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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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Thiel S, Litvin N, Haben S, Gold R, Hellwig K. Disease activity and neonatal outcomes after exposure to natalizumab throughout pregnancy. J Neurol Neurosurg Psychiatry 2024; 95:561-570. [PMID: 38124108 PMCID: PMC11103322 DOI: 10.1136/jnnp-2023-332804] [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: 10/15/2023] [Accepted: 12/01/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND After natalizumab discontinuation severe relapses can occur despite pregnancy, but third trimester exposure is associated with neonatal haematological abnormalities (HA). The best time point for stopping natalizumab during pregnancy is unclear. METHODS Prospective, observational cohort with 350 natalizumab exposed pregnancies from the German Multiple Sclerosis and Pregnancy Registry. Clinical disease activity and neonatal outcomes are compared between women with natalizumab discontinuation during (1st Trim-group) versus after the first trimester (maintaining-group) and for subgroup analysis before (<30-subgroup) or after (≥30-subgroup) the 30th gestational week (gw). RESULTS Baseline characteristics did not significantly differ between the 1st Trim-group (n=179; median exposure duration: 2.60 gw, IQR 1.30-3.60) and the maintaining-group (n=171; median exposure duration: 30.9 gw, IQR 26.9-33.3). Fewer relapses occurred during pregnancy and the postpartum year in the maintaining-group (25.7%) compared with the 1st Trim-group (62.6%; p<0.001). Women in ≥30-subgroup had a significantly lower relapse risk in the first 6 months postpartum (relapse rate ratio: 0.36, 95% CI: 0.15 to 0.84). In total, 7.5% retained meaningful disability 12 months postpartum. No significant effect on neonatal outcomes were observed, but anaemia (OR: 2.62, 95% CI: 1.12 to 6.52) and thrombocytopaenia (OR: 2.64, 95% CI: 1.15 to 6.46) were significantly more common in the ≥30-subgroup. 21.8% of all neonates were born small for gestational age, independent of the timing of natalizumab discontinuation. CONCLUSION Continuing natalizumab during pregnancy after gw 30 decreases the relapse risk postpartum going along with a higher risk for HA in the newborns. These results add relevant knowledge as a basis for informed risk-benefit discussion.
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Affiliation(s)
- Sandra Thiel
- Universitätsklinik für Neurologie der Ruhr-Universität Bochum, Katholisches Klinikum Bochum Sankt Josef-Hospital, Bochum, Nordrhein-Westfalen, Germany
| | - Nastassja Litvin
- Universitätsklinik für Neurologie der Ruhr-Universität Bochum, Katholisches Klinikum Bochum Sankt Josef-Hospital, Bochum, Nordrhein-Westfalen, Germany
| | - Sabrina Haben
- Universitätsklinik für Neurologie der Ruhr-Universität Bochum, Katholisches Klinikum Bochum Sankt Josef-Hospital, Bochum, Nordrhein-Westfalen, Germany
| | - Ralf Gold
- Universitätsklinik für Neurologie der Ruhr-Universität Bochum, Katholisches Klinikum Bochum Sankt Josef-Hospital, Bochum, Nordrhein-Westfalen, Germany
| | - Kerstin Hellwig
- Universitätsklinik für Neurologie der Ruhr-Universität Bochum, Katholisches Klinikum Bochum Sankt Josef-Hospital, Bochum, Nordrhein-Westfalen, Germany
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Melo EMVD, Mendes MF, Olival GSD. What is the importance of family planning in multiple sclerosis? A study in the Brazilian population. Mult Scler Relat Disord 2024; 85:105538. [PMID: 38492319 DOI: 10.1016/j.msard.2024.105538] [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: 12/11/2023] [Revised: 02/09/2024] [Accepted: 03/04/2024] [Indexed: 03/18/2024]
Abstract
INTRODUCTION Multiple Sclerosis is a disease of young females at a reproductive age. OBJECTIVE discuss family planning in the context of providing care for women with MS. METHOD patients with Multiple Sclerosis, female, aged between 18 and 45 years, from 01/Nov/2021 to 16/Jan/2022 participated, all of whom answered a questionnaire made available on the Google forms platform. RESULTS A total of 233 responses were validated. Most patients discuss family planning during their medical care (61.4 %), use low-efficacy contraceptive methods (68.7 %) and do not plan to become pregnant (70.1 %). There is a high rate of use of disease-modifying treatments (88.9 %). Among those who had already become pregnant, most of them became pregnant before diagnosis and were statically younger than patients who became pregnant after diagnosis. CONCLUSION Family planning should be discussed early on and be actively initiated by the health care professional assisting the patient and incorporated into the routine consultation. We suggest efforts should be put into ensuring a decrease in the rate of unplanned pregnancy in this population. Also, it is crucial to guarantee effective contraception in patients who express the wish not to become pregnant and are using disease-modifying treatments.
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Affiliation(s)
- Elisa Matias Vieira de Melo
- Avenida Onze de Junho, Santa Casa de São Paulo, Faculdade de Ciências Médicas, 1071, Sala 510. Vila Clementino, São Paulo, SP, Brazil.
| | - Maria Fernanda Mendes
- Avenida Onze de Junho, Santa Casa de São Paulo, Faculdade de Ciências Médicas, 1071, Sala 510. Vila Clementino, São Paulo, SP, Brazil
| | - Guilherme Sciascia do Olival
- Avenida Onze de Junho, Santa Casa de São Paulo, Faculdade de Ciências Médicas, 1071, Sala 510. Vila Clementino, São Paulo, SP, Brazil
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Sahloul O, Louapre C, Beigneux Y, Lubetzki C, Maillart E, Roux T. Evidence of disease activity during pregnancy and post-partum in MS patients treated with high-efficacy therapies. Mult Scler Relat Disord 2024; 85:105557. [PMID: 38520946 DOI: 10.1016/j.msard.2024.105557] [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: 01/13/2024] [Revised: 03/07/2024] [Accepted: 03/16/2024] [Indexed: 03/25/2024]
Abstract
BACKGROUND Multiple sclerosis (MS) predominantly affects women of childbearing age. Due to the risk of teratogenicity, women with active multiple sclerosis (MS) who require high-efficacy therapies (HET) may need to discontinue treatment during pregnancy. Fingolimod and Natalizumab withdrawal increases the risk of disease reactivation, a risk not commonly associated with anti-CD20 therapies. However, comparative data are limited during pregnancy and post-partum. Our aim was to compare evidence of disease activity during pregnancy and post-partum in women treated with HET (anti-CD20 therapies, Natalizumab or Fingolimod) before conception, whether or not exposed during pregnancy. METHODS In this single-center retrospective study, we included consecutive pregnancies of relapsing-remitting MS patients and classified them in three groups according to the last HET used before conception: « anti-CD20 » « Natalizumab (NTZ) » and « Fingolimod (FGD) ». The main outcome was annualized relapse rate (ARR) during pregnancy and post-partum. RESULTS We included 66 pregnancies: 21, 24 and 21 in anti-CD20, NTZ and FGD groups respectively. Overall, mean ARR (SD) increased from 0.36 (0.6) during the preconception year to 0.60 (1.3) during pregnancy and to 1.03 (2.0) in the first 3 months post-partum. Mean ARR in anti-CD20 group (0.09 (0.3)) during pregnancy and the first 3 months post-partum was lower compared with NTZ (0.48 (0.6); p = 0,09) and FGD (1.50 (1.8); p = 0.001) groups. Proportion of pregnancies with radiological activity during pregnancy and post-partum in anti-CD20 group (5.2 %) was lower compared with NTZ (63.1 %; p < 0.001) and FGD (72.2 %; p < 0.001) groups. There was no significant difference in the evolution of EDSS score from conception to post-partum between each group (p = 0.75). CONCLUSION Evidence of disease activity was significantly lower in patients exposed to anti-CD20 therapies before conception. This study suggests that use of anti-CD20 therapies is an efficient option to prevent disease reactivation during pregnancy and post-partum.
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Affiliation(s)
- Oussama Sahloul
- Neurology Department, Pitié-Salpêtrière University Hospital, Paris, France.
| | - Céline Louapre
- Neurology Department, Pitié-Salpêtrière University Hospital, Paris, France
| | - Ysoline Beigneux
- Neurology Department, Pitié-Salpêtrière University Hospital, Paris, France
| | - Catherine Lubetzki
- Neurology Department, Pitié-Salpêtrière University Hospital, Paris, France
| | - Elisabeth Maillart
- Neurology Department, Pitié-Salpêtrière University Hospital, Paris, France
| | - Thomas Roux
- Neurology Department, Pitié-Salpêtrière University Hospital, Paris, France
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Radzik AM, Amezcua L, Anderson A, Gilmore S, Ahmad S, Brandstadter R, Fabian MT, Graham EL, Hodgkinson S, Horton L, Jacobs DA, Katz Sand IB, Kohli A, Levine L, McLemore M, Okai AF, Patel J, Poole S, Riley C, Satyanarayan S, Tardo L, Verter E, Villacorta V, Zimmerman V, Zuroff L, Williams MJ, Houtchens MK, Bove R. Disparities by Race in Pregnancy Care and Clinical Outcomes in Women With Multiple Sclerosis: A Diverse Multicenter Cohort. Neurology 2024; 102:e208100. [PMID: 38261988 PMCID: PMC10962915 DOI: 10.1212/wnl.0000000000208100] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 11/15/2023] [Indexed: 01/25/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Racial disparities exist in both neurologic and obstetric populations, underscoring the importance of evaluating pregnancy outcomes in diverse women with multiple sclerosis (MS). The objective of this multicenter retrospective study was to compare pregnancy care and outcomes between Black and Hispanic (underrepresented) and White women with MS. METHODS Demographic and clinical data were extracted from medical records of 9 US MS centers for women with MS/clinically isolated syndrome who delivered live births between 2010 and 2021. Sites identified at last 15 consecutive Black/Hispanic women and a matching number of White women. Socioeconomic factors, pregnancy, and MS care/outcomes were compared between groups (underrepresented and White and then Black and Hispanic) using Wilcoxon rank sum (U statistic and effect size r reported), χ2, t tests and logistic regressions as appropriate to data type. Multiple imputation by chained equation was used to account for missing data. RESULTS Overall, 294 pregnancies resulting in live births were analyzed ( 81 Black, 67 Hispanic, and 146 White mothers). Relative to underrepresented women, White women lived in areas of higher median (interquartile range [IQR]) Child Opportunity Index (79 [45.8] vs 22 [45.8], U = 3,824, r = 0.56, p < 0.0001) and were more often employed (84.9% vs 75%, odds ratio [OR] 2.57, CI 1.46-4.50, p = 0.0008) and privately insured (93.8% vs 56.8%, OR 11.6, CI 5.5-24.5, p < 0.0001) and more received a 14-week ultrasound (98.6% vs 93.9%, OR 4.66, CI 0.99-21.96, p = 0.027). Mode of delivery was significantly different between the three groups (X2(10,294) = 20.38, p = 0.03); notably, Black women had the highest rates of emergency cesarean deliveries, and Hispanic women highest rates of uncomplicated vaginal deliveries. Babies born to underrepresented women had lower median (IQR) birthweights than babies born to White women (3,198 g [435.3 g] vs 3,275 g [412.5 g], U = 9,255, r = 0.12, p = 0.04) and shorter median (IQR) breastfeeding duration (4.5 [3.3] vs 6.0 [4.2] months, U = 8,184, r = 0.21, p = 0.003). While underrepresented women were younger than White women (mean [SD] 30.9 [4.8] vs 33.8 [4.0], t = 1.97, CI 1.96-3.98, p < 0.0001), their median (Q1-Q3, IQR) Expanded Disability Status Scale was higher (1.5 [1-2.5, 1.5] vs 1 [0-1.5, 1.5], U = 7,260, r = 0.29, p < 0.0001) before pregnancy. Finally, medical records were missing more key data for Black women (19.7% missing vs 8.9% missing, OR 2.54, CI 1.25-5.06, p = 0.008). DISCUSSION In this geographically diverse multicenter cohort, underrepresented women entered pregnancy with higher disability and fewer health care resources. Pregnancy represents a pivotal window where structural factors affect maternal and fetal health and neurologic trajectories; it is a critical period to optimize care and health outcomes.
