly EE, Engel C, Pearsall R, Brenton JN, Bove R, Oh U, Goldman MD. Multiple Sclerosis and Family Planning: A Survey Study of the Patient Experience. Neurol Clin Pract 2024; 14:e200222. [PMID: 38148835 PMCID: PMC10751018 DOI: 10.1212/cpj.0000000000200222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 11/04/2023] [Indexed: 12/28/2023]
Abstract
Background and Objectives Multiple sclerosis (MS) commonly affects women in their childbearing years, necessitating discussion between patients and their MS treatment team around the issues of family planning, pregnancy, and postpartum experiences. This study assessed the impact of a diagnosis of MS on women's reproductive decision-making and on their perception of counseling received surrounding pregnancy. It also sought to evaluate trends in pregnancy and postpartum experiences and determine whether experiences differed by race, ethnicity, and zip code. Methods Women with an MS diagnosis seen at the University of Virginia MS Clinic or at Virginia Commonwealth University (VCU) MS Clinic were invited to participate in a survey study. MS disease and pregnancy history, and, when appropriate, reasons for pregnancy avoidance were collected. Respondents who had >1 pregnancy following MS diagnosis were asked to evaluate the counseling they received from medical professionals and to share their pregnancy experiences including complications during pregnancy, delivery outcomes, and postpartum experience including breastfeeding. Results Of the 280 respondents, 76.6% were currently receiving MS specialty care. Most of them (79.3%) had not been pregnant following MS diagnosis. Of them, 20.1% indicated that this decision was driven by MS-related concerns: MS worsening with pregnancy (47%); ability to care for child secondary to MS (35%); passing MS onto child (19%); stopping disease-modifying therapies to attempt pregnancy (14%); lack of knowledge about options for pregnancy and MS (9%). Women with a more recent estimated decade of pregnancy were more likely to report neurologist counseling regarding MS and pregnancy (pregnancy before 2000: 40%, 2000-2010: 64.7%, 2010- present: 83.3%; χ2 0.020). Breastfeeding initiation was reported in 71.4% of postdiagnosis pregnancies (median duration 6 months, interquartile range 1.75-11). Discussion Over the past few decades, women with MS have received a wide range of evolving guidance surrounding family planning, pregnancy, and postpartum care. Survey data suggest improvements in MS/pregnancy counseling and medical management in recent years, which may be driven by an increase in research in the field. There remains an important need and opportunity to improve counseling of women with MS who are considering pregnancy.
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Affiliation(s)
- Erin E Kelly
- Virginia Commonwealth University School of Medicine (EEK), Richmond; Virginia Tech Carilion School of Medicine (CE), Roanoke; College of Arts and Sciences (RP); Division of Child Neurology (JNB), Department of Neurology, University of Virginia, Charlottesville; UCSF Weill Institute for Neurosciences (RB), University of California San Francisco; and Virginia Commonwealth University (UO, MDG)
| | - Casey Engel
- Virginia Commonwealth University School of Medicine (EEK), Richmond; Virginia Tech Carilion School of Medicine (CE), Roanoke; College of Arts and Sciences (RP); Division of Child Neurology (JNB), Department of Neurology, University of Virginia, Charlottesville; UCSF Weill Institute for Neurosciences (RB), University of California San Francisco; and Virginia Commonwealth University (UO, MDG)
| | - Rylan Pearsall
- Virginia Commonwealth University School of Medicine (EEK), Richmond; Virginia Tech Carilion School of Medicine (CE), Roanoke; College of Arts and Sciences (RP); Division of Child Neurology (JNB), Department of Neurology, University of Virginia, Charlottesville; UCSF Weill Institute for Neurosciences (RB), University of California San Francisco; and Virginia Commonwealth University (UO, MDG)
| | - J Nicholas Brenton
- Virginia Commonwealth University School of Medicine (EEK), Richmond; Virginia Tech Carilion School of Medicine (CE), Roanoke; College of Arts and Sciences (RP); Division of Child Neurology (JNB), Department of Neurology, University of Virginia, Charlottesville; UCSF Weill Institute for Neurosciences (RB), University of California San Francisco; and Virginia Commonwealth University (UO, MDG)
| | - Riley Bove
- Virginia Commonwealth University School of Medicine (EEK), Richmond; Virginia Tech Carilion School of Medicine (CE), Roanoke; College of Arts and Sciences (RP); Division of Child Neurology (JNB), Department of Neurology, University of Virginia, Charlottesville; UCSF Weill Institute for Neurosciences (RB), University of California San Francisco; and Virginia Commonwealth University (UO, MDG)
| | - Unsong Oh
- Virginia Commonwealth University School of Medicine (EEK), Richmond; Virginia Tech Carilion School of Medicine (CE), Roanoke; College of Arts and Sciences (RP); Division of Child Neurology (JNB), Department of Neurology, University of Virginia, Charlottesville; UCSF Weill Institute for Neurosciences (RB), University of California San Francisco; and Virginia Commonwealth University (UO, MDG)
| | - Myla D Goldman
- Virginia Commonwealth University School of Medicine (EEK), Richmond; Virginia Tech Carilion School of Medicine (CE), Roanoke; College of Arts and Sciences (RP); Division of Child Neurology (JNB), Department of Neurology, University of Virginia, Charlottesville; UCSF Weill Institute for Neurosciences (RB), University of California San Francisco; and Virginia Commonwealth University (UO, MDG)
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11
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Haben S, Ciplea AI, Tokic M, Timmesfeld N, Thiel S, Gold R, Langer-Gould AM, Hellwig K. Early postpartum treatment strategies and early postpartum relapses in women with active multiple sclerosis. J Neurol Neurosurg Psychiatry 2024; 95:151-157. [PMID: 37536925 PMCID: PMC10850706 DOI: 10.1136/jnnp-2023-331525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 07/20/2023] [Indexed: 08/05/2023]
Abstract
BACKGROUND Relapse risk after delivery is increased in women with active multiple sclerosis (MS), the best strategy to reduce it is unknown. We aimed to assess the association of four different postpartum strategies with relapses during the first 6 months post partum. METHODS This cohort study includes data prospectively collected through structured telephone interviews from the German Multiple Sclerosis and Pregnancy Registry. Pregnancies with active MS (fingolimod or natalizumab treatment OR relapse within 1 year before pregnancy) and postpartum follow-up of ≥6 months were included. We compared four strategies: (1) intention to breastfeed exclusively without disease-modifying therapy (DMT) (exclusive breast feeding ≥2 months or switching to non-exclusive/weaning within 2 weeks after a relapse during the first 2 months), (2) early treatment with natalizumab/fingolimod and (3) other DMT initiated within 6 weeks post partum before a relapse. If women did not or only partially breastfed, or started DMT≤6 weeks after delivery after a relapse or later, we assumed (4) no-DMT-no-exclusive- breastfeeding-strategy. Main outcome was time to postpartum MS relapses. RESULTS In 867 women with 911 pregnancies, most (n=416) intended to breastfeed exclusively or had no-DMT-no-exclusive-breastfeeding-strategy (n=290); fewer started fingolimod (n=38), natalizumab (n=74) or another DMT (n=93) early. Recurrent time-to-event analysis showed a statistically significant reduction in relapse hazard only with the natalizumab/fingolimod-strategy as of months 3-4 post partum compared with intention-to-breastfeed-exclusively-strategy. The very early relapse risk was highest in no-DMT-no-exclusive-breastfeeding-strategy. CONCLUSION In active MS, an early postpartum treatment strategy should be determined well before delivery. Natalizumab/fingolimod-strategy reduced postpartum relapse hazard from month 3, but none diminished the early postpartum relapse hazard.
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Affiliation(s)
- Sabrina Haben
- Department of Neurology, Katholisches Klinikum Bochum, Ruhr-Universität Bochum, Bochum, Germany
| | - Andrea I Ciplea
- Department of Neurology, Katholisches Klinikum Bochum, Ruhr-Universität Bochum, Bochum, Germany
| | - Marianne Tokic
- Medical Informatics, Biometry and Epidemiology, Ruhr-Universitat Bochum, Bochum, Germany
| | - Nina Timmesfeld
- Medical Informatics, Biometry and Epidemiology, Ruhr-Universitat Bochum, Bochum, Germany
| | - Sandra Thiel
- Department of Neurology, Katholisches Klinikum Bochum, Ruhr-Universität Bochum, Bochum, Germany
| | - Ralf Gold
- Department of Neurology, Katholisches Klinikum Bochum, Ruhr-Universität Bochum, Bochum, Germany
| | | | - Kerstin Hellwig
- Department of Neurology, Katholisches Klinikum Bochum, Ruhr-Universität Bochum, Bochum, Germany
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12
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Ganz T, Zveik O, Fainstein N, Lachish M, Rechtman A, Sofer L, Brill L, Ben-Hur T, Vaknin-Dembinsky A. Oligodendrocyte progenitor cells differentiation induction with MAPK/ERK inhibitor fails to support repair processes in the chronically demyelinated CNS. Glia 2023; 71:2815-2831. [PMID: 37610097 DOI: 10.1002/glia.24453] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 07/23/2023] [Accepted: 07/24/2023] [Indexed: 08/24/2023]
Abstract
Remyelination failure is considered a major obstacle in treating chronic-progressive multiple sclerosis (MS). Studies have shown blockage in the differentiation of resident oligodendrocyte progenitor cells (OPC) into myelin-forming cells, suggesting that pushing OPC into a differentiation program might be sufficient to overcome remyelination failure. Others stressed the need for a permissive environment to allow proper activation, migration, and differentiation of OPC. PD0325901, a MAPK/ERK inhibitor, was previously shown to induce OPC differentiation, non-specific immunosuppression, and a significant therapeutic effect in acute demyelinating MS models. We examined PD0325901 effects in the chronically inflamed central nervous system. Treatment with PD0325901 induced OPC differentiation into mature oligodendrocytes with high morphological complexity. However, treatment of Biozzi mice with chronic-progressive experimental autoimmune encephalomyelitis with PD0325901 showed no clinical improvement in comparison to the control group, no reduction in demyelination, nor induction of OPC migration into foci of demyelination. PD0325901 induced a direct general immunosuppressive effect on various cell populations, leading to a diminished phagocytic capability of microglia and less activation of lymph-node cells. It also significantly impaired the immune-modulatory functions of OPC. Our findings suggest OPC regenerative function depends on a permissive environment, which may include pro-regenerative inflammatory elements. Furthermore, they indicate that maintaining a delicate balance between the pro-myelinating and immune functions of OPC is of importance. Thus, the highly complex mission of creating a pro-regenerative environment depends upon an appropriate immune response controlled in time, place, and intensity. We suggest the need to employ a multi-systematic therapeutic approach, which cannot be achieved through a single molecule-based therapy.