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Affiliation(s)
- Anne Marie Radzik
- From the University of California San Francisco (A.M.R.); Department of Neurology (L.A.), University of Southern California, Los Angeles; Department of Neurology (A.A., S.P., R. Bove), UCSF Weill Institute for the Neurosciences, and Department of Neurology (S.G.), University of California San Francisco; Department of Neurology (S.A., E.L.G.), Northwestern University, Chicago, IL; Department of Neurology (R. Brandstadter, D.A.J., V.Z., L.Z.), Hospital of the University of Pennsylvania, Philadelphia; Corinne Goldsmith Dickinson Center for MS (M.T.F., I.B.K.S., A.K., J.P., S.S., E.V.), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; Brigham and Women's Hospital (S.H., M.K.H.), Boston, MA; University of Texas Southwestern Medical Center (L.H., L.T.), Dallas; Center for Translational and Computational Neuroimmunology and Multiple Sclerosis Center (L.L., C.R.), Department of Neurology, Columbia University Irving Medical Center, New York, NY; Family Health Care Nursing Department (M.M.), School of Nursing, University of California San Francisco; North Texas Institute of Neurology and Headache (A.F.O.), Frisco; University of Southern California (V.V.), Los Angeles; and Joi Life Wellness Group (M.J.W.), Multiple Sclerosis Center, Smyrna, GA
| | - Lilyana Amezcua
- From the University of California San Francisco (A.M.R.); Department of Neurology (L.A.), University of Southern California, Los Angeles; Department of Neurology (A.A., S.P., R. Bove), UCSF Weill Institute for the Neurosciences, and Department of Neurology (S.G.), University of California San Francisco; Department of Neurology (S.A., E.L.G.), Northwestern University, Chicago, IL; Department of Neurology (R. Brandstadter, D.A.J., V.Z., L.Z.), Hospital of the University of Pennsylvania, Philadelphia; Corinne Goldsmith Dickinson Center for MS (M.T.F., I.B.K.S., A.K., J.P., S.S., E.V.), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; Brigham and Women's Hospital (S.H., M.K.H.), Boston, MA; University of Texas Southwestern Medical Center (L.H., L.T.), Dallas; Center for Translational and Computational Neuroimmunology and Multiple Sclerosis Center (L.L., C.R.), Department of Neurology, Columbia University Irving Medical Center, New York, NY; Family Health Care Nursing Department (M.M.), School of Nursing, University of California San Francisco; North Texas Institute of Neurology and Headache (A.F.O.), Frisco; University of Southern California (V.V.), Los Angeles; and Joi Life Wellness Group (M.J.W.), Multiple Sclerosis Center, Smyrna, GA
| | - Annika Anderson
- From the University of California San Francisco (A.M.R.); Department of Neurology (L.A.), University of Southern California, Los Angeles; Department of Neurology (A.A., S.P., R. Bove), UCSF Weill Institute for the Neurosciences, and Department of Neurology (S.G.), University of California San Francisco; Department of Neurology (S.A., E.L.G.), Northwestern University, Chicago, IL; Department of Neurology (R. Brandstadter, D.A.J., V.Z., L.Z.), Hospital of the University of Pennsylvania, Philadelphia; Corinne Goldsmith Dickinson Center for MS (M.T.F., I.B.K.S., A.K., J.P., S.S., E.V.), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; Brigham and Women's Hospital (S.H., M.K.H.), Boston, MA; University of Texas Southwestern Medical Center (L.H., L.T.), Dallas; Center for Translational and Computational Neuroimmunology and Multiple Sclerosis Center (L.L., C.R.), Department of Neurology, Columbia University Irving Medical Center, New York, NY; Family Health Care Nursing Department (M.M.), School of Nursing, University of California San Francisco; North Texas Institute of Neurology and Headache (A.F.O.), Frisco; University of Southern California (V.V.), Los Angeles; and Joi Life Wellness Group (M.J.W.), Multiple Sclerosis Center, Smyrna, GA
| | - Serena Gilmore
- From the University of California San Francisco (A.M.R.); Department of Neurology (L.A.), University of Southern California, Los Angeles; Department of Neurology (A.A., S.P., R. Bove), UCSF Weill Institute for the Neurosciences, and Department of Neurology (S.G.), University of California San Francisco; Department of Neurology (S.A., E.L.G.), Northwestern University, Chicago, IL; Department of Neurology (R. Brandstadter, D.A.J., V.Z., L.Z.), Hospital of the University of Pennsylvania, Philadelphia; Corinne Goldsmith Dickinson Center for MS (M.T.F., I.B.K.S., A.K., J.P., S.S., E.V.), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; Brigham and Women's Hospital (S.H., M.K.H.), Boston, MA; University of Texas Southwestern Medical Center (L.H., L.T.), Dallas; Center for Translational and Computational Neuroimmunology and Multiple Sclerosis Center (L.L., C.R.), Department of Neurology, Columbia University Irving Medical Center, New York, NY; Family Health Care Nursing Department (M.M.), School of Nursing, University of California San Francisco; North Texas Institute of Neurology and Headache (A.F.O.), Frisco; University of Southern California (V.V.), Los Angeles; and Joi Life Wellness Group (M.J.W.), Multiple Sclerosis Center, Smyrna, GA
| | - Sophie Ahmad
- From the University of California San Francisco (A.M.R.); Department of Neurology (L.A.), University of Southern California, Los Angeles; Department of Neurology (A.A., S.P., R. Bove), UCSF Weill Institute for the Neurosciences, and Department of Neurology (S.G.), University of California San Francisco; Department of Neurology (S.A., E.L.G.), Northwestern University, Chicago, IL; Department of Neurology (R. Brandstadter, D.A.J., V.Z., L.Z.), Hospital of the University of Pennsylvania, Philadelphia; Corinne Goldsmith Dickinson Center for MS (M.T.F., I.B.K.S., A.K., J.P., S.S., E.V.), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; Brigham and Women's Hospital (S.H., M.K.H.), Boston, MA; University of Texas Southwestern Medical Center (L.H., L.T.), Dallas; Center for Translational and Computational Neuroimmunology and Multiple Sclerosis Center (L.L., C.R.), Department of Neurology, Columbia University Irving Medical Center, New York, NY; Family Health Care Nursing Department (M.M.), School of Nursing, University of California San Francisco; North Texas Institute of Neurology and Headache (A.F.O.), Frisco; University of Southern California (V.V.), Los Angeles; and Joi Life Wellness Group (M.J.W.), Multiple Sclerosis Center, Smyrna, GA
| | - Rachel Brandstadter
- From the University of California San Francisco (A.M.R.); Department of Neurology (L.A.), University of Southern California, Los Angeles; Department of Neurology (A.A., S.P., R. Bove), UCSF Weill Institute for the Neurosciences, and Department of Neurology (S.G.), University of California San Francisco; Department of Neurology (S.A., E.L.G.), Northwestern University, Chicago, IL; Department of Neurology (R. Brandstadter, D.A.J., V.Z., L.Z.), Hospital of the University of Pennsylvania, Philadelphia; Corinne Goldsmith Dickinson Center for MS (M.T.F., I.B.K.S., A.K., J.P., S.S., E.V.), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; Brigham and Women's Hospital (S.H., M.K.H.), Boston, MA; University of Texas Southwestern Medical Center (L.H., L.T.), Dallas; Center for Translational and Computational Neuroimmunology and Multiple Sclerosis Center (L.L., C.R.), Department of Neurology, Columbia University Irving Medical Center, New York, NY; Family Health Care Nursing Department (M.M.), School of Nursing, University of California San Francisco; North Texas Institute of Neurology and Headache (A.F.O.), Frisco; University of Southern California (V.V.), Los Angeles; and Joi Life Wellness Group (M.J.W.), Multiple Sclerosis Center, Smyrna, GA
| | - Michelle T Fabian
- From the University of California San Francisco (A.M.R.); Department of Neurology (L.A.), University of Southern California, Los Angeles; Department of Neurology (A.A., S.P., R. Bove), UCSF Weill Institute for the Neurosciences, and Department of Neurology (S.G.), University of California San Francisco; Department of Neurology (S.A., E.L.G.), Northwestern University, Chicago, IL; Department of Neurology (R. Brandstadter, D.A.J., V.Z., L.Z.), Hospital of the University of Pennsylvania, Philadelphia; Corinne Goldsmith Dickinson Center for MS (M.T.F., I.B.K.S., A.K., J.P., S.S., E.V.), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; Brigham and Women's Hospital (S.H., M.K.H.), Boston, MA; University of Texas Southwestern Medical Center (L.H., L.T.), Dallas; Center for Translational and Computational Neuroimmunology and Multiple Sclerosis Center (L.L., C.R.), Department of Neurology, Columbia University Irving Medical Center, New York, NY; Family Health Care Nursing Department (M.M.), School of Nursing, University of California San Francisco; North Texas Institute of Neurology and Headache (A.F.O.), Frisco; University of Southern California (V.V.), Los Angeles; and Joi Life Wellness Group (M.J.W.), Multiple Sclerosis Center, Smyrna, GA
| | - Edith L Graham
- From the University of California San Francisco (A.M.R.); Department of Neurology (L.A.), University of Southern California, Los Angeles; Department of Neurology (A.A., S.P., R. Bove), UCSF Weill Institute for the Neurosciences, and Department of Neurology (S.G.), University of California San Francisco; Department of Neurology (S.A., E.L.G.), Northwestern University, Chicago, IL; Department of Neurology (R. Brandstadter, D.A.J., V.Z., L.Z.), Hospital of the University of Pennsylvania, Philadelphia; Corinne Goldsmith Dickinson Center for MS (M.T.F., I.B.K.S., A.K., J.P., S.S., E.V.), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; Brigham and Women's Hospital (S.H., M.K.H.), Boston, MA; University of Texas Southwestern Medical Center (L.H., L.T.), Dallas; Center for Translational and Computational Neuroimmunology and Multiple Sclerosis Center (L.L., C.R.), Department of Neurology, Columbia University Irving Medical Center, New York, NY; Family Health Care Nursing Department (M.M.), School of Nursing, University of California San Francisco; North Texas Institute of Neurology and Headache (A.F.O.), Frisco; University of Southern California (V.V.), Los Angeles; and Joi Life Wellness Group (M.J.W.), Multiple Sclerosis Center, Smyrna, GA
| | - Sophia Hodgkinson
- From the University of California San Francisco (A.M.R.); Department of Neurology (L.A.), University of Southern California, Los Angeles; Department of Neurology (A.A., S.P., R. Bove), UCSF Weill Institute for the Neurosciences, and Department of Neurology (S.G.), University of California San Francisco; Department of Neurology (S.A., E.L.G.), Northwestern University, Chicago, IL; Department of Neurology (R. Brandstadter, D.A.J., V.Z., L.Z.), Hospital of the University of Pennsylvania, Philadelphia; Corinne Goldsmith Dickinson Center for MS (M.T.F., I.B.K.S., A.K., J.P., S.S., E.V.), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; Brigham and Women's Hospital (S.H., M.K.H.), Boston, MA; University of Texas Southwestern Medical Center (L.H., L.T.), Dallas; Center for Translational and Computational Neuroimmunology and Multiple Sclerosis Center (L.L., C.R.), Department of Neurology, Columbia University Irving Medical Center, New York, NY; Family Health Care Nursing Department (M.M.), School of Nursing, University of California San Francisco; North Texas Institute of Neurology and Headache (A.F.O.), Frisco; University of Southern California (V.V.), Los Angeles; and Joi Life Wellness Group (M.J.W.), Multiple Sclerosis Center, Smyrna, GA
| | - Lindsay Horton
- From the University of California San Francisco (A.M.R.); Department of Neurology (L.A.), University of Southern California, Los Angeles; Department of Neurology (A.A., S.P., R. Bove), UCSF Weill Institute for the Neurosciences, and Department of Neurology (S.G.), University of California San Francisco; Department of Neurology (S.A., E.L.G.), Northwestern University, Chicago, IL; Department of Neurology (R. Brandstadter, D.A.J., V.Z., L.Z.), Hospital of the University of Pennsylvania, Philadelphia; Corinne Goldsmith Dickinson Center for MS (M.T.F., I.B.K.S., A.K., J.P., S.S., E.V.), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; Brigham and Women's Hospital (S.H., M.K.H.), Boston, MA; University of Texas Southwestern Medical Center (L.H., L.T.), Dallas; Center for Translational and Computational Neuroimmunology and Multiple Sclerosis Center (L.L., C.R.), Department of Neurology, Columbia University Irving Medical Center, New York, NY; Family Health Care Nursing Department (M.M.), School of Nursing, University of California San Francisco; North Texas Institute of Neurology and Headache (A.F.O.), Frisco; University of Southern California (V.V.), Los Angeles; and Joi Life Wellness Group (M.J.W.), Multiple Sclerosis Center, Smyrna, GA
| | - Dina A Jacobs
- From the University of California San Francisco (A.M.R.); Department of Neurology (L.A.), University of Southern California, Los Angeles; Department of Neurology (A.A., S.P., R. Bove), UCSF Weill Institute for the Neurosciences, and Department of Neurology (S.G.), University of California San Francisco; Department of Neurology (S.A., E.L.G.), Northwestern University, Chicago, IL; Department of Neurology (R. Brandstadter, D.A.J., V.Z., L.Z.), Hospital of the University of Pennsylvania, Philadelphia; Corinne Goldsmith Dickinson Center for MS (M.T.F., I.B.K.S., A.K., J.P., S.S., E.V.), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; Brigham and Women's Hospital (S.H., M.K.H.), Boston, MA; University of Texas Southwestern Medical Center (L.H., L.T.), Dallas; Center for Translational and Computational Neuroimmunology and Multiple Sclerosis Center (L.L., C.R.), Department of Neurology, Columbia University Irving Medical Center, New York, NY; Family Health Care Nursing Department (M.M.), School of Nursing, University of California San Francisco; North Texas Institute of Neurology and Headache (A.F.O.), Frisco; University of Southern California (V.V.), Los Angeles; and Joi Life Wellness Group (M.J.W.), Multiple Sclerosis Center, Smyrna, GA
| | - Ilana B Katz Sand
- From the University of California San Francisco (A.M.R.); Department of Neurology (L.A.), University of Southern California, Los Angeles; Department of Neurology (A.A., S.P., R. Bove), UCSF Weill Institute for the Neurosciences, and Department of Neurology (S.G.), University of California San Francisco; Department of Neurology (S.A., E.L.G.), Northwestern University, Chicago, IL; Department of Neurology (R. Brandstadter, D.A.J., V.Z., L.Z.), Hospital of the University of Pennsylvania, Philadelphia; Corinne Goldsmith Dickinson Center for MS (M.T.F., I.B.K.S., A.K., J.P., S.S., E.V.), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; Brigham and Women's Hospital (S.H., M.K.H.), Boston, MA; University of Texas Southwestern Medical Center (L.H., L.T.), Dallas; Center for Translational and Computational Neuroimmunology and Multiple Sclerosis Center (L.L., C.R.), Department of Neurology, Columbia University Irving Medical Center, New York, NY; Family Health Care Nursing Department (M.M.), School of Nursing, University of California San Francisco; North Texas Institute of Neurology and Headache (A.F.O.), Frisco; University of Southern California (V.V.), Los Angeles; and Joi Life Wellness Group (M.J.W.), Multiple Sclerosis Center, Smyrna, GA
| | - Amit Kohli
- From the University of California San Francisco (A.M.R.); Department of Neurology (L.A.), University of Southern California, Los Angeles; Department of Neurology (A.A., S.P., R. Bove), UCSF Weill Institute for the Neurosciences, and Department of Neurology (S.G.), University of California San Francisco; Department of Neurology (S.A., E.L.G.), Northwestern University, Chicago, IL; Department of Neurology (R. Brandstadter, D.A.J., V.Z., L.Z.), Hospital of the University of Pennsylvania, Philadelphia; Corinne Goldsmith Dickinson Center for MS (M.T.F., I.B.K.S., A.K., J.P., S.S., E.V.), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; Brigham and Women's Hospital (S.H., M.K.H.), Boston, MA; University of Texas Southwestern Medical Center (L.H., L.T.), Dallas; Center for Translational and Computational Neuroimmunology and Multiple Sclerosis Center (L.L., C.R.), Department of Neurology, Columbia University Irving Medical Center, New York, NY; Family Health Care Nursing Department (M.M.), School of Nursing, University of California San Francisco; North Texas Institute of Neurology and Headache (A.F.O.), Frisco; University of Southern California (V.V.), Los Angeles; and Joi Life Wellness Group (M.J.W.), Multiple Sclerosis Center, Smyrna, GA
| | - Libby Levine
- From the University of California San Francisco (A.M.R.); Department of Neurology (L.A.), University of Southern California, Los Angeles; Department of Neurology (A.A., S.P., R. Bove), UCSF Weill Institute for the Neurosciences, and Department of Neurology (S.G.), University of California San Francisco; Department of Neurology (S.A., E.L.G.), Northwestern University, Chicago, IL; Department of Neurology (R. Brandstadter, D.A.J., V.Z., L.Z.), Hospital of the University of Pennsylvania, Philadelphia; Corinne Goldsmith Dickinson Center for MS (M.T.F., I.B.K.S., A.K., J.P., S.S., E.V.), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; Brigham and Women's Hospital (S.H., M.K.H.), Boston, MA; University of Texas Southwestern Medical Center (L.H., L.T.), Dallas; Center for Translational and Computational Neuroimmunology and Multiple Sclerosis Center (L.L., C.R.), Department of Neurology, Columbia University Irving Medical Center, New York, NY; Family Health Care Nursing Department (M.M.), School of Nursing, University of California San Francisco; North Texas Institute of Neurology and Headache (A.F.O.), Frisco; University of Southern California (V.V.), Los Angeles; and Joi Life Wellness Group (M.J.W.), Multiple Sclerosis Center, Smyrna, GA
| | - Monica McLemore
- From the University of California San Francisco (A.M.R.); Department of Neurology (L.A.), University of Southern California, Los Angeles; Department of Neurology (A.A., S.P., R. Bove), UCSF Weill Institute for the Neurosciences, and Department of Neurology (S.G.), University of California San Francisco; Department of Neurology (S.A., E.L.G.), Northwestern University, Chicago, IL; Department of Neurology (R. Brandstadter, D.A.J., V.Z., L.Z.), Hospital of the University of Pennsylvania, Philadelphia; Corinne Goldsmith Dickinson Center for MS (M.T.F., I.B.K.S., A.K., J.P., S.S., E.V.), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; Brigham and Women's Hospital (S.H., M.K.H.), Boston, MA; University of Texas Southwestern Medical Center (L.H., L.T.), Dallas; Center for Translational and Computational Neuroimmunology and Multiple Sclerosis Center (L.L., C.R.), Department of Neurology, Columbia University Irving Medical Center, New York, NY; Family Health Care Nursing Department (M.M.), School of Nursing, University of California San Francisco; North Texas Institute of Neurology and Headache (A.F.O.), Frisco; University of Southern California (V.V.), Los Angeles; and Joi Life Wellness Group (M.J.W.), Multiple Sclerosis Center, Smyrna, GA
| | - Annette F Okai
- From the University of California San Francisco (A.M.R.); Department of Neurology (L.A.), University of Southern California, Los Angeles; Department of Neurology (A.A., S.P., R. Bove), UCSF Weill Institute for the Neurosciences, and Department of Neurology (S.G.), University of California San Francisco; Department of Neurology (S.A., E.L.G.), Northwestern University, Chicago, IL; Department of Neurology (R. Brandstadter, D.A.J., V.Z., L.Z.), Hospital of the University of Pennsylvania, Philadelphia; Corinne Goldsmith Dickinson Center for MS (M.T.F., I.B.K.S., A.K., J.P., S.S., E.V.), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; Brigham and Women's Hospital (S.H., M.K.H.), Boston, MA; University of Texas Southwestern Medical Center (L.H., L.T.), Dallas; Center for Translational and Computational Neuroimmunology and Multiple Sclerosis Center (L.L., C.R.), Department of Neurology, Columbia University Irving Medical Center, New York, NY; Family Health Care Nursing Department (M.M.), School of Nursing, University of California San Francisco; North Texas Institute of Neurology and Headache (A.F.O.), Frisco; University of Southern California (V.V.), Los Angeles; and Joi Life Wellness Group (M.J.W.), Multiple Sclerosis Center, Smyrna, GA
| | - Jasmin Patel
- From the University of California San Francisco (A.M.R.); Department of Neurology (L.A.), University of Southern California, Los Angeles; Department of Neurology (A.A., S.P., R. Bove), UCSF Weill Institute for the Neurosciences, and Department of Neurology (S.G.), University of California San Francisco; Department of Neurology (S.A., E.L.G.), Northwestern University, Chicago, IL; Department of Neurology (R. Brandstadter, D.A.J., V.Z., L.Z.), Hospital of the University of Pennsylvania, Philadelphia; Corinne Goldsmith Dickinson Center for MS (M.T.F., I.B.K.S., A.K., J.P., S.S., E.V.), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; Brigham and Women's Hospital (S.H., M.K.H.), Boston, MA; University of Texas Southwestern Medical Center (L.H., L.T.), Dallas; Center for Translational and Computational Neuroimmunology and Multiple Sclerosis Center (L.L., C.R.), Department of Neurology, Columbia University Irving Medical Center, New York, NY; Family Health Care Nursing Department (M.M.), School of Nursing, University of California San Francisco; North Texas Institute of Neurology and Headache (A.F.O.), Frisco; University of Southern California (V.V.), Los Angeles; and Joi Life Wellness Group (M.J.W.), Multiple Sclerosis Center, Smyrna, GA
| | - Shane Poole
- From the University of California San Francisco (A.M.R.); Department of Neurology (L.A.), University of Southern California, Los Angeles; Department of Neurology (A.A., S.P., R. Bove), UCSF Weill Institute for the Neurosciences, and Department of Neurology (S.G.), University of California San Francisco; Department of Neurology (S.A., E.L.G.), Northwestern University, Chicago, IL; Department of Neurology (R. Brandstadter, D.A.J., V.Z., L.Z.), Hospital of the University of Pennsylvania, Philadelphia; Corinne Goldsmith Dickinson Center for MS (M.T.F., I.B.K.S., A.K., J.P., S.S., E.V.), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; Brigham and Women's Hospital (S.H., M.K.H.), Boston, MA; University of Texas Southwestern Medical Center (L.H., L.T.), Dallas; Center for Translational and Computational Neuroimmunology and Multiple Sclerosis Center (L.L., C.R.), Department of Neurology, Columbia University Irving Medical Center, New York, NY; Family Health Care Nursing Department (M.M.), School of Nursing, University of California San Francisco; North Texas Institute of Neurology and Headache (A.F.O.), Frisco; University of Southern California (V.V.), Los Angeles; and Joi Life Wellness Group (M.J.W.), Multiple Sclerosis Center, Smyrna, GA
| | - Claire Riley
- From the University of California San Francisco (A.M.R.); Department of Neurology (L.A.), University of Southern California, Los Angeles; Department of Neurology (A.A., S.P., R. Bove), UCSF Weill Institute for the Neurosciences, and Department of Neurology (S.G.), University of California San Francisco; Department of Neurology (S.A., E.L.G.), Northwestern University, Chicago, IL; Department of Neurology (R. Brandstadter, D.A.J., V.Z., L.Z.), Hospital of the University of Pennsylvania, Philadelphia; Corinne Goldsmith Dickinson Center for MS (M.T.F., I.B.K.S., A.K., J.P., S.S., E.V.), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; Brigham and Women's Hospital (S.H., M.K.H.), Boston, MA; University of Texas Southwestern Medical Center (L.H., L.T.), Dallas; Center for Translational and Computational Neuroimmunology and Multiple Sclerosis Center (L.L., C.R.), Department of Neurology, Columbia University Irving Medical Center, New York, NY; Family Health Care Nursing Department (M.M.), School of Nursing, University of California San Francisco; North Texas Institute of Neurology and Headache (A.F.O.), Frisco; University of Southern California (V.V.), Los Angeles; and Joi Life Wellness Group (M.J.W.), Multiple Sclerosis Center, Smyrna, GA
| | - Sammita Satyanarayan
- From the University of California San Francisco (A.M.R.); Department of Neurology (L.A.), University of Southern California, Los Angeles; Department of Neurology (A.A., S.P., R. Bove), UCSF Weill Institute for the Neurosciences, and Department of Neurology (S.G.), University of California San Francisco; Department of Neurology (S.A., E.L.G.), Northwestern University, Chicago, IL; Department of Neurology (R. Brandstadter, D.A.J., V.Z., L.Z.), Hospital of the University of Pennsylvania, Philadelphia; Corinne Goldsmith Dickinson Center for MS (M.T.F., I.B.K.S., A.K., J.P., S.S., E.V.), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; Brigham and Women's Hospital (S.H., M.K.H.), Boston, MA; University of Texas Southwestern Medical Center (L.H., L.T.), Dallas; Center for Translational and Computational Neuroimmunology and Multiple Sclerosis Center (L.L., C.R.), Department of Neurology, Columbia University Irving Medical Center, New York, NY; Family Health Care Nursing Department (M.M.), School of Nursing, University of California San Francisco; North Texas Institute of Neurology and Headache (A.F.O.), Frisco; University of Southern California (V.V.), Los Angeles; and Joi Life Wellness Group (M.J.W.), Multiple Sclerosis Center, Smyrna, GA
| | - Lauren Tardo