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Affiliation(s)
- Tal Ganz
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- The Department of Neurology and Laboratory of Neuroimmunology, The Agnes-Ginges Center for Human Neurogenetics, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Omri Zveik
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- The Department of Neurology and Laboratory of Neuroimmunology, The Agnes-Ginges Center for Human Neurogenetics, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Nina Fainstein
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- The Department of Neurology and Laboratory of Neuroimmunology, The Agnes-Ginges Center for Human Neurogenetics, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Marva Lachish
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- The Department of Neurology and Laboratory of Neuroimmunology, The Agnes-Ginges Center for Human Neurogenetics, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Ariel Rechtman
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- The Department of Neurology and Laboratory of Neuroimmunology, The Agnes-Ginges Center for Human Neurogenetics, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Lihi Sofer
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- The Department of Neurology and Laboratory of Neuroimmunology, The Agnes-Ginges Center for Human Neurogenetics, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Livnat Brill
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- The Department of Neurology and Laboratory of Neuroimmunology, The Agnes-Ginges Center for Human Neurogenetics, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Tamir Ben-Hur
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- The Department of Neurology and Laboratory of Neuroimmunology, The Agnes-Ginges Center for Human Neurogenetics, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Adi Vaknin-Dembinsky
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- The Department of Neurology and Laboratory of Neuroimmunology, The Agnes-Ginges Center for Human Neurogenetics, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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13
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Kahila S, Zveik O, Levin N, Brill L, Rechtman A, Haham N, Imbar T, Vaknin-Dembinsky A. Brain MRI activity during the year before pregnancy can predict long-term clinical worsening in patients with Multiple Sclerosis. Neurol Sci 2023; 44:3989-3996. [PMID: 37358691 DOI: 10.1007/s10072-023-06909-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 06/08/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND Pregnancy has been observed to reduce the frequency of relapses in Multiple Sclerosis (MS) patients, but the relapse risk tends to increase during the early post-partum period. Increased pre- and post-partum disease activity may predict a poor long-term prognosis. This study aimed to evaluate the correlation between magnetic resonance imaging (MRI) activity during the year before pregnancy and long-term clinically meaningful worsening in Expanded Disability Status Scale (EDSS). METHODS This observational, retrospective, case-control study included 141 pregnancies in 99 females with MS. Statistical analyses were used to evaluate the correlation between MRI activity during the year pre-pregnancy and post-partum clinical worsening during a 5-year follow-up. Clustered logistic regression was used to investigate the predictors of 5-year clinically meaningful worsening in EDSS (lt-EDSS). RESULTS We found a significant correlation between an active MRI pre-pregnancy and lt-EDSS (p = 0.0006). EDSS pre-pregnancy and lt-EDSS were also significantly correlated (p = 0.043). Using a multivariate model, we predicted which females would not experience long-term clinical deterioration by a stable MRI pre-pregnancy (92.7% specificity; p = 0.004). CONCLUSIONS An active MRI pre-conception is a strong predictor of lt-EDSS and a higher annual relapse rate during the follow-up period, regardless of whether the female had clinical evidence of disease activity prior to conception and delivery. Optimizing disease control and achieving imaging stability prior to conception may reduce the risk of long-term clinical deterioration.
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Affiliation(s)
- Shahar Kahila
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- Department of Neurology and Laboratory of Neuroimmunology, The Agnes-Ginges Center for Neurogenetics, Hadassah-Hebrew University Medical Center, Ein-Kerem, P.O.B. 12000, 91120, Jerusalem, Israel
- Department of Military Medicine and "Tzameret", Faculty of Medicine, Hebrew University of Jerusalem, and Medical Corps, Israel Defense Forces, Jerusalem, Israel
| | - Omri Zveik
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- Department of Neurology and Laboratory of Neuroimmunology, The Agnes-Ginges Center for Neurogenetics, Hadassah-Hebrew University Medical Center, Ein-Kerem, P.O.B. 12000, 91120, Jerusalem, Israel
| | - Netta Levin
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- Department of Neurology and Laboratory of Neuroimmunology, The Agnes-Ginges Center for Neurogenetics, Hadassah-Hebrew University Medical Center, Ein-Kerem, P.O.B. 12000, 91120, Jerusalem, Israel
| | - Livnat Brill
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- Department of Neurology and Laboratory of Neuroimmunology, The Agnes-Ginges Center for Neurogenetics, Hadassah-Hebrew University Medical Center, Ein-Kerem, P.O.B. 12000, 91120, Jerusalem, Israel
| | - Ariel Rechtman
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- Department of Neurology and Laboratory of Neuroimmunology, The Agnes-Ginges Center for Neurogenetics, Hadassah-Hebrew University Medical Center, Ein-Kerem, P.O.B. 12000, 91120, Jerusalem, Israel
| | - Nitzan Haham
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- Department of Neurology and Laboratory of Neuroimmunology, The Agnes-Ginges Center for Neurogenetics, Hadassah-Hebrew University Medical Center, Ein-Kerem, P.O.B. 12000, 91120, Jerusalem, Israel
| | - Tal Imbar
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Ein-Kerem, 91120, Jerusalem, Israel
| | - Adi Vaknin-Dembinsky
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
- Department of Neurology and Laboratory of Neuroimmunology, The Agnes-Ginges Center for Neurogenetics, Hadassah-Hebrew University Medical Center, Ein-Kerem, P.O.B. 12000, 91120, Jerusalem, Israel.
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14
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Carbone L, Landi D, Di Girolamo R, Anserini P, Centonze D, Marfia GA, Alviggi C. Optimizing the "Time to pregnancy" in women with multiple sclerosis: the OPTIMUS Delphi survey. Front Neurol 2023; 14:1255496. [PMID: 37869135 PMCID: PMC10588727 DOI: 10.3389/fneur.2023.1255496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 08/22/2023] [Indexed: 10/24/2023] Open
Abstract
Background The debate on how to manage women affected by multiple sclerosis (MS) during reproductive age is still open, as is the issue of fertility in such patients. Main issue regard the identification of the optimal window for pregnancy and how to deal with medical therapy before and during conception. The aim of this Delphi consensus was to collect the opinions of a multidisciplinary group, involving reproductive medicine specialists and neurologists with experience in the management of multiple sclerosis women with reproductive desire. Methods Four experts plus scientific coordinators developed a questionnaire distributed online to 10 neurologists and later discussed the responses and amended a list of statements. The statements were then distributed via an online survey to 23 neurologists (comprising the first 10), who voted on their level of agreement/disagreement with each statement. Consensus was achieved if agreement or disagreement with a statement exceeded 66%. Results Twenty-one statements reached consensus after two rounds of voting, leading to the following main recommendations: (1) Fertility evaluation should be suggested to wMS, in case of the need to shorten time to pregnancy and before treatment switch in women on DMTs contraindicated in pregnancy, particularly in case of highly active disease and age > 35 years. (2) ART should not be discouraged in wMS, but the use of DMTs until pregnancy confirmation should be suggested; ART may be considered in order to reduce time to pregnancy in MS women with a reduced ovarian reserve and/or age > 35 years, but in case of an expected poor ART prognosis and the need for more than one ART cycle, a switch to a high-efficacy DMD before ART should be offered. (3) Oocyte cryopreservation may be considered in women with reduced ovarian reserve, with unpredictable time to complete diagnostic workup and achieve disease control; a risk/cost-benefit analysis must be performed in women >35 years, considering the diminished ovarian reserve. Conclusion This consensus will help MS neurologists to support family planning in wMS, respecting MS therapeutic needs while also taking into account the safety and impact of advancing age on fertility.
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Affiliation(s)
- Luigi Carbone
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Doriana Landi
- Multiple Sclerosis Clinical and Research Unit, University Hospital of Rome Tor Vergata, Rome, Italy
| | - Raffaella Di Girolamo
- Department of Public Health, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Paola Anserini
- UOS Physiopathology of Human Reproduction, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Diego Centonze
- Department of Systems Medicine, Laboratory of Synaptic Immunopathology, “Tor Vergata” University, Rome, Italy
- Unit of Neurology, IRCCS Neuromed, Pozzilli, Isernia, Italy
| | | | - Carlo Alviggi
- Department of Public Health, School of Medicine, University of Naples Federico II, Naples, Italy
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15
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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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Schubert C, Steinberg L, Peper J, Ramien C, Hellwig K, Köpke S, Solari A, Giordano A, Gold SM, Friede T, Heesen C, Rahn AC. Postpartum relapse risk in multiple sclerosis: a systematic review and meta-analysis. J Neurol Neurosurg Psychiatry 2023; 94:718-725. [PMID: 36807056 DOI: 10.1136/jnnp-2022-330533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 02/07/2023] [Indexed: 02/22/2023]
Abstract
The influence of pregnancy on the course of multiple sclerosis (MS) has long been controversial. While historical evidence suggests a substantial decline in relapse rates during pregnancy followed by a rebound in the postpartum period, more recent work yielded equivocal results. We performed a systematic review and meta-analysis on data from cohort studies to determine whether women with MS experience increased relapse rates after delivery. A systematic literature search was conducted in the databases MEDLINE and Epistemonikos on the topic 'motherhood choice in MS' in March 2022. We included cohort studies assessing the association between pregnancy and MS relapse activity defined by the annualised relapse rate after 3, 6, 9 and 12 months post partum. Furthermore, information about disease-modifying therapies (DMT) and breast feeding was considered, if available. 5369 publications were identified. Of these, 93 full-text articles on MS relapse activity during the postpartum period were screened. 11 studies including 2739 pregnancies were eligible. Women with MS showed a significantly increased relapse rate in the first 6 months post partum, compared with preconception with the incidence rate ratio (IRR) almost doubled in the first 3 months post partum (1.87, 95% CI 1.40 to 2.50). However, at 10-12 months post partum, the IRR decreased significantly (0.81, 95% CI 0.67 to 0.98). Subanalysis on influencing parameters suggested that preconceptional DMTs (IRR for highly-effective DMTs 2.76, 95% CI 1.34 to 5.69) and exclusive breast feeding (risk ratio 0.39, 95% CI 0.18 to 0.86) significantly influenced postpartum relapse risk. Increased postpartum annualised relapse rate and possible modifiers should be considered in counselling women with MS who are considering pregnancy.
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Affiliation(s)
- Charlotte Schubert
- Institute of Neuroimmunology and Multiple Sclerosis, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lea Steinberg
- Institute of Neuroimmunology and Multiple Sclerosis, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Julia Peper
- Institute of Social Medicine and Epidemiology, University of Lübeck, Lübeck, Germany
| | - Caren Ramien
- Institute of Neuroimmunology and Multiple Sclerosis, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kerstin Hellwig
- Department of Neurology, Ruhr University Bochum, Bochum, Germany
| | - Sascha Köpke
- Faculty of Medicine and University Hospital Cologne, University Hospital Cologne, Köln, Germany
| | - Alessandra Solari
- Unit of Neuroepidemiology, Foundation IRCCS Carlo Besta Neurological Institute, Milano, Italy
| | - Andrea Giordano
- Unit of Neuroepidemiology, Foundation IRCCS Carlo Besta Neurological Institute, Milano, Italy
| | - Stefan M Gold
- Institute of Neuroimmunology and Multiple Sclerosis, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Psychiatry and Neurosciences, Charite Universitatsmedizin Berlin, Berlin, Germany
| | - Tim Friede
- Medical Statistics, University Medical Center Göttingen, Göttingen, Germany
| | - Christoph Heesen
- Institute of Neuroimmunology and Multiple Sclerosis, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anne Christin Rahn
- Institute of Social Medicine and Epidemiology, University of Lübeck, Lübeck, Germany
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Klehmet J, Begus-Nahrmann Y, Taipale K, Niemczyk G, Rehberg-Weber K. Impact of interferon beta exposure on birth outcome and child development - Results from the post-authorisation safety study PRIMA. Mult Scler Relat Disord 2023; 77:104844. [PMID: 37393802 DOI: 10.1016/j.msard.2023.104844] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 05/26/2023] [Accepted: 06/19/2023] [Indexed: 07/04/2023]
Abstract
BACKGROUND Interferon beta therapies are well-established disease-modifying treatments for patients with relapsing multiple sclerosis (MS). Based on clinical evidence from two large cohort studies, both, the EMA and FDA updated the labels of the interferon beta class in terms of pregnancy and breastfeeding in 2019 and 2020, respectively. To complement pregnancy label updates with patient-reported real-world data, this study examined German pregnancy and outcome reports including available data on child development from women with MS treated with peginterferon beta-1a or intramuscular (IM) interferon beta-1a. METHODS The post-authorisation safety study PRIMA included adult women diagnosed with relapsing-remitting MS or clinically isolated syndrome, who were treated with peginterferon beta-1a or IM interferon beta-1a before or during pregnancy and registered in the marketing authorisation holder's MS Service center patient support program. In the prospective part of the study, conducted from April to October 2021, data on developmental milestones of the newborns were collected via telephone interview from mothers reporting live births. RESULTS In total, 426 women were enrolled, reporting 542 pregnancies that resulted in 466 live births. A total of 162 women completed the questionnaire for 192 live births (53.1% male). Newborns had Apgar scores indicative of healthy infants. Weight, length and head circumference at birth and physical growth curves up to 48 months lay within the expected range of the German general population. Most newborn screenings and examinations during check-ups were inconspicuous over the study period of 48 months. Out of 158 breastfed infants, 112 (70.9%) were breastfed exclusively until month 5. CONCLUSION Study results confirmed former reports indicating that exposure to interferon beta therapies during pregnancy or lactation had no adverse effects on intrauterine growth and child development over the study period, which covered the first 4 years of life. These real-world data obtained within the scope of a patient support program for peginterferon beta-1a or IM interferon beta-1a corroborate German and Scandinavian registry data and support the label update of all interferon beta therapies. REGISTRATION NCT04655222, EUPAS38347.