- From the University of California San Francisco (A.M.R.); Department of Neurology (L.A.), University of Southern California, Los Angeles; Department of Neurology (A.A., S.P., R. Bove), UCSF Weill Institute for the Neurosciences, and Department of Neurology (S.G.), University of California San Francisco; Department of Neurology (S.A., E.L.G.), Northwestern University, Chicago, IL; Department of Neurology (R. Brandstadter, D.A.J., V.Z., L.Z.), Hospital of the University of Pennsylvania, Philadelphia; Corinne Goldsmith Dickinson Center for MS (M.T.F., I.B.K.S., A.K., J.P., S.S., E.V.), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; Brigham and Women's Hospital (S.H., M.K.H.), Boston, MA; University of Texas Southwestern Medical Center (L.H., L.T.), Dallas; Center for Translational and Computational Neuroimmunology and Multiple Sclerosis Center (L.L., C.R.), Department of Neurology, Columbia University Irving Medical Center, New York, NY; Family Health Care Nursing Department (M.M.), School of Nursing, University of California San Francisco; North Texas Institute of Neurology and Headache (A.F.O.), Frisco; University of Southern California (V.V.), Los Angeles; and Joi Life Wellness Group (M.J.W.), Multiple Sclerosis Center, Smyrna, GA
| | - Elizabeth Verter
- From the University of California San Francisco (A.M.R.); Department of Neurology (L.A.), University of Southern California, Los Angeles; Department of Neurology (A.A., S.P., R. Bove), UCSF Weill Institute for the Neurosciences, and Department of Neurology (S.G.), University of California San Francisco; Department of Neurology (S.A., E.L.G.), Northwestern University, Chicago, IL; Department of Neurology (R. Brandstadter, D.A.J., V.Z., L.Z.), Hospital of the University of Pennsylvania, Philadelphia; Corinne Goldsmith Dickinson Center for MS (M.T.F., I.B.K.S., A.K., J.P., S.S., E.V.), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; Brigham and Women's Hospital (S.H., M.K.H.), Boston, MA; University of Texas Southwestern Medical Center (L.H., L.T.), Dallas; Center for Translational and Computational Neuroimmunology and Multiple Sclerosis Center (L.L., C.R.), Department of Neurology, Columbia University Irving Medical Center, New York, NY; Family Health Care Nursing Department (M.M.), School of Nursing, University of California San Francisco; North Texas Institute of Neurology and Headache (A.F.O.), Frisco; University of Southern California (V.V.), Los Angeles; and Joi Life Wellness Group (M.J.W.), Multiple Sclerosis Center, Smyrna, GA
| | - Veronica Villacorta
- From the University of California San Francisco (A.M.R.); Department of Neurology (L.A.), University of Southern California, Los Angeles; Department of Neurology (A.A., S.P., R. Bove), UCSF Weill Institute for the Neurosciences, and Department of Neurology (S.G.), University of California San Francisco; Department of Neurology (S.A., E.L.G.), Northwestern University, Chicago, IL; Department of Neurology (R. Brandstadter, D.A.J., V.Z., L.Z.), Hospital of the University of Pennsylvania, Philadelphia; Corinne Goldsmith Dickinson Center for MS (M.T.F., I.B.K.S., A.K., J.P., S.S., E.V.), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; Brigham and Women's Hospital (S.H., M.K.H.), Boston, MA; University of Texas Southwestern Medical Center (L.H., L.T.), Dallas; Center for Translational and Computational Neuroimmunology and Multiple Sclerosis Center (L.L., C.R.), Department of Neurology, Columbia University Irving Medical Center, New York, NY; Family Health Care Nursing Department (M.M.), School of Nursing, University of California San Francisco; North Texas Institute of Neurology and Headache (A.F.O.), Frisco; University of Southern California (V.V.), Los Angeles; and Joi Life Wellness Group (M.J.W.), Multiple Sclerosis Center, Smyrna, GA
| | - Vanessa Zimmerman
- From the University of California San Francisco (A.M.R.); Department of Neurology (L.A.), University of Southern California, Los Angeles; Department of Neurology (A.A., S.P., R. Bove), UCSF Weill Institute for the Neurosciences, and Department of Neurology (S.G.), University of California San Francisco; Department of Neurology (S.A., E.L.G.), Northwestern University, Chicago, IL; Department of Neurology (R. Brandstadter, D.A.J., V.Z., L.Z.), Hospital of the University of Pennsylvania, Philadelphia; Corinne Goldsmith Dickinson Center for MS (M.T.F., I.B.K.S., A.K., J.P., S.S., E.V.), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; Brigham and Women's Hospital (S.H., M.K.H.), Boston, MA; University of Texas Southwestern Medical Center (L.H., L.T.), Dallas; Center for Translational and Computational Neuroimmunology and Multiple Sclerosis Center (L.L., C.R.), Department of Neurology, Columbia University Irving Medical Center, New York, NY; Family Health Care Nursing Department (M.M.), School of Nursing, University of California San Francisco; North Texas Institute of Neurology and Headache (A.F.O.), Frisco; University of Southern California (V.V.), Los Angeles; and Joi Life Wellness Group (M.J.W.), Multiple Sclerosis Center, Smyrna, GA
| | - Leah Zuroff
- From the University of California San Francisco (A.M.R.); Department of Neurology (L.A.), University of Southern California, Los Angeles; Department of Neurology (A.A., S.P., R. Bove), UCSF Weill Institute for the Neurosciences, and Department of Neurology (S.G.), University of California San Francisco; Department of Neurology (S.A., E.L.G.), Northwestern University, Chicago, IL; Department of Neurology (R. Brandstadter, D.A.J., V.Z., L.Z.), Hospital of the University of Pennsylvania, Philadelphia; Corinne Goldsmith Dickinson Center for MS (M.T.F., I.B.K.S., A.K., J.P., S.S., E.V.), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; Brigham and Women's Hospital (S.H., M.K.H.), Boston, MA; University of Texas Southwestern Medical Center (L.H., L.T.), Dallas; Center for Translational and Computational Neuroimmunology and Multiple Sclerosis Center (L.L., C.R.), Department of Neurology, Columbia University Irving Medical Center, New York, NY; Family Health Care Nursing Department (M.M.), School of Nursing, University of California San Francisco; North Texas Institute of Neurology and Headache (A.F.O.), Frisco; University of Southern California (V.V.), Los Angeles; and Joi Life Wellness Group (M.J.W.), Multiple Sclerosis Center, Smyrna, GA
| | - Mitzi J Williams
- From the University of California San Francisco (A.M.R.); Department of Neurology (L.A.), University of Southern California, Los Angeles; Department of Neurology (A.A., S.P., R. Bove), UCSF Weill Institute for the Neurosciences, and Department of Neurology (S.G.), University of California San Francisco; Department of Neurology (S.A., E.L.G.), Northwestern University, Chicago, IL; Department of Neurology (R. Brandstadter, D.A.J., V.Z., L.Z.), Hospital of the University of Pennsylvania, Philadelphia; Corinne Goldsmith Dickinson Center for MS (M.T.F., I.B.K.S., A.K., J.P., S.S., E.V.), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; Brigham and Women's Hospital (S.H., M.K.H.), Boston, MA; University of Texas Southwestern Medical Center (L.H., L.T.), Dallas; Center for Translational and Computational Neuroimmunology and Multiple Sclerosis Center (L.L., C.R.), Department of Neurology, Columbia University Irving Medical Center, New York, NY; Family Health Care Nursing Department (M.M.), School of Nursing, University of California San Francisco; North Texas Institute of Neurology and Headache (A.F.O.), Frisco; University of Southern California (V.V.), Los Angeles; and Joi Life Wellness Group (M.J.W.), Multiple Sclerosis Center, Smyrna, GA
| | - Maria K Houtchens
- From the University of California San Francisco (A.M.R.); Department of Neurology (L.A.), University of Southern California, Los Angeles; Department of Neurology (A.A., S.P., R. Bove), UCSF Weill Institute for the Neurosciences, and Department of Neurology (S.G.), University of California San Francisco; Department of Neurology (S.A., E.L.G.), Northwestern University, Chicago, IL; Department of Neurology (R. Brandstadter, D.A.J., V.Z., L.Z.), Hospital of the University of Pennsylvania, Philadelphia; Corinne Goldsmith Dickinson Center for MS (M.T.F., I.B.K.S., A.K., J.P., S.S., E.V.), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; Brigham and Women's Hospital (S.H., M.K.H.), Boston, MA; University of Texas Southwestern Medical Center (L.H., L.T.), Dallas; Center for Translational and Computational Neuroimmunology and Multiple Sclerosis Center (L.L., C.R.), Department of Neurology, Columbia University Irving Medical Center, New York, NY; Family Health Care Nursing Department (M.M.), School of Nursing, University of California San Francisco; North Texas Institute of Neurology and Headache (A.F.O.), Frisco; University of Southern California (V.V.), Los Angeles; and Joi Life Wellness Group (M.J.W.), Multiple Sclerosis Center, Smyrna, GA
| | - Riley Bove
- From the University of California San Francisco (A.M.R.); Department of Neurology (L.A.), University of Southern California, Los Angeles; Department of Neurology (A.A., S.P., R. Bove), UCSF Weill Institute for the Neurosciences, and Department of Neurology (S.G.), University of California San Francisco; Department of Neurology (S.A., E.L.G.), Northwestern University, Chicago, IL; Department of Neurology (R. Brandstadter, D.A.J., V.Z., L.Z.), Hospital of the University of Pennsylvania, Philadelphia; Corinne Goldsmith Dickinson Center for MS (M.T.F., I.B.K.S., A.K., J.P., S.S., E.V.), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; Brigham and Women's Hospital (S.H., M.K.H.), Boston, MA; University of Texas Southwestern Medical Center (L.H., L.T.), Dallas; Center for Translational and Computational Neuroimmunology and Multiple Sclerosis Center (L.L., C.R.), Department of Neurology, Columbia University Irving Medical Center, New York, NY; Family Health Care Nursing Department (M.M.), School of Nursing, University of California San Francisco; North Texas Institute of Neurology and Headache (A.F.O.), Frisco; University of Southern California (V.V.), Los Angeles; and Joi Life Wellness Group (M.J.W.), Multiple Sclerosis Center, Smyrna, GA
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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: 3] [Impact Index Per Article: 3.0] [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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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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8
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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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9
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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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10
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Hellwig K, Tokic M, Thiel S, Hemat S, Timmesfeld N, Ciplea AI, Gold R, Langer-Gould AM. Multiple Sclerosis Disease Activity and Disability Following Cessation of Fingolimod for Pregnancy. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2023; 10:10/4/e200110. [PMID: 37217309 DOI: 10.1212/nxi.0000000000200110] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 02/08/2023] [Indexed: 05/24/2023]
Abstract
BACKGROUND AND OBJECTIVE Discontinuation of fingolimod ≥2 months before pregnancy is recommended to minimize potential teratogenicity. The magnitude of MS pregnancy relapse risk, particularly severe relapses, after fingolimod cessation is unclear, as is whether this risk is reduced by pregnancy or modifiable factors. METHODS Pregnancies who stopped fingolimod treatment within 1 year before or during pregnancy were identified from the German MS and Pregnancy Registry. Data were collected through structured telephone-administered questionnaires and neurologists' notes. Severe relapses were defined as a ≥2.0 increase in Expanded Disability Status Scale (EDSS) or new or worsening relapse-related ambulatory impairment. Women who continued to meet this definition 1 year postpartum were classified as reaching the Severe Relapse Disability Composite Score (SRDCS). Multivariable models accounting for measures of disease severity and repeated events were used. RESULTS Of the 213 pregnancies among 201 women (mean age at pregnancy onset 32 years) identified, 56.81% (n = 121) discontinued fingolimod after conception. Relapses during pregnancy (31.46%) and the postpartum year (44.60%) were common. Nine pregnancies had a severe relapse during pregnancy and additional 3 during the postpartum year. One year postpartum, 11 of these (6.32% of n = 174 with complete EDSS information) reached the SRDCS. Adjusted relapse rates during pregnancy were slightly higher compared with the year before pregnancy (relapse rate ratio = 1.24, 95% CI 0.91-1.68). Neither exclusive breastfeeding nor resuming fingolimod within 4 weeks of delivery were associated with a reduced risk of postpartum relapses. Most pregnancies relapsed during the first 3 months postpartum (n = 55/204, 26.96%). DISCUSSION Relapses during pregnancy after fingolimod cessation are common. Approximately 6% of women will retain clinically meaningful disability from these pregnancy-related, fingolimod cessation relapses 1 year postpartum. This information should be shared with women on fingolimod desiring pregnancy, and optimizing MS treatment with nonteratogenic approaches should be discussed.
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Affiliation(s)
- Kerstin Hellwig
- From the Department of Neurology (K.H., S.T., S.H., A.I.C., R.G.), St. Josef-Hospital-Katholisches Klinikum Bochum, Ruhr University Bochum; Department of Medical Informatics (M.T., N.T.), Biometry and Epidemiology, Ruhr University Bochum, Germany; Department of Neurology (A.M.L.-G.), Los Angeles Medical Center, Southern California Permanente Medical Group.
| | - Marianne Tokic
- From the Department of Neurology (K.H., S.T., S.H., A.I.C., R.G.), St. Josef-Hospital-Katholisches Klinikum Bochum, Ruhr University Bochum; Department of Medical Informatics (M.T., N.T.), Biometry and Epidemiology, Ruhr University Bochum, Germany; Department of Neurology (A.M.L.-G.), Los Angeles Medical Center, Southern California Permanente Medical Group
| | - Sandra Thiel
- From the Department of Neurology (K.H., S.T., S.H., A.I.C., R.G.), St. Josef-Hospital-Katholisches Klinikum Bochum, Ruhr University Bochum; Department of Medical Informatics (M.T., N.T.), Biometry and Epidemiology, Ruhr University Bochum, Germany; Department of Neurology (A.M.L.-G.), Los Angeles Medical Center, Southern California Permanente Medical Group
| | - Spalmai Hemat
- From the Department of Neurology (K.H., S.T., S.H., A.I.C., R.G.), St. Josef-Hospital-Katholisches Klinikum Bochum, Ruhr University Bochum; Department of Medical Informatics (M.T., N.T.), Biometry and Epidemiology, Ruhr University Bochum, Germany; Department of Neurology (A.M.L.-G.), Los Angeles Medical Center, Southern California Permanente Medical Group
| | - Nina Timmesfeld
- From the Department of Neurology (K.H., S.T., S.H., A.I.C., R.G.), St. Josef-Hospital-Katholisches Klinikum Bochum, Ruhr University Bochum; Department of Medical Informatics (M.T., N.T.), Biometry and Epidemiology, Ruhr University Bochum, Germany; Department of Neurology (A.M.L.-G.), Los Angeles Medical Center, Southern California Permanente Medical Group
| | - Andrea I Ciplea
- From the Department of Neurology (K.H., S.T., S.H., A.I.C., R.G.), St. Josef-Hospital-Katholisches Klinikum Bochum, Ruhr University Bochum; Department of Medical Informatics (M.T., N.T.), Biometry and Epidemiology, Ruhr University Bochum, Germany; Department of Neurology (A.M.L.-G.), Los Angeles Medical Center, Southern California Permanente Medical Group
| | - Ralf Gold
- From the Department of Neurology (K.H., S.T., S.H., A.I.C., R.G.), St. Josef-Hospital-Katholisches Klinikum Bochum, Ruhr University Bochum; Department of Medical Informatics (M.T., N.T.), Biometry and Epidemiology, Ruhr University Bochum, Germany; Department of Neurology (A.M.L.-G.), Los Angeles Medical Center, Southern California Permanente Medical Group
| | - Annette M Langer-Gould
- From the Department of Neurology (K.H., S.T., S.H., A.I.C., R.G.), St. Josef-Hospital-Katholisches Klinikum Bochum, Ruhr University Bochum; Department of Medical Informatics (M.T., N.T.), Biometry and Epidemiology, Ruhr University Bochum, Germany; Department of Neurology (A.M.L.-G.), Los Angeles Medical Center, Southern California Permanente Medical Group
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11
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Krysko KM, Dobson R, Alroughani R, Amato MP, Bove R, Ciplea AI, Fragoso Y, Houtchens M, Jokubaitis VG, Magyari M, Abdelnasser A, Padma V, Thiel S, Tintore M, Vukusic S, Hellwig K. Family planning considerations in people with multiple sclerosis. Lancet Neurol 2023; 22:350-366. [PMID: 36931808 DOI: 10.1016/s1474-4422(22)00426-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 09/16/2022] [Accepted: 10/07/2022] [Indexed: 03/17/2023]
Abstract
Multiple sclerosis is often diagnosed in patients who are planning on having children. Although multiple sclerosis does not negatively influence most pregnancy outcomes, less is known regarding the effects of fetal exposure to novel disease-modifying therapies (DMTs). The withdrawal of some DMTs during pregnancy can modify the natural history of multiple sclerosis, resulting in a substantial risk of pregnancy-related relapse and disability. Drug labels are typically restrictive and favour fetal safety over maternal safety. Emerging data reporting outcomes in neonates exposed to DMTs in utero and through breastfeeding will allow for more careful and individualised treatment decisions. This emerging research is particularly important to guide decision making in women with high disease activity or who are treated with DMTs associated with risk of discontinuation rebound. As increasing data are generated in this field, periodic updates will be required to provide the most up to date guidance on how best to achieve multiple sclerosis stability during pregnancy and post partum, balanced with fetal and newborn safety.
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Affiliation(s)
- Kristen M Krysko
- Division of Neurology, Department of Medicine, St Michael's Hospital, University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, Toronto, ON, Canada
| | - Ruth Dobson
- Preventive Neurology Unit, Wolfson Institute of Population Health, Queen Mary University London, London, UK; Department of Neurology, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Raed Alroughani
- Department of Medicine, Division of Neurology, Amiri Hospital, Sharq, Kuwait
| | - Maria Pia Amato
- Department NEUROFARBA, Section of Neurosciences, University of Florence, Florence, Italy; IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy
| | - Riley Bove
- UCSF Weill Institute for Neuroscience, Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - Andrea I Ciplea
- Department of Neurology, Katholisches Klinikum, Ruhr University Bochum, Bochum, Germany
| | - Yara Fragoso
- Multiple Sclerosis and Headache Research Institute, Santos, Brazil; Departamento de Neurologia, Universidade Metropolitana de Santos, Santos, Brazil
| | - Maria Houtchens
- Department of Neurology, Partners MS Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Vilija G Jokubaitis
- Department of Neuroscience, Monash University, Melbourne, VIC, Australia; Department of Neurology, Alfred Health, Melbourne, VIC, Australia
| | - Melinda Magyari
- Danish Multiple Sclerosis Center, Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Azza Abdelnasser
- Department of Neurology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Vasantha Padma
- Department of Neurology, Neurosciences Center, AIIMS, New Delhi, India
| | - Sandra Thiel
- Department of Neurology, Katholisches Klinikum, Ruhr University Bochum, Bochum, Germany
| | - Mar Tintore
- Department of Neurology-Neuroimmunology, Multiple Sclerosis Centre of Catalonia, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Sandra Vukusic
- Hospices Civils de Lyon, Hôpital Neurologique Pierre Wertheimer, Service de Neurologie, sclérose en plaques, pathologies de la myéline et neuro-inflammation, Bron, France; Centre de Recherche en Neurosciences de Lyon, Observatoire Français de la Sclérose en Plaques, INSERM 1028 et CNRS UMR 5292, Lyon, France; Université Claude Bernard Lyon 1, Université de Lyon, Lyon, France; Eugène Devic EDMUS Foundation against multiple sclerosis, state-approved foundation, Bron, France
| | - Kerstin Hellwig
- Department of Neurology, Katholisches Klinikum, Ruhr University Bochum, Bochum, Germany.
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12
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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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14
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Eid K, Torkildsen Ø, Aarseth J, Celius EG, Cortese M, Holmøy T, Kapali A, Myhr KM, Torkildsen CF, Wergeland S, Gilhus NE, Bjørk MH. Abuse and revictimization in adulthood in multiple sclerosis: a cross-sectional study during pregnancy. J Neurol 2022; 269:5901-5909. [PMID: 35780399 PMCID: PMC9553842 DOI: 10.1007/s00415-022-11249-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 06/17/2022] [Accepted: 06/20/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Knowledge concerning exposure to abuse in adulthood and in pregnancy in people with multiple sclerosis (MS) is sparse. OBJECTIVE To determine the occurrence of adult abuse and abuse in relation to pregnancy in women with MS and their risk of revictimization (repeated abuse as adults after childhood abuse). METHODS This cross-sectional study comprised pregnant women from the Norwegian Mother, Father and Child Cohort study. Information on abuse was acquired through self-completed questionnaires. We used logistic regression to estimate adjusted odds ratios (aORs) with 95% confidence intervals (CIs). RESULTS We identified 106 women with MS at enrollment through linkage with national health registries. The reference group consisted of 77,278 women without MS. Twenty-seven women (26%) with MS reported any adult abuse compared to 15,491 women (20%) without MS, aOR 1.33 (0.85-2.09). Twenty-two (21%) women with MS reported systematic emotional abuse compared to 13% without MS, aOR 1.75 (1.08-2.83). Ten women (10%) with MS reported sexual abuse, compared to 6% without MS, aOR 1.72 (0.89-3.33). More women with MS reported rape as an adult, aOR 2.37 (1.02-5.49). Women with MS had higher risk of revictimization as adults, after childhood abuse, aOR 2.23 (1.22-4.10). The risk of abuse during pregnancy or 6 months preceding pregnancy was similar between the groups. CONCLUSIONS Women with MS had increased occurrence of systematic emotional abuse, rape, and revictimization as adults, compared to women without MS.
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Affiliation(s)
- Karine Eid
- Department of Neurology, Haukeland University Hospital, Jonas Lies vei 71, 5053, Bergen, Norway.
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Øivind Torkildsen
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Neurology, Neuro-SysMed, Haukeland University Hospital, Bergen, Norway
| | - Jan Aarseth
- Department of Neurology, Neuro-SysMed, Haukeland University Hospital, Bergen, Norway
- The Norwegian Multiple Sclerosis Registry and Biobank, Haukeland University Hospital, Bergen, Norway
| | - Elisabeth G Celius
- Department of Neurology, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Marianna Cortese
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Trygve Holmøy
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway
| | - Akash Kapali
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Kjell-Morten Myhr
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Neurology, Neuro-SysMed, Haukeland University Hospital, Bergen, Norway
| | - Cecilie F Torkildsen
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Obstetrics and Gynecology, Stavanger University Hospital, Stavanger, Norway
| | - Stig Wergeland
- Department of Neurology, Neuro-SysMed, Haukeland University Hospital, Bergen, Norway
- The Norwegian Multiple Sclerosis Registry and Biobank, Haukeland University Hospital, Bergen, Norway
| | - Nils Erik Gilhus
- Department of Neurology, Haukeland University Hospital, Jonas Lies vei 71, 5053, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Marte-Helene Bjørk
- Department of Neurology, Haukeland University Hospital, Jonas Lies vei 71, 5053, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
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15
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Ramesh V, Opara CO, Khan FY, Kabiraj G, Kauser H, Palakeel JJ, Ali M, Chaduvula P, Chhabra S, Lamsal Lamichhane S, Khan S. Adverse Obstetric Outcomes in Pregnant Women Using Natalizumab for the Treatment of Multiple Sclerosis: A Systematic Review. Cureus 2022; 14:e29952. [PMID: 36381897 PMCID: PMC9635932 DOI: 10.7759/cureus.29952] [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: 07/23/2022] [Accepted: 10/05/2022] [Indexed: 11/07/2022] Open
Abstract
Multiple sclerosis is a common disease in women of childbearing age, characterized by demyelination of the central nervous system. Among the different treatment options available, disease-modifying therapies (DMTs) are the most efficacious, and natalizumab (NAT) is an injectable DMT best for relapsing-remitting multiple sclerosis. However, it comes under pregnancy category C drug classification. This systematic review aims to analyze the adverse outcomes of using NAT during pregnancy. PubMed/Medline, PubMed Central (PMC), ScienceDirect, and Google Scholar were the databases used to search for articles. Appropriate keywords and Medical Subject Headings (MeSH) strategy were used to identify relevant articles. Articles were then screened using inclusion/exclusion criteria followed by the title and abstract screening. The Joanna Briggs Institute (JBI) quality appraisal tools were used for quality check, and nine articles were finalized for review. NAT suspension during pregnancy is shown to have a high risk of disease relapse. Despite the risk of mild hematological abnormalities in the newborn and the risk of spontaneous abortions at the same rate as that of the general population, NAT use can be considered safe in pregnancy. These adverse outcomes can be minimized by strict monitoring of patients. Studies of better quality with larger sample sizes are needed for further investigation.