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Affiliation(s)
- Juliane Klehmet
- Department of Neurology, Jüdisches Krankenhaus Berlin, Heinz-Galinski-Strasse 1, Berlin-Mitte 13347, Federal Republic of Germany.
| | | | - Kirsi Taipale
- Biogen GmbH, Riedenburger Straße 7, München 81677, Federal Republic of Germany
| | - Gabriele Niemczyk
- Biogen GmbH, Riedenburger Straße 7, München 81677, Federal Republic of Germany
| | - Karin Rehberg-Weber
- Biogen GmbH, Riedenburger Straße 7, München 81677, Federal Republic of Germany
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Potential Protective Role of Pregnancy and Breastfeeding in Delaying Onset Symptoms Related to Multiple Sclerosis. Medicina (B Aires) 2023; 59:medicina59030619. [PMID: 36984620 PMCID: PMC10057678 DOI: 10.3390/medicina59030619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 03/04/2023] [Accepted: 03/09/2023] [Indexed: 03/22/2023] Open
Abstract
The impact of pregnancy and breastfeeding on the development and outcomes of Multiple sclerosis (MS) has been debated for decades. Since several factors can influence the evolution of the disease, the protective role of multiparity and breastfeeding remains uncertain, as well the role of hormone replacement therapy in the perimenopausal period. We report two cases of relatively late-onset MS in two parous women, who developed their first neurological symptoms after six and nine pregnancies, respectively. Both women breastfed each of their children for 3 to 12 months. One of them underwent surgical menopause and received hormone replacement therapy for 7 years before MS onset. We performed a systematic literature review to highlight the characteristics shared by women who develop the disease in similar conditions, after unique hormonal imbalances, and to collect promising evidence on this controversial issue. Several studies suggest that the beneficial effects of pregnancy and breastfeeding on MS onset and disability accumulation may only be realized when several pregnancies occur. However, these data on pregnancy and breastfeeding and their long-term benefits on MS outcomes suffer from the possibility of reverse causality, as women with milder impairment might choose to become pregnant more readily than those with a higher level of disability. Thus, the hypothesis that multiparity might have a protective role on MS outcomes needs to be tested in larger prospective cohort studies of neo-diagnosed women, evaluating both clinical and radiological features at presentation.
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Oreja-Guevara C, Rabanal A, Rodríguez CH, Benito YA, Bilbao MM, Gónzalez-Suarez I, Gómez-Palomares JL. Assisted Reproductive Techniques in Multiple Sclerosis: Recommendations from an Expert Panel. Neurol Ther 2023; 12:427-439. [PMID: 36746871 PMCID: PMC10043068 DOI: 10.1007/s40120-023-00439-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 01/12/2023] [Indexed: 02/08/2023] Open
Abstract
INTRODUCTION Multiple sclerosis (MS) is mainly diagnosed in women of reproductive age. However, there is a paucity of guidelines jointly prepared by neurologists and gynaecologists on managing women with MS and the desire for motherhood. Therefore, in this review we propose recommendations for such cases, with an particular focus on those requiring assisted reproductive techniques (ART). METHODS A group of seven MS experts (4 neurologists and 3 gynaecologists) came together for three discussion sessions to achieve consensus. RESULTS The recommendations reported here focus on the importance of early preconception counselling, the management of disease-modifying therapies before and during ART procedures, important considerations for women with MS regarding ART (intrauterine insemination, in vitro fertilisation and oocyte cryopreservation) and the paramount relevance of multidisciplinary units to manage these patients. CONCLUSIONS Early preconception consultations are essential to individualising pregnancy management in women with MS, and an early, well-planned, spontaneous pregnancy should be the aim whenever possible. The management of women with MS and the desire for motherhood by multidisciplinary units is warranted to ensure appropriate guidance through the entire pregnancy.
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Affiliation(s)
- Celia Oreja-Guevara
- Department of Neurology, Health Research Institute of the Hospital Clínico San Carlos (IdISSC), Hospital Clinico San Carlos, Madrid, Spain. .,Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid (UCM), Madrid, Spain.
| | - Aintzane Rabanal
- Human Reproduction Unit, Obstetrics and Gynaecology Department, Biocruces Health Research Institute, Cruces University Hospital, University of the Basque Country, Bilbao, Spain
| | | | - Yolanda Aladro Benito
- Department of Neurology, Research Institute, Hospital Universitario de Getafe, Madrid, Spain
| | - Mar Mendibe Bilbao
- Neuroscience Department, Biocruces Health Research Institute, Cruces University Hospital, University of the Basque Country, Bilbao, Spain
| | | | - José Luis Gómez-Palomares
- Wilson Fertiliy-Balearic Center for In Vitro Fertilization CEFIVBA-Wilson Fertility, Mallorca, Spain
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20
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Graham EL. Neuroimmunological Disorders. Neurol Clin 2023; 41:315-330. [PMID: 37030960 DOI: 10.1016/j.ncl.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
Multiple sclerosis is a disease that tends to affect women during their childbearing years. Although relapse risk decreases during pregnancy, patients should still be optimized on disease-modifying therapy before and after pregnancy to minimize gaps in treatment. Exclusive breastfeeding may reduce the chances of disease relapse postpartum, and many disease-modifying therapies are considered to be safe while breastfeeding. Treatments for other neuroimmunologic disorders such as neuromyelitis optica spectrum disorder, myelin oligodendrocyte glycoprotein antibody-associated disease, neurosarcoidosis, and central nervous system vasculitis may require rituximab before and prednisone or intravenous immunoglobulin therapy during pregnancy.
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21
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Pregnancy planning and management for women with multiple sclerosis: what has changed over the last 15 years? An Italian single-center experience. Mult Scler Relat Disord 2023; 70:104526. [PMID: 36689891 DOI: 10.1016/j.msard.2023.104526] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 01/10/2023] [Accepted: 01/18/2023] [Indexed: 01/22/2023]
Abstract
BACKGROUND Pregnancy planning is a relevant issue in the management of Multiple Sclerosis (MS), which commonly involves women of childbearing age. Increased knowledge and a wider therapeutic scenario could have changed the approach of neurologists towards this topic over time. Our aim was to describe how pregnancy planning and management for women with MS have changed in the last 15 years. METHODS We retrospectively collected clinical data of female patients with relapsing-remitting MS (RRMS), referred to the Neurology Clinic of the University-Hospital "Policlinico G. Rodolico" of Catania, who became pregnant between 2005-2020. We compared data about MS and pregnancy between two time periods according to pregnancy onset (2005-2012; 2013-2020). RESULTS 190 patients with RRMS carried 253 pregnancies in the observation period. Women undergoing a pregnancy in the last period (2013-2020), as compared to women who had pregnancy in the first period (2005-2012), were older (p<0.01), more often treated before and during pregnancy with high-efficacy disease-modifying drugs (DMD) (p<0.001), and exhibited lower annualized relapse rates (ARR) before (p=0.01) and after pregnancy (p<0.001). CONCLUSION Results from our experience suggest that nowadays DMD are more frequently used in women of childbearing age, even during pregnancy, leading to a reduced ARR before and after delivery in absence of increased obstetric complications.
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22
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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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23
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Vukusic S, Carra-Dalliere C, Ciron J, Maillart E, Michel L, Leray E, Guennoc AM, Bourre B, Laplaud D, Androdias G, Bensa C, Bigaut K, Biotti D, Branger P, Casez O, Cohen M, Daval E, Deschamps R, Donze C, Dubessy AL, Dulau C, Durand-Dubief F, Guillaume M, Hebant B, Kremer L, Kwiatkowski A, Lannoy J, Maarouf A, Manchon E, Mathey G, Moisset X, Montcuquet A, Pique J, Roux T, Marignier R, Lebrun-Frenay C. Pregnancy and multiple sclerosis: 2022 recommendations from the French multiple sclerosis society. Mult Scler 2023; 29:11-36. [PMID: 36317497 DOI: 10.1177/13524585221129472] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE The objective of this study was to develop evidence-based recommendations on pregnancy management for persons with multiple sclerosis (MS). BACKGROUND MS typically affects young women in their childbearing years. Increasing evidence is available to inform questions raised by MS patients and health professionals about pregnancy issues. METHODS The French Group for Recommendations in Multiple Sclerosis (France4MS) reviewed PubMed and university databases (January 1975 through June 2021). The RAND/UCLA appropriateness method was developed to synthesise the scientific literature and expert opinions on healthcare topics; it was used to reach a formal agreement. Fifty-six MS experts worked on the full-text review and initial wording of recommendations. A group of 62 multidisciplinary healthcare specialists validated the final proposal of summarised evidence. RESULTS A strong agreement was reached for all 104 proposed recommendations. They cover diverse topics, such as pregnancy planning, follow-up during pregnancy and postpartum, delivery routes, locoregional analgesia or anaesthesia, prevention of postpartum relapses, breastfeeding, vaccinations, reproductive assistance, management of relapses and disease-modifying treatments. CONCLUSION The 2022 recommendations of the French MS society should be helpful to harmonise counselling and treatment practice for pregnancy in persons with MS, allowing for better and individualised choices.
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Affiliation(s)
- Sandra Vukusic
- Sclérose en Plaques, Pathologies de la Myéline et Neuro-Inflammation, Service de Neurologie, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Bron, France/INSERM 1028 et CNRS UMR 5292, Observatoire Français de la Sclérose en Plaques, Centre de Recherche en Neurosciences de Lyon, Bron, France/Université Claude Bernard Lyon 1, Université de Lyon, Lyon, France/Eugène Devic EDMUS Foundation against Multiple Sclerosis, State-approved Foundation, Bron, France
| | | | - Jonathan Ciron
- Centre Ressources et Compétences sclérose en plaques (CRC-SEP) et Service de Neurologie B4, Hôpital Pierre-Paul Riquet, CHU Toulouse Purpan, Toulouse, France INSERM UMR1291 - CNRS UMR5051, Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity), Université Toulouse 3, Toulouse, France
| | - Elisabeth Maillart
- Neurology Department, Pitié-Salpêtrière Hospital, CRC-SEP, Paris, France
| | - Laure Michel
- Neurology Department, CIC_P1414 INSERM, Rennes University Hospital, Rennes, France
| | - Emmanuelle Leray
- EHESP, CNRS, Inserm, Arènes - UMR 6051, RSMS (Recherche sur les Services et Management en Santé) - U 1309, Université de Rennes, Rennes, France
| | | | | | - David Laplaud
- Center for Research in Transplantation and Translational Immunology, UMR 1064, Nantes Université and INSERM, Nantes, France/CIC INSERM 1413, CRC-SEP Pays de la Loire, CHU Nantes, Nantes, France
| | - Géraldine Androdias
- Sclérose en Plaques, Pathologies de la Myéline et Neuro-Inflammation, Service de Neurologie, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Bron, France/Clinique de la Sauvegarde, Ramsay Santé, Lyon, France
| | - Caroline Bensa
- CRC-SEP, Neurology Department, Hôpital Fondation Adolphe de Rothschild, Paris, France
| | - Kevin Bigaut
- CRC-SEP, Service de Neurologie, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Damien Biotti
- Centre Ressources et Compétences sclérose en plaques (CRC-SEP) et Service de Neurologie B4, Hôpital Pierre-Paul Riquet, CHU Toulouse Purpan, Toulouse, France INSERM UMR1291 - CNRS UMR5051, Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity), Université Toulouse 3, Toulouse, France
| | - Pierre Branger
- Service de Neurologie, CHU de Caen Normandie, Caen, France
| | - Olivier Casez
- Pathologies Inflammatoires du Système Nerveux, Neurologie, CHU Grenoble Alpes, Grenoble, France/Translational Research in Autoimmunity and Inflammation Group (T-RAIG), TIMC-IMAG, Université de Grenoble Alpes, Grenoble, France
| | - Mikael Cohen
- CRCSEP Côte d'Azur, CHU de Nice Pasteur 2, Nice, France/Université Nice Côte d'Azur UR2CA-URRIS, Nice, France
| | - Elodie Daval
- Service de Neurologie, CHU de Besançon, Besançon, France
| | - Romain Deschamps
- CRC-SEP, Neurology Department, Hôpital Fondation Adolphe de Rothschild, Paris, France
| | - Cécile Donze
- Hôpital saint Philibert, Groupement des Hôpitaux de l'Institut Catholique de Lille, Faculté de médecine et de maïeutique de Lille, Lomme, France
| | - Anne-Laure Dubessy
- Department of Neurology, Saint-Antoine Hospital, APHP-6, Paris, France/Sorbonne University, Paris, France
| | - Cécile Dulau
- CRC-SEP, Hôpital Pellegrin, CHU de Bordeaux, Bordeaux, France
| | - Françoise Durand-Dubief
- Sclérose en Plaques, Pathologies de la Myéline et Neuro-Inflammation, Service de Neurologie, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Bron, France
| | | | | | - Laurent Kremer
- CRC-SEP, Service de Neurologie, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Arnaud Kwiatkowski
- Department of Neurology, Lille Catholic Hospitals, Lille Catholic University, Lille, France
| | - Julien Lannoy
- Service de Neurologie, Centre Hospitalier de Lens, Lens, France
| | - Adil Maarouf
- CRMBM, UMR 7339, CNRS, Aix-Marseille Université, Marseille, France/APHM Hôpital de la Timone, Marseille, France
| | - Eric Manchon
- Department of Neurology, Gonesse Hospital, Gonesse, France
| | - Guillaume Mathey
- Service de neurologie, Centre Hospitalier Régional Universitaire de Nancy - Hôpital Central, Nancy, France
| | - Xavier Moisset
- Neuro-Dol, Inserm, Université Clermont Auvergne, Clermont-Ferrand, France/Department of neurology et CRC-SEP, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | | | - Julie Pique
- Sclérose en Plaques, Pathologies de la Myéline et Neuro-Inflammation, Service de Neurologie, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Bron, France/INSERM 1028 et CNRS UMR 5292, Centre de Recherche en Neurosciences de Lyon, Bron, France/Université Claude Bernard Lyon 1, Lyon, France
| | - Thomas Roux
- Neurology Department, Pitié-Salpêtrière Hospital, CRC-SEP, Paris, France
| | - Romain Marignier
- Sclérose en Plaques, Pathologies de la Myéline et Neuro-Inflammation, Service de Neurologie, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Bron, France/INSERM 1028 et CNRS UMR 5292, Centre de Recherche en Neurosciences de Lyon, Lyon, France/Université Claude Bernard Lyon 1, Université de Lyon, Lyon, France
| | - Christine Lebrun-Frenay
- Service de Neurologie, CHU de Besançon, Besançon, France/Université Nice Côte d'Azur UR2CA-URRIS, Nice, France
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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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25
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Brown HK, Vigod SN, Fung K, Chen S, Guttmann A, Havercamp SM, Parish SL, Ray JG, Lunsky Y. Perinatal mental illness among women with disabilities: a population-based cohort study. Soc Psychiatry Psychiatr Epidemiol 2022; 57:2217-2228. [PMID: 35939075 PMCID: PMC9722243 DOI: 10.1007/s00127-022-02347-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 07/25/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE To examine the risk of perinatal mental illness, including new-onset disorders and recurrent or ongoing use of mental health care, comparing women with physical, sensory, intellectual/developmental, and multiple disabilities to those without a disability. METHODS From all women aged 15-49 years with a singleton birth in Ontario, Canada (2003-2018), those with physical (n = 144,972), sensory (n = 45,249), intellectual/developmental (n = 2,227), and ≥ 2 of these disabilities ("multiple disabilities"; n = 8,883), were compared to 1,601,363 without a disability on risk of healthcare system contact for mental illness from conception to 365 days postpartum. The cohort was stratified into: (1) no pre-pregnancy mental illness (to identify new-onset illness), (2) distal mental illness (> 2 years pre-pregnancy, to identify recurrent illness), and (3) recent mental illness (0-2 years pre-pregnancy, to identify ongoing contact). Modified Poisson regression generated relative risks (aRR), adjusted for age, parity, income quintile, and rural residence. RESULTS About 14.7, 26.5, and 56.6% of women with no disabilities had new-onset, recurrent, and ongoing contact for mental illness, respectively, perinatally. Risks were elevated across disability groups for new-onset (physical: aRR 1.18, 95% CI 1.16-1.20; sensory: 1.11, 1.08-1.15; intellectual/developmental: 1.38, 1.17-1.62; multiple: 1.24, 1.15-1.33), recurrent (physical: 1.10, 1.08-1.12; sensory 1.06, 1.02-1.09; intellectual/developmental: 1.24, 1.11-1.37; multiple: 1.16, 1.09-1.23), and ongoing contact (physical: 1.09, 1.08-1.10; sensory: 1.08, 1.06-1.10; intellectual/developmental: 1.31, 1.26-1.37; multiple: 1.20, 1.16-1.23). CONCLUSION The heightened use of new, recurrent, and ongoing mental health care across disability groups in the perinatal period suggests that adapted screening and intervention approaches are critical to optimize perinatal mental health in this population.
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Affiliation(s)
- Hilary K Brown
- Department of Health & Society, University of Toronto Scarborough, Toronto, Canada.
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.
- Department of Psychiatry, University of Toronto, Toronto, Canada.
- ICES (Formerly the Institute for Clinical Evaluative Sciences), Toronto, Canada.
- Women's College Research Institute, Women's College Hospital, Toronto, Canada.
| | - Simone N Vigod
- Department of Psychiatry, University of Toronto, Toronto, Canada
- ICES (Formerly the Institute for Clinical Evaluative Sciences), Toronto, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, Canada
| | - Kinwah Fung
- ICES (Formerly the Institute for Clinical Evaluative Sciences), Toronto, Canada
| | - Simon Chen
- ICES (Formerly the Institute for Clinical Evaluative Sciences), Toronto, Canada
| | - Astrid Guttmann
- ICES (Formerly the Institute for Clinical Evaluative Sciences), Toronto, Canada
- Hospital for Sick Children, Toronto, Canada
- Edwin HS Leong Centre for Healthy Children, University of Toronto, Toronto, Canada
- Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Susan M Havercamp
- Center for Psychiatry and Behavioral Health, Wexner Medical Center, Ohio State University, Columbus, USA
| | - Susan L Parish
- College of Health Professions, Virginia Commonwealth University, Richmond, USA
| | - Joel G Ray
- ICES (Formerly the Institute for Clinical Evaluative Sciences), Toronto, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Yona Lunsky
- Department of Psychiatry, University of Toronto, Toronto, Canada
- ICES (Formerly the Institute for Clinical Evaluative Sciences), Toronto, Canada
- Azrieli Adult Neurodevelopmental Centre, Centre for Addiction & Mental Health, Toronto, Canada
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Mainguy M, Tillaut H, Degremont A, Le Page E, Mainguy C, Duros S, Polard E, Leray E. Assessing the Risk of Relapse Requiring Corticosteroids After In Vitro Fertilization in Women With Multiple Sclerosis. Neurology 2022; 99:e1916-e1925. [PMID: 35953288 DOI: 10.1212/wnl.0000000000201027] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 06/13/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Several studies have shown an increased risk of relapse after in vitro fertilization (IVF) in women with multiple sclerosis (MS), especially when a gonadotrophin-releasing hormone (GnRH) agonist stimulation protocol was used. Our objective was to investigate the risk of relapse after IVF in women with MS, overall and according to stimulation protocol (GnRH agonists vs antagonists), using data from the French national health insurance database. METHODS This retrospective cohort study included all women with MS who have benefited from IVF between January 1, 2010, and December 31, 2015, in France. Three-month exposed periods after IVF were compared with unexposed periods before IVF, each woman being her own control. Four outcomes were considered: annualized relapse rate (ARR), proportion of IVF with relapse, difference in the number of relapses "after-before," and the delay from IVF to the first relapse. Relapses were identified by an algorithm based on MS-related hospital admissions and the use of corticosteroid therapy. Stimulation protocols and disease-modifying therapies (DMTs) were identified using drug claims. Zero-inflated Poisson regression models adjusted for age at IVF and the presence of DMT were used. A random effect on women was included because women may undergo multiple IVF procedures. Subgroup analyses by stimulation protocol and IVF outcome (pregnancy or failure) were conducted. RESULTS A total of 225 women accounting for 338 IVF procedures were included (the mean age at the first IVF 34.6 ± 4.5 years; 36% of women underwent at least 2 IVF procedures during the period). No increase in the risk of relapse after IVF was found overall (before vs after IVF: 0.20 vs 0.18 relapse per patient-year; 7.7% vs 7.1% of IVF with women having at least one relapse) and in subgroups. A lower ARR before and after IVF was observed among women who remained treated until IVF. DISCUSSION The maintenance of DMT until IVF seemed to be a determining factor in reducing the risk of relapse. Women with MS should be reassured because we did not show an increased risk of relapse requiring the use of corticosteroid therapy after IVF neither with GnRH agonists nor with GnRH antagonists.
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Affiliation(s)
- Marie Mainguy
- From the Univ Rennes (M.M., E.L.), EHESP, CNRS, Inserm, ARENES-UMR, France; Univ Rennes (H.T.), Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail)-UMR, Rennes, France; Pharmacovigilance (A.D., E.P.), Pharmacoepidemiology and Drug Information Centre, Department of Clinical Pharmacology, Rennes University Hospital, France; Neurology Department CRCSEP (E.L.P.), Rennes Clinical Investigation Centre CIC-P, Rennes University Hospital Rennes University INSERM, France; and Department of Gynecology Obstetric and Reproductive Medecine (C.M., S.D.), University Hospital, Rennes, France
| | - Hélène Tillaut
- From the Univ Rennes (M.M., E.L.), EHESP, CNRS, Inserm, ARENES-UMR, France; Univ Rennes (H.T.), Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail)-UMR, Rennes, France; Pharmacovigilance (A.D., E.P.), Pharmacoepidemiology and Drug Information Centre, Department of Clinical Pharmacology, Rennes University Hospital, France; Neurology Department CRCSEP (E.L.P.), Rennes Clinical Investigation Centre CIC-P, Rennes University Hospital Rennes University INSERM, France; and Department of Gynecology Obstetric and Reproductive Medecine (C.M., S.D.), University Hospital, Rennes, France
| | - Adeline Degremont
- From the Univ Rennes (M.M., E.L.), EHESP, CNRS, Inserm, ARENES-UMR, France; Univ Rennes (H.T.), Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail)-UMR, Rennes, France; Pharmacovigilance (A.D., E.P.), Pharmacoepidemiology and Drug Information Centre, Department of Clinical Pharmacology, Rennes University Hospital, France; Neurology Department CRCSEP (E.L.P.), Rennes Clinical Investigation Centre CIC-P, Rennes University Hospital Rennes University INSERM, France; and Department of Gynecology Obstetric and Reproductive Medecine (C.M., S.D.), University Hospital, Rennes, France
| | - Emmanuelle Le Page
- From the Univ Rennes (M.M., E.L.), EHESP, CNRS, Inserm, ARENES-UMR, France; Univ Rennes (H.T.), Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail)-UMR, Rennes, France; Pharmacovigilance (A.D., E.P.), Pharmacoepidemiology and Drug Information Centre, Department of Clinical Pharmacology, Rennes University Hospital, France; Neurology Department CRCSEP (E.L.P.), Rennes Clinical Investigation Centre CIC-P, Rennes University Hospital Rennes University INSERM, France; and Department of Gynecology Obstetric and Reproductive Medecine (C.M., S.D.), University Hospital, Rennes, France
| | - Christelle Mainguy
- From the Univ Rennes (M.M., E.L.), EHESP, CNRS, Inserm, ARENES-UMR, France; Univ Rennes (H.T.), Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail)-UMR, Rennes, France; Pharmacovigilance (A.D., E.P.), Pharmacoepidemiology and Drug Information Centre, Department of Clinical Pharmacology, Rennes University Hospital, France; Neurology Department CRCSEP (E.L.P.), Rennes Clinical Investigation Centre CIC-P, Rennes University Hospital Rennes University INSERM, France; and Department of Gynecology Obstetric and Reproductive Medecine (C.M., S.D.), University Hospital, Rennes, France
| | - Solène Duros
- From the Univ Rennes (M.M., E.L.), EHESP, CNRS, Inserm, ARENES-UMR, France; Univ Rennes (H.T.), Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail)-UMR, Rennes, France; Pharmacovigilance (A.D., E.P.), Pharmacoepidemiology and Drug Information Centre, Department of Clinical Pharmacology, Rennes University Hospital, France; Neurology Department CRCSEP (E.L.P.), Rennes Clinical Investigation Centre CIC-P, Rennes University Hospital Rennes University INSERM, France; and Department of Gynecology Obstetric and Reproductive Medecine (C.M., S.D.), University Hospital, Rennes, France
| | - Elisabeth Polard
- From the Univ Rennes (M.M., E.L.), EHESP, CNRS, Inserm, ARENES-UMR, France; Univ Rennes (H.T.), Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail)-UMR, Rennes, France; Pharmacovigilance (A.D., E.P.), Pharmacoepidemiology and Drug Information Centre, Department of Clinical Pharmacology, Rennes University Hospital, France; Neurology Department CRCSEP (E.L.P.), Rennes Clinical Investigation Centre CIC-P, Rennes University Hospital Rennes University INSERM, France; and Department of Gynecology Obstetric and Reproductive Medecine (C.M., S.D.), University Hospital, Rennes, France
| | - Emmanuelle Leray
- From the Univ Rennes (M.M., E.L.), EHESP, CNRS, Inserm, ARENES-UMR, France; Univ Rennes (H.T.), Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail)-UMR, Rennes, France; Pharmacovigilance (A.D., E.P.), Pharmacoepidemiology and Drug Information Centre, Department of Clinical Pharmacology, Rennes University Hospital, France; Neurology Department CRCSEP (E.L.P.), Rennes Clinical Investigation Centre CIC-P, Rennes University Hospital Rennes University INSERM, France; and Department of Gynecology Obstetric and Reproductive Medecine (C.M., S.D.), University Hospital, Rennes, France.