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16
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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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17
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Hernández-Preciado MR, Marquez-Pedroza J, Sánchez-Rosales NA, García-Rivera JDJ, Kobayashi-Gutiérrez A, Torres-Mendoza BM, Chavarría-Avila E, Montaño-Serrano RA, Cortes-Enriquez F, Mireles-Ramírez MA. Effect of Rituximab Compared with Natalizumab and Fingolimod in Patients with Relapsing-Remitting Multiple Sclerosis: A Cohort Study. J Clin Med 2022; 11:jcm11133584. [PMID: 35806869 PMCID: PMC9267823 DOI: 10.3390/jcm11133584] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 06/16/2022] [Accepted: 06/20/2022] [Indexed: 02/01/2023] Open
Abstract
The objective of this study was to evaluate the clinical files of patients with RRMS who started rituximab (RTX) compared with a second-line treatment (natalizumab (NTZ) or fingolimod (FTY)). This was a historical cohort study. We compared the effect according to the Expanded Disability Status Scale (EDSS) and the number of relapses in RRMS patients receiving these treatments after a mean period of 12 months. We found a statistically significant difference (p < 0.001) when comparing the EDSS scores and the annual relapse rates of patients receiving RTX with those receiving NTZ or FTY. This study is essential for our clinical practice, since patients with limited treatment options represent a challenge with regard to the management of their medical care. However, clinical trials and prospective studies with long follow-up periods are necessary to provide sufficient evidence on the efficacy of RTX and thus include this treatment in the therapeutic profile of patients with MS.
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Affiliation(s)
- Martha Rocio Hernández-Preciado
- High Specialty Medical Unit, Western National Medical Center of the Mexican Institute of Social Security, Guadalajara 44340, Mexico
- Neurosciences Division, Western Biomedical Research Center (IMSS), Guadalajara 44340, Mexico
| | - Jazmin Marquez-Pedroza
- High Specialty Medical Unit, Western National Medical Center of the Mexican Institute of Social Security, Guadalajara 44340, Mexico
| | - Nayeli Alejandra Sánchez-Rosales
- High Specialty Medical Unit, Western National Medical Center of the Mexican Institute of Social Security, Guadalajara 44340, Mexico
| | - José de Jesús García-Rivera
- High Specialty Medical Unit, Western National Medical Center of the Mexican Institute of Social Security, Guadalajara 44340, Mexico
| | - Antonio Kobayashi-Gutiérrez
- High Specialty Medical Unit, Western National Medical Center of the Mexican Institute of Social Security, Guadalajara 44340, Mexico
| | - Blanca Miriam Torres-Mendoza
- Neurosciences Division, Western Biomedical Research Center (IMSS), Guadalajara 44340, Mexico
- Department of Philosophical and Methodological Disciplines, University Health Sciences Center, University of Guadalajara, Guadalajara 44340, Mexico
| | - Efraín Chavarría-Avila
- Department of Philosophical and Methodological Disciplines, University Health Sciences Center, University of Guadalajara, Guadalajara 44340, Mexico
| | | | - Fernando Cortes-Enriquez
- Department of Neurology, Hospital General Regional No 45 of the Mexican Institute of Social Security, Guadalajara 44910, Mexico
| | - Mario Alberto Mireles-Ramírez
- High Specialty Medical Unit, Western National Medical Center of the Mexican Institute of Social Security, Guadalajara 44340, Mexico
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18
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Krajnc N, Bsteh G, Berger T, Mares J, Hartung HP. Monoclonal Antibodies in the Treatment of Relapsing Multiple Sclerosis: an Overview with Emphasis on Pregnancy, Vaccination, and Risk Management. Neurotherapeutics 2022; 19:753-773. [PMID: 35378683 PMCID: PMC8978776 DOI: 10.1007/s13311-022-01224-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2022] [Indexed: 01/10/2023] Open
Abstract
Monoclonal antibodies have become a mainstay in the treatment of patients with relapsing multiple sclerosis (RMS) and provide some benefit to patients with primary progressive MS. They are highly precise by specifically targeting molecules displayed on cells involved in distinct immune mechanisms of MS pathophysiology. They not only differ in the target antigen they recognize but also by the mode of action that generates their therapeutic effect. Natalizumab, an [Formula: see text]4[Formula: see text]1 integrin antagonist, works via binding to cell surface receptors, blocking the interaction with their ligands and, in that way, preventing the migration of leukocytes across the blood-brain barrier. On the other hand, the anti-CD52 monoclonal antibody alemtuzumab and the anti-CD20 monoclonal antibodies rituximab, ocrelizumab, ofatumumab, and ublituximab work via eliminating selected pathogenic cell populations. However, potential adverse effects may be serious and can necessitate treatment discontinuation. Most importantly, those are the risk for (opportunistic) infections, but also secondary autoimmune diseases or malignancies. Monoclonal antibodies also carry the risk of infusion/injection-related reactions, primarily in early phases of treatment. By careful patient selection and monitoring during therapy, the occurrence of these potentially serious adverse effects can be minimized. Monoclonal antibodies are characterized by a relatively long pharmacologic half-life and pharmacodynamic effects, which provides advantages such as permitting infrequent dosing, but also creates disadvantages regarding vaccination and family planning. This review presents an overview of currently available monoclonal antibodies for the treatment of RMS, including their mechanism of action, efficacy and safety profile. Furthermore, we provide practical recommendations for risk management, vaccination, and family planning.
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Affiliation(s)
- Nik Krajnc
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Gabriel Bsteh
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Thomas Berger
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Jan Mares
- Department of Neurology, Palacky University Olomouc, Olomouc, Czech Republic
| | - Hans-Peter Hartung
- Department of Neurology, Medical University of Vienna, Vienna, Austria.
- Department of Neurology, Palacky University Olomouc, Olomouc, Czech Republic.
- Department of Neurology, Medical Faculty, Heinrich-Heine University, Moorenstrasse 5, 40225, Düsseldorf, Germany.
- Brain and Mind Center, University of Sydney, Sydney, Australia.
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19
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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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20
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Kopp TI, Lidegaard Ø, Magyari M. Hormone therapy and disease activity in Danish women with multiple sclerosis - a population-based cohort study. Eur J Neurol 2022; 29:1753-1762. [PMID: 35196406 PMCID: PMC9314629 DOI: 10.1111/ene.15299] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 02/03/2022] [Accepted: 02/15/2022] [Indexed: 11/30/2022]
Abstract
Background and purpose Sex differences in multiple sclerosis (MS) prevalence and disease course are thought to be driven by hormones. Exogenous exposure to estrogens may affect MS disease course. Thus, our aim was to investigate the association between hormone therapy (HT) and disease activity and disability accrual among women with MS. Methods A register‐based cohort study was conducted with prospectively enrolled cases from the Danish MS registry. Information on hormone exposure was retrieved from the National Prescription Registry. Outcomes were relapse rate, relapse rate ratio, recurrent relapses, 6‐month confirmed and sustained Expanded Disability Status Scale (EDSS) milestones 4 and 6, and recurrent EDSS worsening. Results In all, 3325 women were eligible for analyses, of whom 333 (10%) were ever on HT at some time during follow‐up. We found no association between HT and disability accrual, although a trend for increasing risk with increasing length of use was seen. The risk of reaching 6‐month confirmed and sustained EDSS 4 among users was 0.6 (95% confidence interval [CI] = 0.3–1.2) after <1 year of use and 1.4 (95% CI = 0.9–2.2) after >5 years of HT compared to never use. The risk of recurrent relapse was increased by 20% (95% CI = 1.0–1.4) among current users of HT compared to nonusers. However, the risk of recurrent relapses was driven by the first calendar period (1996–2005) before the introduction of high‐efficacy disease‐modifying therapy. Conclusions Our findings from this nationwide MS population suggest that HT does not affect disability accrual in women with MS, especially if used for <5 years.
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Affiliation(s)
- Tine Iskov Kopp
- The Danish Multiple Sclerosis Registry, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Øjvind Lidegaard
- Department of Gynaecology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Melinda Magyari
- The Danish Multiple Sclerosis Registry, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,The Danish Multiple Sclerosis Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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21
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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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22
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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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23
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Hellwig K, Tokic M, Thiel S, Esters N, Spicher C, Timmesfeld N, Ciplea AI, Gold R, Langer-Gould A. Multiple Sclerosis Disease Activity and Disability Following Discontinuation of Natalizumab for Pregnancy. JAMA Netw Open 2022; 5:e2144750. [PMID: 35072719 PMCID: PMC8787598 DOI: 10.1001/jamanetworkopen.2021.44750] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
IMPORTANCE The magnitude of risk of pregnancy-related multiple sclerosis relapses, particularly severe relapses, following natalizumab cessation is unclear, as is whether this risk is reduced by pregnancy or other modifiable factors. OBJECTIVE To determine the association of early natalizumab withdrawal before or during pregnancy with risk of severe relapses and relapse-related disability. DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study used data from the German Multiple Sclerosis and Pregnancy Registry, which enrolled participants between November 2006 and February 2018. Data were collected through structured telephone-administered questionnaires and review of neurologists' notes. Registry patients who stopped natalizumab treatment within the 2 years before or in the first trimester of pregnancy were included in this analysis. Data were analyzed between January and November 2021. EXPOSURES Cessation of natalizumab before pregnancy or until the first trimester. MAIN OUTCOMES AND MEASURES Severe and significant relapse-related disability was defined as at least a 2.0-point increase on the expanded disability status scale or new or worsening relapse-related ambulatory impairment. Multivariable models accounting for measures of disease severity and repeated events were used. RESULTS The cohort comprised 255 women with 274 pregnancies (mean [SD] age at pregnancy onset, 31.25 [4.27] years) who stopped natalizumab before pregnancy (n = 85; median time before last menstrual period, 14.29 weeks [IQR, 3.14-42.43 weeks]) or in the first trimester (n = 189). During pregnancy and the postpartum year, relapses were reported in 183 pregnancies (66.78%), severe relapses in 44 pregnancies (16.05%), and potentially life-threatening relapses in 3 pregnancies (1.10%). One year post partum, significant relapse-related disability was accrued in 29 pregnancies (10.58%). Relapses during pregnancy (n = 109; 39.78%) and in the postpartum period (n = 135; 49.27%) were common. Pregnancy (as a time-dependent covariate) was not associated with a reduced relapse risk (adjusted HR, 0.90; 95% CI, 0.64-1.27). Neither exclusive breastfeeding (adjusted HR, 1.34; 95% CI, 0.86-2.10) nor restarting natalizumab within 4 weeks post partum (adjusted HR, 1.06; 95% CI, 0.48-2.36) were associated with a reduced risk of early postpartum relapses 6 months after delivery. However, the relapse rate ratio during 12 months post partum was lower (0.49; 95% CI, 0.28-0.86) when natalizumab was restarted in the first 4 weeks after birth. CONCLUSIONS AND RELEVANCE This cohort study's finding suggest that 10% of women may retain clinically meaningful disability from pregnancy-related natalizumab cessation relapses 1 year post partum. This information should be shared with women on natalizumab who desire pregnancy to weigh the high risk of pregnancy-related relapses and disability to the partly uncertain risks of continuing natalizumab throughout pregnancy or switching to depleting agents before conception.