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27
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Landi D, Bovis F, Grimaldi A, Annovazzi PO, Bertolotto A, Bianchi A, Borriello G, Brescia Morra V, Bucello S, Buscarinu MC, Caleri F, Capobianco M, Capra R, Cellerino M, Centonze D, Cerqua R, Chisari CG, Clerico M, Cocco E, Cola G, Cordioli C, Curti E, d'Ambrosio A, D'Amico E, De Luca G, Di Filippo M, Di Lemme S, Fantozzi R, Ferraro D, Ferraro E, Gallo A, Gasperini C, Granella F, Inglese M, Lanzillo R, Lorefice L, Lus G, Malucchi S, Margoni M, Mataluni G, Mirabella M, Moiola L, Nicoletti CG, Nociti V, Patti F, Pinardi F, Portaccio E, Pozzilli C, Ragonese P, Rasia S, Salemi G, Signoriello E, Vitetta F, Totaro R, Sormani MP, Amato MP, Marfia GA. Exposure to natalizumab throughout pregnancy: effectiveness and safety in an Italian cohort of women with multiple sclerosis. J Neurol Neurosurg Psychiatry 2022:jnnp-2022-329657. [PMID: 36180219 DOI: 10.1136/jnnp-2022-329657] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Accepted: 08/23/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Assessing the risk of clinical and radiological reactivation during pregnancy and post partum in women with multiple sclerosis (MS) treated with natalizumab (NTZ) throughout pregnancy (LONG_EXP) compared with women interrupting treatment before (NO_EXP) and within >-30 days and ≤90 days from conception (SHORT_EXP), and describing newborns' outcomes. METHODS Maternal clinical and radiological outcomes and obstetric and fetal outcomes were retrospectively collected and compared among groups (NO_EXP, SHORT_EXP, LONG_EXP). Predictors of clinical and radiological reactivation were investigated through univariable and multivariable analysis. RESULTS 170 eligible pregnancies from 163 women referring to 29 Italian MS centres were included. Annualised relapse rate (ARR) was significantly lower in LONG_EXP (n=66, 0.02 (0.001-0.09)) compared with NO_EXP (n=31, 0.43 (0.21-0.75), p=0.002) and SHORT_EXP (n=73, 0.46 (0.30-0.66), p=0.0004) during pregnancy, and in LONG_EXP (0.12 (0.05-0.24)) compared with SHORT_EXP (0.30 (0.17-0.50), p=0.008) during post partum. Gadolinium-enhancing (Gd+) lesions were less frequent in LONG_EXP (n=6/50, 2.00%) compared with NO_EXP (n=9/21, 42.86%) and SHORT_EXP after delivery (n=17/49, 34.69%, p=0.010).Delaying NTZ resumption after delivery significantly increased the risk of relapses (OR=1.29 (95% CI 1.07 to 1.57), p=0.009) and Gd+ lesions (OR=1.49 (95% CI 1.17 to 1.89, p=0.001). Newborns' weight, length, head circumference and gestational age did not differ among groups after adjusting for confounders. Anaemia was tracked in 4/69 LONG_EXP newborns. Congenital anomaly rate was within the expected range for the untreated MS population. CONCLUSIONS Our findings indicate that in women with MS treated with NTZ before conception, continuation of NTZ throughout pregnancy and its early resumption after delivery mitigate the risk of clinical and radiological reactivation. This approach has no major impact on newborns' outcomes.
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Affiliation(s)
- Doriana Landi
- Multiple Sclerosis Clinical and Research Unit, Department of Systems Medicine, University of Rome Tor Vergata, Roma, Italy
| | - Francesca Bovis
- Department of Health Sciences, Section of Biostatistics, University of Genova, Genoa, Italy
| | - Alfonso Grimaldi
- Multiple Sclerosis Clinical and Research Unit, Department of Systems Medicine, University of Rome Tor Vergata, Roma, Italy
| | - Pietro Osvaldo Annovazzi
- Multiple Sclerosis Center, Neurology II Unit, ASST Valle Olona, Gallarate Hospital, Gallarate, Italy
| | - Antonio Bertolotto
- Multiple Sclerosis Center (CRESM), Department of Neurology, 'San Luigi Gonzaga' University Hospital, Orbassano, Italy
| | - Alessia Bianchi
- Unit of Neurology, Department of Biomedicine, Neurosciences and Advanced Diagnostics, Palermo University, Palermo, Italy
| | - Giovanna Borriello
- Multiple Sclerosis Center, 'S. Andrea' Hospital, Sapienza University of Rome, Rome, Italy
| | - Vincenzo Brescia Morra
- Department of Neurosciences Reproductive Sciences and Odontostomatology, Multiple Sclerosis Center, Federico II University, Naples, Italy
| | - Sebastiano Bucello
- Multiple Sclerosis Center, "E. Muscatello" Hospital - ASP8, Augusta (SR), Italy
| | - Maria Chiara Buscarinu
- Department of Neuroscience, Mental Health and Sensory Organs, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Francesca Caleri
- Multiple Sclerosis Center, Department of Neurology, 'F. Tappeiner' Hospital, Merano (BZ), Italy
| | - Marco Capobianco
- Multiple Sclerosis Center (CRESM), Department of Neurology, 'San Luigi Gonzaga' University Hospital, Orbassano, Italy
| | - Ruggero Capra
- Multiple Sclerosis Center, Spedali Civili of Brescia, Montichiari (BS), Italy
| | - Maria Cellerino
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genova, Italy
| | - Diego Centonze
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- Unit of Neurology, IRCCS Neuromed, Pozzilli (IS), Italy
| | - Raffaella Cerqua
- Neurological Clinic, Department of Experimental and Clinical Medicine, Ospedali Riuniti, Ancona, Italy
| | - Clara Grazia Chisari
- Department of Medical and Surgical Sciences and Advanced Technologies 'G.F. Ingrassia', Section of Neurosciences, University of Catania, Catania, Italy
| | - Marinella Clerico
- Clinical and Biological Sciences Department, Neurology Unit, University of Torino, 'San Luigi Gonzaga' Hospital, Orbassano, Italy
| | - Eleonora Cocco
- Multiple Sclerosis Center, Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy
| | - Gaia Cola
- Multiple Sclerosis Clinical and Research Unit, Department of Systems Medicine, University of Rome Tor Vergata, Roma, Italy
| | - Cinzia Cordioli
- Multiple Sclerosis Center, Spedali Civili of Brescia, Montichiari (BS), Italy
| | - Erica Curti
- Unit of Neurology, Department of General and Specialized Medicine, Parma University Hospital, Parma, Italy
| | - Alessandro d'Ambrosio
- I Division of Neurology, Department of Advanced Medical and Surgical Sciences (DAMSS), University of Campania "Luigi Vanvitelli", Napoli, Italy
| | - Emanuele D'Amico
- Department of Medical and Surgical Sciences and Advanced Technologies 'G.F. Ingrassia', Section of Neurosciences, University of Catania, Catania, Italy
| | - Giovanna De Luca
- Multiple Sclerosis Center, 'SS Annunziata' Hospital, 'Gabriele d'Annunzio' University Chieti-Pesacara, Chieti, Italy
| | - Massimiliano Di Filippo
- Section of Neurology, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | | | | | - Diana Ferraro
- Department of Biomedical Metabolic and Neurosciences, University of Modena and Reggio Emilia, Modena, Italy
| | | | - Antonio Gallo
- I Division of Neurology, Department of Advanced Medical and Surgical Sciences (DAMSS), University of Campania "Luigi Vanvitelli", Napoli, Italy
| | - Claudio Gasperini
- Department of Neurosciences, 'San Camillo Forlanini' Hospital, Rome, Italy
| | - Franco Granella
- Unit of Neurology, Department of General and Specialized Medicine, Parma University Hospital, Parma, Italy
| | - Matilde Inglese
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genova, Italy
- Department of Neurology, Policlinico 'San Martino Hospital'-Sistema Sanitario Regione, Genoa, Italy
| | - Roberta Lanzillo
- Department of Neurosciences Reproductive Sciences and Odontostomatology, Multiple Sclerosis Center, Federico II University, Naples, Italy
| | - Lorena Lorefice
- Multiple Sclerosis Centre, Binaghi Hospital, ATS Sardegna-Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Giacomo Lus
- Department of Advanced Medical and Surgical Sciences, II Division of Neurology, Multiple Sclerosis Center, University of Campania 'L. Vanvitelli', Naples, Italy
| | - Simona Malucchi
- Multiple Sclerosis Center (CRESM), Department of Neurology, 'San Luigi Gonzaga' University Hospital, Orbassano, Italy
| | - Monica Margoni
- Multiple Sclerosis Center of the Veneto Region, Department of Neurosciences, University of Padua, Padua, Italy
| | - Giorgia Mataluni
- Multiple Sclerosis Clinical and Research Unit, Department of Systems Medicine, University of Rome Tor Vergata, Roma, Italy
| | - Massimiliano Mirabella
- Department of Neurosciences, Centro di Ricerca Sclerosi Multipla (CERSM), Università Cattolica del Sacro Cuore, Rome, Italy, 'A.Gemelli' University Hospital, Rome, Italy
| | - Lucia Moiola
- Multiple Sclerosis Center, Neurology Department, San Raffaele Hospital IRCCS, Milan, Italy
| | - Carolina Gabri Nicoletti
- Multiple Sclerosis Clinical and Research Unit, Department of Systems Medicine, University of Rome Tor Vergata, Roma, Italy
| | - Viviana Nociti
- Department of Neurosciences, Centro di Ricerca Sclerosi Multipla (CERSM), Università Cattolica del Sacro Cuore, Rome, Italy, 'A.Gemelli' University Hospital, Rome, Italy
| | - Francesco Patti
- Department of Medical and Surgical Sciences and Advanced Technologies 'G.F. Ingrassia', Section of Neurosciences, University of Catania, Catania, Italy
| | - Federica Pinardi
- UOSI Multiple Sclerosis Rehabilitation, IRCCS Istituto delle scienze neurologiche, Bologna, Italy
| | - Emilio Portaccio
- Division Neurological Rehabilitation, Department of NEUROFARBA, University of Florence, Florence, Italy
| | - Carlo Pozzilli
- Multiple Sclerosis Center, Department of Human Neurosciences, 'S.Andrea' Hospital, Sapienza University of Rome, Rome, Italy
| | - Paolo Ragonese
- Unit of Neurology, Department of Biomedicine, Neurosciences and Advanced Diagnostics, Palermo University, Palermo, Italy
| | - Sarah Rasia
- Multiple Sclerosis Center, Spedali Civili of Brescia, Montichiari (BS), Italy
| | - Giuseppe Salemi
- Unit of Neurology, Department of Biomedicine, Neurosciences and Advanced Diagnostics, Palermo University, Palermo, Italy
| | - Elisabetta Signoriello
- Department of Advanced Medical and Surgical Sciences, II Division of Neurology, Multiple Sclerosis Center, University of Campania 'L. Vanvitelli', Naples, Italy
| | - Francesca Vitetta
- Neurology Unit, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy
| | - Rocco Totaro
- Demyelinating Disease Center, Neurology Unit, University of L'Aquila, L'Aquila, Italy
| | - Maria Pia Sormani
- Department of Health Sciences, Section of Biostatistics, University of Genova, Genoa, Italy
| | - Maria Pia Amato
- Division Neurological Rehabilitation, Department of NEUROFARBA, University of Florence, Florence, Italy
- IRCCS, Fondazione Don Carlo Gnocchi, Florence, Italy
| | - Girolama Alessandra Marfia
- Multiple Sclerosis Clinical and Research Unit, Department of Systems Medicine, University of Rome Tor Vergata, Roma, Italy
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The Rate of Hospitalization of Pregnant Women with Multiple Sclerosis in Poland. J Clin Med 2022; 11:jcm11195615. [PMID: 36233482 PMCID: PMC9572960 DOI: 10.3390/jcm11195615] [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: 08/05/2022] [Revised: 09/07/2022] [Accepted: 09/20/2022] [Indexed: 11/28/2022] Open
Abstract
Multiple sclerosis (MS) is most often diagnosed in women of childbearing age. Therefore, it is important to examine the impact of pregnancy on the course of MS and to enable patients to make decisions about motherhood based on reliable data. The main objective of this study was to assess the impact of pregnancy on the course of MS by comparing the frequency of MS-related hospitalizations during pregnancy and 40 weeks postpartum versus 40 weeks before pregnancy. We used administrative health claims to identify female patients with MS, their deliveries, and their MS-related hospital admissions and calculated the frequency of MS-related hospital admissions before, during, and after pregnancy. We observed that MS is diagnosed approximately three times less often during pregnancy than before or after pregnancy. The number of MS-related hospital admissions decreased during pregnancy, especially in the third trimester. In contrast with other studies, we did not observe an increased level of MS-related admissions postpartum. The number of hospitalizations reported with steroid injections and emergency department visits also decreased during pregnancy. Our results show that pregnancy has a protective effect on the course of MS.
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29
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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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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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McCombe PA. The role of sex and pregnancy in multiple sclerosis: what do we know and what should we do? Expert Rev Neurother 2022; 22:377-392. [PMID: 35354378 DOI: 10.1080/14737175.2022.2060079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Multiple sclerosis (MS) is more prevalent in women than in men. The sex of the patient, and pregnancy, are reported to be associated with the clinical features of MS. The mechanism of this is unclear. AREAS COVERED This review summarizes data about sex differences in MS and the role of pregnancy. Possible mechanisms for the effects of sex and pregnancy are summarized, and practical suggestions for addressing these issues are provided. EXPERT OPINION There is considerable interdependence of the variables that are associated with MS. Men have a worse outcome of MS, and this could be due to the same factors that lead to greater incidence of neurodegenerative disease in men. The possible role of parity on the long-term outcome of MS is of interest. Future studies that look at the mechanisms of the effects of the sex of the patient on the outcome of MS are required. However, there are some actions that can be taken without further research. We can concentrate on public health measures that address the modifiable risk factors for MS and ensure that disease is controlled in women who intend to become pregnant and use appropriate disease modifying agents during pregnancy.
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Affiliation(s)
- Pamela A McCombe
- The University of Queensland, Centre for Clinical Research, Royal Brisbane and Women's Hospital, Herston, Australia
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Zveik O, Fainstein N, Rechtman A, Haham N, Ganz T, Lavon I, Brill L, Vaknin-Dembinsky A. Cerebrospinal fluid of progressive multiple sclerosis patients reduces differentiation and immune functions of oligodendrocyte progenitor cells. Glia 2022; 70:1191-1209. [PMID: 35266197 PMCID: PMC9314832 DOI: 10.1002/glia.24165] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 02/20/2022] [Accepted: 02/21/2022] [Indexed: 12/31/2022]
Abstract
Oligodendrocyte progenitor cells (OPCs) are responsible for remyelination in the central nervous system (CNS) in health and disease. For patients with multiple sclerosis (MS), remyelination is not always successful, and the mechanisms differentiating successful from failed remyelination are not well‐known. Growing evidence suggests an immune role for OPCs, in addition to their regenerative role; however, it is not clear if this helps or hinders the regenerative process. We studied the effect of cerebrospinal fluid (CSF) from relapsing MS (rMS) and progressive MS (pMS) patients on primary OPC differentiation and immune gene expression and function. We observed that CSF from either rMS or pMS patients has a differential effect on the ability of mice OPCs to differentiate into mature oligodendrocytes and to express immune functions. CSF of pMS patients impaired differentiation into mature oligodendrocytes. In addition, it led to decreased major histocompatibility complex class (MHC)‐II expression, tumor necrosis factor (TNF)‐α secretion, nuclear factor kappa‐B (NFκB) activation, and less activation and proliferation of T cells. Our findings suggest that OPCs are not only responsible for remyelination, but they may also play an active role as innate immune cells in the CNS.
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Affiliation(s)
- Omri Zveik
- Faculty of Medicine, Hebrew University of Jerusalem, Department of Neurology and Laboratory of Neuroimmunology, The Agnes-Ginges Center for Neurogenetics, Hadassah - Hebrew University Medical Center, Jerusalem, Israel
| | - Nina Fainstein
- Faculty of Medicine, Hebrew University of Jerusalem, Department of Neurology and Laboratory of Neuroimmunology, The Agnes-Ginges Center for Neurogenetics, Hadassah - Hebrew University Medical Center, Jerusalem, Israel
| | - Ariel Rechtman
- Faculty of Medicine, Hebrew University of Jerusalem, Department of Neurology and Laboratory of Neuroimmunology, The Agnes-Ginges Center for Neurogenetics, Hadassah - Hebrew University Medical Center, Jerusalem, Israel
| | - Nitzan Haham
- Faculty of Medicine, Hebrew University of Jerusalem, Department of Neurology and Laboratory of Neuroimmunology, The Agnes-Ginges Center for Neurogenetics, Hadassah - Hebrew University Medical Center, Jerusalem, Israel
| | - Tal Ganz
- Faculty of Medicine, Hebrew University of Jerusalem, Department of Neurology and Laboratory of Neuroimmunology, The Agnes-Ginges Center for Neurogenetics, Hadassah - Hebrew University Medical Center, Jerusalem, Israel
| | - Iris Lavon
- Faculty of Medicine, Hebrew University of Jerusalem, Department of Neurology and Laboratory of Neuroimmunology, The Agnes-Ginges Center for Neurogenetics, Hadassah - Hebrew University Medical Center, Jerusalem, Israel.,Leslie and Michael Gaffin Center for Neuro-Oncology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Livnat Brill
- Faculty of Medicine, Hebrew University of Jerusalem, Department of Neurology and Laboratory of Neuroimmunology, The Agnes-Ginges Center for Neurogenetics, Hadassah - Hebrew University Medical Center, Jerusalem, Israel
| | - Adi Vaknin-Dembinsky
- Faculty of Medicine, Hebrew University of Jerusalem, Department of Neurology and Laboratory of Neuroimmunology, The Agnes-Ginges Center for Neurogenetics, Hadassah - Hebrew University Medical Center, Jerusalem, Israel
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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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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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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: 9] [Impact Index Per Article: 4.5] [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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Thiel S, Ciplea AI, Gold R, Hellwig K. The German Multiple Sclerosis and Pregnancy Registry: rationale, objective, design, and first results. Ther Adv Neurol Disord 2021; 14:17562864211054956. [PMID: 34840606 PMCID: PMC8613898 DOI: 10.1177/17562864211054956] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 10/04/2021] [Indexed: 12/16/2022] Open
Abstract
Objectives: Multiple sclerosis (MS) and neuromyelitis optica spectrum disorders (NMOSD) predominantly affect women of reproductive age. During the last few decades many disease-modifying therapies (DMTs) have been approved. It is therefore important to provide epidemiological structures for the collection of safety information on exposed pregnancies. Data on disease activity after withdrawal of DMTs are in high demand especially as severe relapses have been described after ceasing highly effective DMTs. Although breastfeeding is recommended, it is still unclear if the early reintroduction, especially of highly effective DMTs, has a beneficial effect on postpartum relapse risk or a combination of both, however safety data are lacking. Methods: The German MS and Pregnancy Registry (DMSKW) is a nationwide, observational, cohort study of pregnant women with MS or NMOSD, founded in 2006. As the study procedure has undergone important adaptation in recent years, described here is the updated methodology including data source and acquisition as well as variables collected within the DMSKW. Results: As of December 2020, the DMSKW database comprises 2579 pregnancies, 2568 with MS and 11 with NMOSD. Women are enrolled at a median gestational week of 11 (range: 0.02–42.1), have a median postpartum follow up of 1.2 years (range: 0–9.2) with 76% of all pregnancies being exposed to a DMT, mostly in the first trimester. Spontaneous abortion and preterm birth occurred in 7% and 10%, respectively; 19% of all women suffered from at least one relapse during pregnancy, with a minimum of 6% during the third trimester of pregnancy. Conclusion: The DMSKW is a valuable structure in providing safety data on drug exposure during pregnancy and lactation in combination with information on disease activity up to 6 years postpartum. This article will be the reference for describing the methods of future publications from the DMSKW.
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Affiliation(s)
- Sandra Thiel
- Department of Neurology, St. Josef Hospital - Katholisches Klinikum Bochum GmbH, Ruhr University Bochum, Bochum, Germany
| | - Andrea I Ciplea
- Department of Neurology, St. Josef Hospital - Katholisches Klinikum Bochum GmbH, Ruhr University Bochum, Bochum, Germany
| | - Ralf Gold
- Department of Neurology, St. Josef Hospital - Katholisches Klinikum Bochum GmbH, Ruhr University Bochum, Bochum, Germany
| | - Kerstin Hellwig
- Department of Neurology, St. Josef Hospital - Katholisches Klinikum Bochum GmbH, Ruhr University Bochum, Gudrunstrasse 56, 44791 Bochum, Germany
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Andersen JB, Wandall-Holm MF, Andersen PK, Sellebjerg F, Magyari M. Pregnancy in women with MS: Impact on long-term disability accrual in a nationwide Danish Cohort. Mult Scler 2021; 28:1239-1247. [PMID: 34791952 DOI: 10.1177/13524585211057767] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Pregnancy is considered to influence the disease course in women with multiple sclerosis (MS). OBJECTIVE The aim of this study was to investigate the effect of pregnancy on long-term disability accrual in women with MS. METHODS The Danish Multiple Sclerosis Registry (DMSR) was used to identify women diagnosed with clinically isolated syndrome or relapsing-remitting MS. Cox models with pregnancy as a time-dependent exposure and propensity score (PS) models were used to evaluate time to reach confirmed Expanded Disability Status Scale (EDSS) score of 4 and 6. RESULTS A total of 425 women became parous and 840 remained nulliparous. When including pregnancy as a time-dependent exposure, a non-significant association with time to reach EDSS 4 (hazard ratio (HR) 0.86, 95% confidence interval (CI) 0.61-1.20) and EDSS 6 (HR 0.70, 95% CI 0.40-1.20) was found. Correspondingly, the PS model showed no association with pregnancy on time to reach EDSS 4 (HR 0.85, 95% CI 0.56-1.28). CONCLUSION This study concludes that pregnancy does not affect long-term disability accumulation.