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Affiliation(s)
- Kerstin Hellwig
- Department of Neurology, St. Josef-Hospital–Katholisches Klinikum Bochum, Ruhr University Bochum, Bochum, Germany
| | - Marianne Tokic
- Department of Medical Informatics, Biometry and Epidemiology, Ruhr University Bochum, Bochum, Germany
| | - Sandra Thiel
- Department of Neurology, St. Josef-Hospital–Katholisches Klinikum Bochum, Ruhr University Bochum, Bochum, Germany
| | - Nina Esters
- Department of Neurology, St. Josef-Hospital–Katholisches Klinikum Bochum, Ruhr University Bochum, Bochum, Germany
| | - Charlotte Spicher
- Department of Neurology, St. Josef-Hospital–Katholisches Klinikum Bochum, Ruhr University Bochum, Bochum, Germany
| | - Nina Timmesfeld
- Department of Medical Informatics, Biometry and Epidemiology, Ruhr University Bochum, Bochum, Germany
| | - Andrea I. Ciplea
- Department of Neurology, St. Josef-Hospital–Katholisches Klinikum Bochum, Ruhr University Bochum, Bochum, Germany
| | - Ralf Gold
- Department of Neurology, St. Josef-Hospital–Katholisches Klinikum Bochum, Ruhr University Bochum, Bochum, Germany
| | - Annette Langer-Gould
- Department of Neurology, Los Angeles Medical Center, Southern California Permanente Medical Group, Los Angeles, California
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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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25
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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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26
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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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27
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Yeh WZ, Widyastuti PA, Van der Walt A, Stankovich J, Havrdova E, Horakova D, Vodehnalova K, Ozakbas S, Eichau S, Duquette P, Kalincik T, Patti F, Boz C, Terzi M, Yamout BI, Lechner-Scott J, Sola P, Skibina OG, Barnett M, Onofrj M, Sá MJ, McCombe PA, Grammond P, Ampapa R, Grand'Maison F, Bergamaschi R, Spitaleri DLA, Van Pesch V, Cartechini E, Hodgkinson S, Soysal A, Saiz A, Gresle M, Uher T, Maimone D, Turkoglu R, Hupperts RM, Amato MP, Granella F, Oreja-Guevara C, Altintas A, Macdonell RA, Castillo-Trivino T, Butzkueven H, Alroughani R, Jokubaitis VG. Natalizumab, Fingolimod and Dimethyl Fumarate Use and Pregnancy-Related Relapse and Disability in Women With Multiple Sclerosis. Neurology 2021; 96:e2989-e3002. [PMID: 33879599 PMCID: PMC8253565 DOI: 10.1212/wnl.0000000000012084] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 03/17/2021] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE To investigate pregnancy-related disease activity in a contemporary multiple sclerosis (MS) cohort. METHODS Using data from the MSBase Registry, we included pregnancies conceived after 31 Dec 2010 from women with relapsing-remitting MS or clinically isolated syndrome. Predictors of intrapartum relapse, and postpartum relapse and disability progression were determined by clustered logistic regression or Cox regression analyses. RESULTS We included 1998 pregnancies from 1619 women with MS. Preconception annualized relapse rate (ARR) was 0.29 (95% CI 0.27-0.32), fell to 0.19 (0.14-0.24) in third trimester, and increased to 0.59 (0.51-0.67) in early postpartum. Among women who used fingolimod or natalizumab, ARR before pregnancy was 0.37 (0.28-0.49) and 0.29 (0.22-0.37), respectively, and increased during pregnancy. Intrapartum ARR decreased with preconception dimethyl fumarate use. ARR spiked after delivery across all DMT groups. Natalizumab continuation into pregnancy reduced the odds of relapse during pregnancy (OR 0.76 per month [0.60-0.95], p=0.017). DMT re-initiation with natalizumab protected against postpartum relapse (HR 0.11 [0.04-0.32], p<0.0001). Breastfeeding women were less likely to relapse (HR 0.61 [0.41-0.91], p=0.016). 5.6% of pregnancies were followed by confirmed disability progression, predicted by higher relapse activity in pregnancy and postpartum. CONCLUSION Intrapartum and postpartum relapse probabilities increased among women with MS after natalizumab or fingolimod cessation. In women considered to be at high relapse risk, use of natalizumab before pregnancy and continued up to 34 weeks gestation, with early re-initiation after delivery is an effective option to minimize relapse risks. Strategies of DMT use have to be balanced against potential fetal/neonatal complications.
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Affiliation(s)
- Wei Zhen Yeh
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
| | - Putu Ayu Widyastuti
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Anneke Van der Walt
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
| | - Jim Stankovich
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Eva Havrdova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Dana Horakova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Karolina Vodehnalova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | | | - Sara Eichau
- Hospital Universitario Virgen Macarena, Spain
| | | | - Tomas Kalincik
- CORe, Department of Medicine, University of Melbourne, Australia
- Melbourne MS Centre, Royal Melbourne Hospital, Australia
| | - Francesco Patti
- Department of Medical and Surgical Sciences and Advanced Technologies
- GF Ingrassia, University of Catania - AOU Policlinico-San Marco, University of Catania
| | - Cavit Boz
- KTU Medical Faculty Farabi Hospital, Turkey
| | | | - Bassem I Yamout
- American University of Beirut, Faculty of Medicine, Nehme and Therese Multiple Sclerosis Center, Beirut, Lebanon
| | | | - Patrizia Sola
- Neurology Unit, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy
| | - Olga G Skibina
- Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
| | | | | | - Maria José Sá
- Department of Neurology, São João Universitary Hospital Center, Porto, Portugal
| | - Pamela Ann McCombe
- St Andrews Place, Australia, & Royal Brisbane and Women's Hospital, Australia
| | - Pierre Grammond
- Centre de réadaptation déficience physique Chaudière-Appalache, Canada
| | | | | | | | | | - Vincent Van Pesch
- Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Belgium
| | | | | | - Aysun Soysal
- Bakirkoy Education and Research Hospital for Psychiatric and Neurological Diseases, Turkey
| | - Albert Saiz
- Service of Neurology, Hospital Clinic, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS)
- Institut de Neurociències, Universitat de Barcelona, Barcelona, Spain
| | - Melissa Gresle
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
| | - Tomas Uher
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Davide Maimone
- Centro Sclerosi Multipla, UOC Neurologia, ARNAS Garibaldi, Catania, Italy
| | - Recai Turkoglu
- Haydarpasa Numune Training and Research Hospital, Turkey
| | | | - Maria Pia Amato
- Department NEUROFARBA, University of Florence, Italy
- IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy
| | | | - Celia Oreja-Guevara
- Department of Neurology, Hospital Clínico San Carlos, Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid (UCM)
- IdISSC, Madrid, Spain
| | - Ayse Altintas
- Department of Neurology, Koc University School of Medicine, Turkey
| | | | | | - Helmut Butzkueven
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
- Box Hill Hospital, Australia
| | | | - Vilija G Jokubaitis
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
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28
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Wattjes MP, Ciccarelli O, Reich DS, Banwell B, de Stefano N, Enzinger C, Fazekas F, Filippi M, Frederiksen J, Gasperini C, Hacohen Y, Kappos L, Li DKB, Mankad K, Montalban X, Newsome SD, Oh J, Palace J, Rocca MA, Sastre-Garriga J, Tintoré M, Traboulsee A, Vrenken H, Yousry T, Barkhof F, Rovira À. 2021 MAGNIMS-CMSC-NAIMS consensus recommendations on the use of MRI in patients with multiple sclerosis. Lancet Neurol 2021; 20:653-670. [PMID: 34139157 DOI: 10.1016/s1474-4422(21)00095-8] [Citation(s) in RCA: 306] [Impact Index Per Article: 102.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 02/15/2021] [Accepted: 03/12/2021] [Indexed: 12/11/2022]
Abstract
The 2015 Magnetic Resonance Imaging in Multiple Sclerosis and 2016 Consortium of Multiple Sclerosis Centres guidelines on the use of MRI in diagnosis and monitoring of multiple sclerosis made an important step towards appropriate use of MRI in routine clinical practice. Since their promulgation, there have been substantial relevant advances in knowledge, including the 2017 revisions of the McDonald diagnostic criteria, renewed safety concerns regarding intravenous gadolinium-based contrast agents, and the value of spinal cord MRI for diagnostic, prognostic, and monitoring purposes. These developments suggest a changing role of MRI for the management of patients with multiple sclerosis. This 2021 revision of the previous guidelines on MRI use for patients with multiple sclerosis merges recommendations from the Magnetic Resonance Imaging in Multiple Sclerosis study group, Consortium of Multiple Sclerosis Centres, and North American Imaging in Multiple Sclerosis Cooperative, and translates research findings into clinical practice to improve the use of MRI for diagnosis, prognosis, and monitoring of individuals with multiple sclerosis. We recommend changes in MRI acquisition protocols, such as emphasising the value of three dimensional-fluid-attenuated inversion recovery as the core brain pulse sequence to improve diagnostic accuracy and ability to identify new lesions to monitor treatment effectiveness, and we provide recommendations for the judicious use of gadolinium-based contrast agents for specific clinical purposes. Additionally, we extend the recommendations to the use of MRI in patients with multiple sclerosis in childhood, during pregnancy, and in the post-partum period. Finally, we discuss promising MRI approaches that might deserve introduction into clinical practice in the near future.
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Affiliation(s)
- Mike P Wattjes
- Department of Diagnostic and Interventional Neuroradiology, Hannover Medical School, Hannover, Germany; Department of Radiology and Nuclear Medicine, Amsterdam UMC, Amsterdam, Netherlands
| | - Olga Ciccarelli
- Faculty of Brain Sciences, University College London Queen Square Institute of Neurology, University College London, London, UK; National Institute for Health Research University College London Hospitals Biomedical Research Centre, London, UK
| | - Daniel S Reich
- Translational Neuroradiology Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Brenda Banwell
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Nicola de Stefano
- Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Christian Enzinger
- Department of Neurology, Medical University of Graz, Graz, Austria; Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
| | - Franz Fazekas
- Department of Neurology, Medical University of Graz, Graz, Austria
| | - Massimo Filippi
- Neuroimaging Research Unit, Institute of Experimental Neurology, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy; Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy; Neurophysiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Jette Frederiksen
- Department of Neurology, Rigshospitalet Glostrup, University Hospital of Copenhagen, Glostrup, Denmark
| | - Claudio Gasperini
- Department of Neurology, San Camillo-Forlanini Hospital, Roma, Italy
| | - Yael Hacohen
- Faculty of Brain Sciences, University College London Queen Square Institute of Neurology, University College London, London, UK; Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK
| | - Ludwig Kappos
- Department of Neurology and Research Center for Clinical Neuroimmunology and Neuroscience, University Hospital of Basel and University of Basel, Basel, Switzerland
| | - David K B Li
- Department of Radiology, University of British Columbia, Vancouver, BC, Canada
| | - Kshitij Mankad
- Department of Neuroradiology, Great Ormond Street Hospital for Children, London, UK
| | - Xavier Montalban
- Multiple Sclerosis Centre of Catalonia, Department of Neurology-Neuroimmunology, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain; Division of Neurology, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Scott D Newsome
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Jiwon Oh
- Division of Neurology, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | | | - Maria A Rocca
- Neuroimaging Research Unit, Institute of Experimental Neurology, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy; Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Jaume Sastre-Garriga
- Multiple Sclerosis Centre of Catalonia, Department of Neurology-Neuroimmunology, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Mar Tintoré
- Multiple Sclerosis Centre of Catalonia, Department of Neurology-Neuroimmunology, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Anthony Traboulsee
- Division of Neurology, University of British Columbia, Vancouver, BC, Canada
| | - Hugo Vrenken
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Amsterdam, Netherlands
| | - Tarek Yousry
- Lysholm Department of Neuroradiology, UCLH National Hospital for Neurology and Neurosurgery, London, UK; Neuroradiological Academic Unit, University College London Queen Square Institute of Neurology, University College London, London, UK
| | - Frederik Barkhof
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Amsterdam, Netherlands; Faculty of Brain Sciences, University College London Queen Square Institute of Neurology, University College London, London, UK; National Institute for Health Research University College London Hospitals Biomedical Research Centre, London, UK
| | - Àlex Rovira
- Section of Neuroradiology, Department of Radiology, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain.