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Affiliation(s)
- Johanna Balslev Andersen
- The Danish Multiple Sclerosis Registry, Department of Neurology, Copenhagen University Hospital, Rigshospitalet, Glostrup, Denmark
| | - Malthe Faurschou Wandall-Holm
- The Danish Multiple Sclerosis Registry, Department of Neurology, Copenhagen University Hospital, Rigshospitalet, Glostrup, Denmark
| | | | - Finn Sellebjerg
- The Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital, Rigshospitalet, Glostrup, Denmark/Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Melinda Magyari
- The Danish Multiple Sclerosis Registry, Department of Neurology, Copenhagen University Hospital, Rigshospitalet, Glostrup, Denmark/The Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital, Rigshospitalet, Glostrup, Denmark/Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Marrie RA, Cutter GR, Fox RJ, Vollmer T, Tyry T, Salter A. NARCOMS and Other Registries in Multiple Sclerosis: Issues and Insights. Int J MS Care 2021; 23:276-284. [PMID: 35035299 PMCID: PMC8745235 DOI: 10.7224/1537-2073.2020-133] [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: 11/18/2022]
Abstract
Observational studies and registries can play a critical role in elucidating the natural and treated history of multiple sclerosis (MS) and identifying factors associated with outcomes such as disability and health-related quality of life. The North American Research Committee on Multiple Sclerosis (NARCOMS) Registry is one of multiple registries worldwide that focuses on people with MS, but one of the very few patient-driven MS registries. On the 25th anniversary of the first data collection for the NARCOMS Registry, we discuss the importance of disease registries in the MS field, describe key concepts related to registry design and management, and highlight findings from MS registries relevant to clinical care or health policy.
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Affiliation(s)
- Ruth Ann Marrie
- From the Department of Internal Medicine and Department of Community Health Sciences, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada (RAM)
| | - Gary R. Cutter
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA (GRC)
| | - Robert J. Fox
- Mellen Center for Multiple Sclerosis, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA (RJF)
| | - Timothy Vollmer
- Department of Neurology, Rocky Mountain Multiple Sclerosis Center at Anschutz Medical Campus, University of Colorado Denver, Denver, CO, USA (TV)
| | | | - Amber Salter
- Division of Biostatistics, Washington University in St Louis, St Louis, MO, USA (AS [now at UT Southwestern Medical Center])
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Effects of Pregnancy and Breastfeeding on Clinical Outcomes and MRI Measurements of Women with Multiple Sclerosis: An Exploratory Real-World Cohort Study. Neurol Ther 2021; 11:39-49. [PMID: 34714518 PMCID: PMC8857366 DOI: 10.1007/s40120-021-00297-6] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 10/20/2021] [Indexed: 11/09/2022] Open
Abstract
Introduction Pregnancy represents an important event for women with multiple sclerosis (MS) and is often accompanied by post-partum disease reactivation. To date, the influence of this reproductive phase on long-term MS outcomes is still largely unexplored. The objective of the study was characterise a large real-world cohort of women with MS to evaluate the effects of pregnancy and breastfeeding on short- and long-term clinical and magnetic resonance imaging (MRI) outcomes while exploring the relationships with MRI measurements of brain atrophy. Methods MS patients with and without pregnancy were recruited. Clinical relapses and MRI activity of the year before conception versus the year after delivery were evaluated. Regression models were performed to investigate the relationships between long-term MS outcomes (EDSS score and MRI brain measurements obtained by SIENAX software) and pregnancy and breastfeeding duration. Results Two hundred ten women with MS were enrolled; of them, 129 (61.4%) had at least one pregnancy. Of all pregnancies (n = 212), those that occurred after MS onset (90 [42.4%]) were examined to evaluate the short-term outcomes. A higher annualised relapse rate in the post-partum year versus the pre-conception year (0.54 ± 0.84 vs. 0.45 ± 0.71; p = 0.04) was observed. A regression analysis showed that clinical activity after delivery was associated with clinical activity of the year before conception (p = 0.001) as well as duration of breastfeeding (p = 0.022). Similarly, post-partum MRI activity was associated with pre-conception MRI activity (p = 0.026) and shorter breastfeeding duration (p = 0.013). Regarding long-term outcomes, having had at least one pregnancy during MS was associated with a lower EDSS score (p = 0.021), while no relationships were reported with MRI measurements. Conversely, a breastfeeding duration > 6 months was associated with lower white matter volume (p = 0.008). Conclusions Our study underlines the importance of considering the effects of pregnancy and breastfeeding on short- and long-term MS outcomes. In the current therapeutic landscape, pregnancy planning and treatment optimisation in the post-partum period, in particular for women who choose to breastfeed, are fundamental for the management of these biological phases so central in a woman’s life.
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Coyle PK. What Can We Learn from Sex Differences in MS? J Pers Med 2021; 11:1006. [PMID: 34683148 PMCID: PMC8537319 DOI: 10.3390/jpm11101006] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 09/26/2021] [Indexed: 01/05/2023] Open
Abstract
Multiple sclerosis (MS) is the major acquired central nervous system disease of young adults. It is a female predominant disease. Multiple aspects of MS are influenced by sex-based differences. This has become an important area of research and study. It teaches us how the impact of sex on a disease can lead to new insights, guidelines, management, and treatments.
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Affiliation(s)
- Patricia K Coyle
- Department of Neurology, Stony Brook University, Stony Brook, NY 11794, USA
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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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Abstract
Multiple sclerosis (MS) is a neurological inflammatory disorder known to attack the heavily myelinated regions of the nervous system including the optic nerves, cerebellum, brainstem and spinal cord. This review will discuss the clinical manifestations and investigations for MS and other similar neurological inflammatory disorders affecting vision, as well as the effects of MS treatments on vision. Assessment of visual pathways is critical, considering MS can involve multiple components of the visual pathway, including optic nerves, uvea, retina and occipital cortex. Optical coherence tomography is increasingly being recognised as a highly sensitive tool in detecting subclinical optic nerve changes. Magnetic resonance imaging (MRI) is critical in MS diagnosis and in predicting long-term disability. Optic neuritis in MS involves unilateral vision loss, with characteristic pain on eye movement. The visual loss in neuromyelitis optica spectrum disorder tends to be more severe with preferential altitudinal field loss, chiasmal and tract lesions are also more common. Other differential diagnoses include chronic relapsing inflammatory optic neuropathy and giant cell arteritis. Leber's hereditary optic neuropathy affects young males and visual loss tends to be painless and subacute, typically involving both optic nerves. MS lesions in the vestibulocerebellum, brainstem, thalamus and basal ganglia may lead to abnormalities of gaze, saccades, pursuit and nystagmus which can be identified on eye examination. Medial longitudinal fasciculus lesions can cause another frequent presentation of MS, internuclear ophthalmoplegia, with failure of ipsilateral eye adduction and contralateral eye abduction nystagmus. Treatments for MS include high-dose corticosteroids for acute relapses and disease-modifying medications for relapse prevention. These therapies may also have adverse effects on vision, including central serous retinopathy with corticosteroid therapy and macular oedema with fingolimod.
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Affiliation(s)
- Roshan Dhanapalaratnam
- Prince of Wales Clinical School, University of New South Wales Sydney, Sydney, Australia
| | - Maria Markoulli
- School of Optometry and Vision Science, University of New South Wales Sydney, Sydney, Australia
| | - Arun V Krishnan
- Prince of Wales Clinical School, University of New South Wales Sydney, Sydney, Australia
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The Impact of Reproductive Issues on Preferences of Women with Relapsing Multiple Sclerosis for Disease-Modifying Treatments. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2021; 13:583-597. [PMID: 32588337 DOI: 10.1007/s40271-020-00429-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Relapsing-remitting multiple sclerosis (RRMS) is an incurable disease characterised by relapses (periods of function loss) followed by full or partial recovery, and potential permanent disability over time. Many disease-modifying treatments (DMTs) exist that help reduce relapses and slow disease progression. Most are contraindicated during conception/pregnancy and some require a discontinuation period before trying to conceive. Although around three-quarters of people with RRMS are women, there is limited knowledge about how reproductive issues impact DMT preference. OBJECTIVE The aim of this study was to measure the preferences for DMTs of women with RRMS who are considering pregnancy. DESIGN An online discrete choice experiment (DCE). METHODS Participants chose between two hypothetical DMTs characterised by a set of attributes, then indicated if they preferred their choice to no treatment. Attributes were identified from interviews and focus groups with people with RRMS and MS professionals, as well as literature reviews, and included the probability of problems with pregnancy, discontinuation of DMTs, and breastfeeding safety. In each DCE task, participants were asked to imagine making decisions in three scenarios: now; when trying to conceive; and when pregnant. ANALYSIS Two mixed logit models were estimated, one to assess the statistical significance between scenarios and one in maximum acceptable risk space to allow comparison of the magnitudes of parameters between scenarios. SAMPLE Women with RRMS who were considering having a child in the future, recruited from a UK MS patient register. RESULTS Sixty respondents completed the survey. Participants preferred no treatment in 12.6% of choices in the 'now' scenario, rising significantly to 37.6% in the 'trying to conceive' scenario and 60.3% in the 'pregnant' scenario (Kruskal-Wallis p < 0.001). This pattern corresponds with results from models that included a no-treatment alternative-specific constant (ASC) capturing differences between taking and not taking a DMT not specified by the attributes. The ASC was lower in the trying to conceive scenario than in the now scenario, and lower still in the pregnant scenario, indicating an intrinsic preference for no treatment. Participants also placed relatively less preference on reducing relapses and avoiding disease progression in the trying to conceive and pregnant scenarios compared with a lower risk of problems with pregnancy. In the trying to conceive scenario, participants' preference for treatments with shorter washout periods increased. CONCLUSION Women with RRMS considering having a child prefer DMTs with more favourable reproduction-related attributes, even when not trying to conceive. Reproductive issues also influenced preferences for DMT attributes not directly related to pregnancy, with preferences dependent on the life circumstances in which choices were made. The design of the DCE highlights the benefits of considering the scenario in which participants make choices, as they may change over time.
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Simone IL, Tortorella C, Ghirelli A. Influence of Pregnancy in Multiple Sclerosis and Impact of Disease-Modifying Therapies. Front Neurol 2021; 12:697974. [PMID: 34276545 PMCID: PMC8280312 DOI: 10.3389/fneur.2021.697974] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 05/26/2021] [Indexed: 01/25/2023] Open
Abstract
Purpose of this Review: This article is a systematic review on the influence pregnancy has on multiple sclerosis and the resulting impact of disease-modifying therapies. Findings: Multiple sclerosis predominantly affects young women with a clinical onset most often during the child-bearing age. The impact of multiple sclerosis and disease-modifying therapies on fertility, pregnancy, fetal outcome, and breastfeeding is a pivotal topic when it comes to clinical practice. The introduction of disease-modifying therapies has changed not only the natural history of the disease but also the perspective of pregnancy in women with multiple sclerosis. Family planning requires careful consideration, especially because many disease-modifying drugs are contraindicated during pregnancy. In this article, we review current evidence collected from published literature and drug-specific pregnancy registers on the use of disease-modifying therapies. Additionally, we discuss safety profiles for each drug and correlate them to both risk for the exposed fetus and risk for the mothers interrupting treatments when seeking pregnancy.
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Affiliation(s)
- Isabella Laura Simone
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari, Bari, Italy
| | - Carla Tortorella
- Department of Neurosciences, San Camillo-Forlanini Hospital, Rome, Italy
| | - Alma Ghirelli
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari, Bari, Italy
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Nguyen AL, Vodehnalova K, Kalincik T, Signori A, Havrdova EK, Lechner-Scott J, Skibina OG, Eastaugh A, Taylor L, Baker J, McGuinn N, Rath L, Maltby V, Sormani MP, Butzkueven H, Van der Walt A, Horakova D, Jokubaitis VG. Association of Pregnancy With the Onset of Clinically Isolated Syndrome. JAMA Neurol 2021; 77:1496-1503. [PMID: 32926074 DOI: 10.1001/jamaneurol.2020.3324] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Importance Multiple sclerosis (MS) is usually diagnosed in women during their childbearing years. Currently, no consensus exists on whether pregnancy can delay the first episode of demyelination or clinically isolated syndrome (CIS). Objective To investigate the association of pregnancy with time to CIS onset. Design, Setting, and Participants This multicenter cohort study collected reproductive history (duration of each pregnancy, date of delivery, length of breastfeeding) on all participants between September 1, 2016, and June 25, 2019. Adult women being treated at the MS outpatient clinics of 4 tertiary hospitals in 2 countries (Charles University and General University Hospital in Prague, Czech Republic; Royal Melbourne Hospital in Melbourne, Australia; Alfred Hospital in Melbourne, Australia; and John Hunter Hospital in Newcastle, Australia) were recruited to participate in the study. Preexisting data (date of CIS onset, date of birth, sex, date of clinical onset, and Expanded Disability Status Scale result) were collected from MSBase, an international registry of long-term prospectively collected data on patients with MS. Data analyses were performed from June 1, 2019, to February 3, 2020. Exposures Gravida (defined as any pregnancy, including pregnancy that ended in miscarriage and induced abortion) and parity (defined as childbirth after gestational age of more than 20 weeks, including livebirth and stillbirth) before CIS onset. Main Outcomes and Measures Time to CIS onset. The following were assessed: (1) whether women with previous pregnancies and childbirths had a delayed onset of CIS compared with those who had never been pregnant and those who had never given birth, and (2) whether a dose response existed, whereby a higher number of gravidity and parity was associated with a later onset of CIS. Results Of the 2557 women included in the study, the mean (SD) age at CIS onset was 31.5 (9.7) years. Of these women, before CIS onset, 1188 (46%) had at least 1 pregnancy and 1100 (43%) had at least 1 childbirth. The mean (SD) age at first pregnancy was 23.3 (4.5) years and at first childbirth was 23.8 (4.5) years. Women with previous pregnancies and childbirths had a later onset of CIS compared with those who had never been pregnant (HR, 0.68; 95% CI, 0.62-0.75; P < .001), with a median delay of 3.3 (95% CI, 2.5-4.1) years. Women who had given birth also had a later CIS onset compared with women who had never given birth (HR 0.68; 95% CI, 0.61-0.75; P < .001), with a similar median delay of 3.4 (95% CI, 1.6-5.2) years. A higher gravidity and parity number was not associated with delay in CIS onset. Conclusions and Relevance This study suggests an association between previous pregnancies and childbirths and timing of CIS onset, but having more pregnancies or childbirths did not appear to be associated with a later CIS onset. Further studies are needed to help explain the mechanisms behind the associations between pregnancy and onset of multiple sclerosis.
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Affiliation(s)
- Ai-Lan Nguyen
- Department of Neurology, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,CORe, Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Karolina Vodehnalova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Tomas Kalincik
- Department of Neurology, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,CORe, Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Alessio Signori
- Department of Health Sciences (DISSAL), Biostatistics Unit, University of Genoa, Genoa, Italy
| | - Eva Kubala Havrdova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Jeannette Lechner-Scott
- Department of Neurology, John Hunter Hospital, Newcastle, New South Wales, Australia.,School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia.,Centre for Brain and Mental Health, Hunter Medical Research Institute, Newcastle, New South Wales, Australia
| | - Olga G Skibina
- Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Alana Eastaugh
- Department of Neurology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Lisa Taylor
- Department of Neurology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Josephine Baker
- Department of Neurology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Nicola McGuinn
- Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Louise Rath
- Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Vicki Maltby
- Department of Neurology, John Hunter Hospital, Newcastle, New South Wales, Australia.,School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia.,Centre for Brain and Mental Health, Hunter Medical Research Institute, Newcastle, New South Wales, Australia
| | - Maria Pia Sormani
- Department of Health Sciences (DISSAL), Biostatistics Unit, University of Genoa, Genoa, Italy
| | - Helmut Butzkueven
- Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Anneke Van der Walt
- Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Dana Horakova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Vilija G Jokubaitis
- Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
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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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Simpson A, Mowry EM, Newsome SD. Early Aggressive Treatment Approaches for Multiple Sclerosis. Curr Treat Options Neurol 2021; 23:19. [PMID: 34025110 PMCID: PMC8121641 DOI: 10.1007/s11940-021-00677-1] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2021] [Indexed: 12/19/2022]
Abstract
Purpose of review This review presents a comprehensive analysis of the current high-efficacy disease-modifying therapies (DMTs) available for treatment of multiple sclerosis (MS). We discuss the existing approved and emerging therapeutics in patients with relapsing and progressive forms of MS using data from clinical trials and observational studies. Treatment considerations in pediatric and pregnant populations are also reviewed. Finally, we discuss the treatment paradigms of the escalation and early aggressive approaches to treatment of MS, with review of ongoing clinical trials to compare these approaches. Recent findings Natalizumab has shown promising data on efficacy in not only randomized trials but also observational studies when compared with placebo, the injectable DMTs, and fingolimod. The anti-CD20 B cell depleting therapies (rituximab, ocrelizumab, and ofatumumab) have also demonstrated superiority in randomized clinical trials compared to their comparator group (placebo, interferon, and teriflunomide, respectively) and rituximab has shown in observational studies to be more effective than older injectable therapies and some of the oral therapies. Alemtuzumab has shown good efficacy in randomized controlled trials and observational studies yet has several potentially severe side effects limiting its use. Mitoxantrone has similarly demonstrated significant reduction in new disease activity compared to placebo but is rarely used due to its severe side effects. Cladribine is an oral DMT often grouped in discussion with other higher efficacy DMTs but may be slightly less effective than the other therapies described in this review. Many emerging targets for therapeutic intervention are currently under investigation that may prove to be beneficial in early aggressive MS, including autologous hematopoietic stem cell transplantation. Summary Traditionally, MS has been treated with an escalation approach, starting patients on a modestly effective DMT and subsequently escalating to a higher efficacy DMT when there is evidence of clinical and/or radiologic breakthrough activity. With the development of higher efficacy therapies and emerging data showing the potential positive long-term impact of these therapies when started earlier in the disease course, many clinicians have shifted to an early aggressive treatment approach in which patients are initially started on a higher efficacy DMT. Two clinical trials, the TRaditional versus Early Aggressive Therapy for MS (TREAT-MS) trial and the Determining the Effectiveness of earLy Intensive Versus Escalation approaches for the treatment of Relapsing-remitting MS (DELIVER-MS) trial, aim to directly compare these treatment strategies and their impact on clinical and radiologic outcomes.
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Affiliation(s)
- Alexandra Simpson
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD USA
| | - Ellen M Mowry
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD USA
| | - Scott D Newsome
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD USA.,Division of Neuroimmunology and Neurological Infections, Johns Hopkins Hospital, 600 North Wolfe St., Pathology 627, Baltimore, MD 21287 USA
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Jokubaitis VG, Skibina O, Alroughani R, Altintas A, Butzkueven H, Eichau S, Fragoso Y, Hellwig K, Hughes SE, Rath L, van der Walt A, Gray O. The MSBase pregnancy, neonatal outcomes, and women's health registry. Ther Adv Neurol Disord 2021; 14:17562864211009104. [PMID: 33912245 PMCID: PMC8047930 DOI: 10.1177/17562864211009104] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 03/18/2021] [Indexed: 11/30/2022] Open
Abstract
Background: Family planning and pregnancy decisions are key considerations in the management of women with multiple sclerosis (MS), who are typically diagnosed between the ages of 20–40 years. Despite a strong evidence base that pregnancy is not harmful for women with MS, many knowledge gaps remain. These include: best management strategies through pregnancy in the era of highly effective disease-modifying therapies (DMT); foetal risks associated with DMT exposure in utero or in relation to breastfeeding; knowledge base around the use of assisted reproductive technologies; the long-term impact of pregnancy on disease outcomes, as well as the impact of long-term DMT use on women’s health and cancer risk. Methods: Here, we describe the new MSBase pregnancy, neonatal outcomes and women’s health registry. We provide the rationale for, and detailed description of, the variables collected within the registry, together with data acquisition details. Conclusion: The present paper will act as a reference document for future studies.
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Affiliation(s)
- Vilija G Jokubaitis
- Department of Neuroscience, Central Clinical School, Monash University, Level 6, 99 Commercial Rd, Melbourne, VIC 3004, Australia
| | - Olga Skibina
- Department of Neurology, Alfred Health, Melbourne, VIC, Australia
| | | | - Ayse Altintas
- Neurology Department, Koc University School of Medicine, Istanbul, Turkey
| | - Helmut Butzkueven
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Sara Eichau
- Hospital Virgen Macarena, Sevilla, Andalucía, Spain
| | - Yara Fragoso
- MS and Headache Research, Universidade Metropolitana de Santos, Sao Paulo, Brazil
| | - Kerstin Hellwig
- Department of Neurology, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Stella E Hughes
- Department of Neurology, Belfast Health and Social Care Trust, Belfast, UK
| | - Louise Rath
- Department of Neurology, Alfred Health, Melbourne, VIC, Australia
| | - Anneke van der Walt
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Orla Gray
- Department of Neurology, South Eastern Health and Social Care Trust, Dundonald, UK
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50
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Lehmann H, Zveik O, Levin N, Brill L, Imbar T, Vaknin-Dembinsky A. Brain MRI activity during the year before pregnancy can predict post-partum clinical relapses. Mult Scler 2021; 27:2232-2239. [PMID: 33783260 DOI: 10.1177/13524585211002719] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND There are fewer multiple sclerosis (MS) relapses during pregnancy, although relapse risk increases in the early post-partum period, as has been predicted by pre-pregnancy or pregnancy disease activity in some studies. OBJECTIVE The aim of this study was to evaluate the correlation between magnetic resonance imaging (MRI) changes in the year before pregnancy and the relapse rate in the year post-partum. METHODS An observational retrospective case-control study included 172 pregnancies in 118 females with MS. Statistical analyses were used to evaluate the correlation between MRI and post-partum relapses. Clustered logistic regression was used to investigate the predictors of early post-partum relapses. RESULTS We found a significant correlation for an active-MRI pre-pregnancy and relapses in the first 3 months post-partum (p < 0.001). Expanded Disability Status Scale (EDSS) pre-pregnancy and relapses in the first 3 months post-partum were also significantly correlated (p = 0.009). Using a multivariate model, we predicted which women will not experience post-partum relapse by EDSS and by an active-MRI pre-pregnancy (96.7% specificity; p < 0.001). CONCLUSION An active-MRI pre-pregnancy is a strong and sensitive predictor of early post-partum relapse, regardless of whether the woman had clinical evidence of disease activity prior to conception and delivery. This finding could provide clinicians with a strategy to minimize post-partum relapse risk in women with MS planning pregnancy.
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Affiliation(s)
- Hillel Lehmann
- Faculty of Medicine, Hebrew University of Jerusalem, Department of Neurology and Laboratory of Neuroimmunology, The Agnes-Ginges Center for Neurogenetics, Hadassah Medical Center, Jerusalem, Israel
| | - Omri Zveik
- Faculty of Medicine, Hebrew University of Jerusalem, Department of Neurology and Laboratory of Neuroimmunology, The Agnes-Ginges Center for Neurogenetics, Hadassah Medical Center, Jerusalem, Israel
| | - Netta Levin
- Faculty of Medicine, Hebrew University of Jerusalem, Department of Neurology and Laboratory of Neuroimmunology, The Agnes-Ginges Center for Neurogenetics, Hadassah Medical Center, Jerusalem, Israel
| | - Livnat Brill
- Faculty of Medicine, Hebrew University of Jerusalem, Department of Neurology and Laboratory of Neuroimmunology, The Agnes-Ginges Center for Neurogenetics, Hadassah Medical Center, Jerusalem, Israel
| | - Tal Imbar
- Department of Obstetrics and Gynecology, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Israel
| | - Adi Vaknin-Dembinsky
- Faculty of Medicine, Hebrew University of Jerusalem, Department of Neurology and Laboratory of Neuroimmunology, The Agnes-Ginges Center for Neurogenetics, Hadassah Medical Center, Jerusalem, Israel
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