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Colaceci S, Zambri F, Marchetti F, Trivelli G, Rossi E, Petruzzo A, Vanacore N, Giusti A. 'A sleeping volcano that could erupt sooner or later'. Lived experiences of women with multiple sclerosis during childbearing age and motherhood: A phenomenological qualitative study. Mult Scler Relat Disord 2021; 51:102938. [PMID: 33882427 DOI: 10.1016/j.msard.2021.102938] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 03/30/2021] [Accepted: 04/03/2021] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Multiple Sclerosis (MS) mainly involves women, impacting many aspects related to childbearing age and maternity. Women with MS can have healthy pregnancies and infants. Needs, challenges and concerns of women with MS should be considered in order to improve care pathway, ensuring a patient-centred approach. Therefore, the aim of this study was to explore personal experiences, expectations, fears in women with MS. METHODS A descriptive phenomenological study, including women with MS during childbearing age, pregnancy and motherhood, carried out from January to April 2019. Women, enrolled in a MS centre with snowball sampling through healthcare network, were invited for a face-to-face or phone interview, digitally audio-recorded and fully transcribed. Two different sets of semi-structured interviews were developed (woman seeking pregnancy / pregnant woman and mother), together with an anonymous form, to collect some main sociodemographic data. Categorical data analysis, inductively and deductively, was processed by 3 different researchers, using Creswell extension to reduce subjective influences. QDA Miner qualitative text analysis software was used. RESULTS The following 6 deductive themes emerged: 1) experience with diagnosis of MS; 2) relationship with the partner, children, and family; 3) pregnancy; 4) delivery; 5) puerperium; 6) care pathway. Experiences with diagnosis can be very different between women. Communication of MS diagnosis appears as an opportunity to strengthen emotional ties, despite sorrow and concerns. Reasons for quarrels and disagreements, both in couple and parents, were due to an overly protective and supportive attitude. Some participants reported difficulty of conceiving. Pregnancy is described as a state of wellbeing, not devoid by fears and worries. Women experienced fatigue and exhaustion especially during the second stage of labour, but spontaneous delivery is described as an empowering experience. Findings about breastfeeding confirm that healthcare professionals have a crucial role regarding initiation, duration and type of breastfeeding and often scarce education and training on the topic, together with lack of reliable scientific sources, lead to a conservative approach. Healthcare providers communication and consulting emerge as indispensable skills. CONCLUSION The study provides a better understanding of how MS impacts women' life during childbearing age, pregnancy and motherhood. Findings support the importance of provide quality and tailored care for women with MS, according to an empathetic and patient-centred approach. Further research should be more comprehensive explorations of mothers' experiences in different cultural contexts, but also partners and offspring of women with MS.
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Affiliation(s)
- Sofia Colaceci
- Departmental faculty of Medicine and Surgery, Saint Camillus International University of Rome and Medical Sciences (UniCamillus), Rome, Italy.
| | - Francesca Zambri
- National Centre for Diseases Prevention and Health Promotion, National Institute of Health, Rome, Italy
| | - Francesca Marchetti
- National Centre for Diseases Prevention and Health Promotion, National Institute of Health, Rome, Italy; Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Gessica Trivelli
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Elisa Rossi
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | | | - Nicola Vanacore
- National Centre for Diseases Prevention and Health Promotion, National Institute of Health, Rome, Italy
| | - Angela Giusti
- National Centre for Diseases Prevention and Health Promotion, National Institute of Health, Rome, Italy
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Barros GMCD, Oliveira BESD, Oliveira GJ, Silva RKP, Cardoso TN, Maia SB. Disease Progression and Obstetric Outcomes of Women with Multiple Sclerosis at a Reference Center in Northeastern Brazil. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2021; 43:165-171. [PMID: 33860499 PMCID: PMC10183912 DOI: 10.1055/s-0040-1722157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
OBJECTIVE To describe the obstetric outcomes of patients with multiple sclerosis (MS) and the impact of pregnancy and the postpartum period on the progression of the disease. METHODS A case series study performed between December 2019 and February 2020, reporting pregnancies occurred between 1996 and 2019. The subjects included were women with MS undergoing follow-up at an MS referral center in Northeastern Brazil, and who had at least one pregnancy after the onset of MS symptoms, or who had their first relapse in the first year after delivery. RESULTS In total, 26 women and 38 pregnancies were analyzed - 32 of them resulted in delivery, and the remaining 6, in miscarriages. There was a significant increase in the prevalence of relapse during the postpartum period when compared with the gestational period. In 16 (42.1%) of the pregnancies, there was exposure to disease-modifying therapies (DMTs) - 14 (36.8%), to interferon β, and 2 (5.3%), to fingolimod. Higher rates of abortion, prematurity and low birth weight were reported in the group was exposed to DMT when compared with the one who was not. CONCLUSION In the sample of the present study, there was a significant increase in the rate of MS relapse during the postpartum period when compared with the gestational period. Additionally, it seems that exposure to DMTs during pregnancy may affect the obstetric outcomes of the patients.
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Affiliation(s)
| | - Bianca Etelvina Santos de Oliveira
- Centro de Referência em Esclerose Múltipla da Paraíba, Fundação Centro Integrado de Apoio ao Portador de Deficiência, João Pessoa, PB, Brazil
| | - Gabriela Januário Oliveira
- Department of Obstetrics and Gynecology, Centro de Ciências Médicas, Universidade Federal da Paraíba, João Pessoa, PB, Brazil
| | - Rômulo Kunrath Pinto Silva
- Department of Obstetrics and Gynecology, Centro de Ciências Médicas, Universidade Federal da Paraíba, João Pessoa, PB, Brazil
| | - Thiago Nóbrega Cardoso
- Departamento de Obstetrícia e Ginecologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Sabina Bastos Maia
- Department of Obstetrics and Gynecology, Centro de Ciências Médicas, Universidade Federal da Paraíba, João Pessoa, PB, Brazil
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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: 6] [Impact Index Per Article: 2.0] [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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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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Alhomoud MA, Khan AS, Alhomoud I. The Potential Preventive Effect of Pregnancy and Breastfeeding on Multiple Sclerosis. Eur Neurol 2021; 84:71-84. [PMID: 33744881 DOI: 10.1159/000514432] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 01/09/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Multiple sclerosis (MS) is an inflammatory demyelinating chronic neurological disease that affects the central nervous system of young adults and their quality of life. Several studies have investigated the effects of pregnancy and breastfeeding on MS. However, the evidence regarding the influence of pregnancy and breastfeeding on MS is still accumulating. This review aimed to summarize the current evidence regarding the effects of pregnancy and breastfeeding on MS. SUMMARY A systematic electronic literature search of the PubMed and Embase databases was conducted to determine relevant published articles. The eligible studies were summarized and evaluated in tables. Key Messages: The majority of the studies indicated that pregnancy appears to lower the rate of MS relapses, particularly in the third trimester. The evidence regarding the effect of breastfeeding on MS remains inconsistent. Despite reports of negative obstetric outcomes in some pregnant women with MS, pregnancies in women with MS should not be categorized as high-risk pregnancies.
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Affiliation(s)
- Mohsen Ali Alhomoud
- Department of Public Health, Ministry of Health, Eastern Province, Al Qatif, Saudi Arabia,
| | - Abdul Sattar Khan
- Family and Community Medicine Department, King Faisal University, Eastern Province, Al Ahsa, Saudi Arabia
| | - Iftetah Alhomoud
- Neurosciences Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
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Abstract
PURPOSE OF REVIEW The fact that multiple sclerosis (MS) predominantly affects women has been recognized for many years. As the age at diagnosis is decreasing, and treatment options are becoming more complex, increasing numbers of women are facing decisions about the use of disease modifying therapy (DMT) in and around pregnancy. RECENT FINDINGS New data are rapidly becoming available, particularly regarding the safety of therapies in both pregnancy and breastfeeding. Effective treatment and suppression of relapses is key to ensuring good outcomes in the longer term for the woman, however this must be balanced against individual risk of relapse and risks to the fetus. Women should be advised that it is possible to breastfeed while taking selected DMT. SUMMARY In this review, we discuss evidence surrounding the safety of DMTs in both pregnancy and breastfeeding, and use this knowledge to suggest approaches to pregnancy and family planning in women with MS.
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Modrego PJ, Urrea MA, de Cerio LD. The effects of pregnancy on relapse rates, disability and peripartum outcomes in women with multiple sclerosis: a systematic review and meta-analysis. J Comp Eff Res 2021; 10:175-186. [PMID: 33565886 DOI: 10.2217/cer-2020-0211] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background: Although previous cohort studies of women with multiple sclerosis (MS) yielded a reduction in relapse rate during pregnancy, the effect size has not been quantified in a comprehensive manner. In addition, the effects on disability progression and peripartum outcomes have been controversial. The purpose of this work is to assess the effect of pregnancy on disease activity, and to assess the effects of MS on pregnancy as well. Materials & methods: We searched in PubMed, Cochrane Library and EMBASE for cohort studies dealing with the effects of pregnancy on relapse rates, disability progression and peripartum outcomes in women with MS. The evaluated outcomes were: changes in the annualized relapse rate (ARR) in pregnancy and puerperium, disability worsening compared with the year before pregnancy, and peripartum outcomes, which were compared with the ones of non-MS women. In the majority of cohorts included here, the women were not under disease modifying therapies during pregnancy. Results: We found 23 cohort studies measuring changes in the ARR during pregnancy and puerperium; 12 were prospective and 11 retrospective. In 17 cohorts there was significant reduction in the ARR during pregnancy compared with prepregnancy period. The pooled mean reduction in the ARR was -0.5 (95% CI: 0.67-0.38), p < 0.001, from 15 cohorts included in meta-analysis. In 18 cohorts the ARR increased in the 3-month puerperium relative to prepregnancy year period; the pooled mean increase in the ARR was 0.22 (95% CI: 0.11-0.33), p < 0.001, from 14 cohorts included in meta-analysis. Disability worsening was addressed in 18 cohorts, and in 14 of them there were no significant changes. Peripartum complications and obstetrical outcomes were assessed in 16 cohorts, of whom 13 were retrospective, without finding significant differences. Conclusion: Pregnancy is associated with lower disease activity, and puerperium with higher disease activity. Disability does not change significantly after pregnancy. The obstetrical outcomes are not very different from those of non-MS women in most cohorts.
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Affiliation(s)
- Pedro J Modrego
- Department of Neurology, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | | | - Leyre Diaz de Cerio
- Department of Neurology, Hospital Universitario Miguel Servet, Zaragoza, Spain
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Krysko KM, Bove R, Dobson R, Jokubaitis V, Hellwig K. Treatment of Women with Multiple Sclerosis Planning Pregnancy. Curr Treat Options Neurol 2021; 23:11. [PMID: 33814892 PMCID: PMC8008016 DOI: 10.1007/s11940-021-00666-4] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2021] [Indexed: 02/01/2023]
Abstract
PURPOSE OF REVIEW We review data available for treatment of multiple sclerosis (MS) before, during, and after pregnancy. We present recent data on disease-modifying therapies (DMT) before/during pregnancy and while breastfeeding, with treatment recommendations. RECENT FINDINGS Observational data support the safety of injectable DMTs (glatiramer acetate, interferon-beta) for use in pregnancy, while some oral DMTs might be associated with fetal risk. Monoclonal antibodies (mAbs) before pregnancy such as rituximab or natalizumab likely do not pose significant fetal risks, but can cross the placenta with neonatal hematological abnormalities if given in the second trimester or later. Breastfeeding is associated with decreased risk of postpartum relapses. Finally, injectables and mAbs likely have low transfer into breastmilk. SUMMARY Many women with MS do not require DMTs during pregnancy, although injectables could be continued. For women with highly active MS, cell-depleting therapies could be given before conception, or natalizumab could be continued through pregnancy, with monitoring of the fetus. Women should be encouraged to breastfeed, and those with higher relapse risk could consider injectables or mAbs while breastfeeding. Further data on safety of DMTs around pregnancy are needed. Maximizing function through non-pharmacologic approaches is complementary to DMTs. Special considerations for pregnancy and DMTs during the COVID-19 pandemic are needed.
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Affiliation(s)
- Kristen M. Krysko
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California San Francisco, 675 Nelson Rising Lane, San Francisco, CA 94158 USA
- Division of Neurology, Department of Medicine, St. Michael’s Hospital, University of Toronto, 9 Donnelly Wing South, 30 Bond Street, Toronto, Ontario M5B 1W8 Canada
| | - Riley Bove
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California San Francisco, 675 Nelson Rising Lane, San Francisco, CA 94158 USA
| | - Ruth Dobson
- Preventive Neurology Unit, Wolfson Institute of Preventive Neurology, Queen Mary University of London, Charterhouse Square, London, UK
- Department of Neurology, Royal London Hospital, Whitechapel, London, UK
| | - Vilija Jokubaitis
- Department of Neuroscience, Monash University, Melbourne, VIC Australia
- Department of Neurology, Alfred Health, Melbourne, VIC Australia
| | - Kerstin Hellwig
- Department of Neurology, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
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Sá MJ, Soares Dos Reis R, Altintas A, Celius EG, Chien C, Comi G, Graus F, Hillert J, Hobart J, Khan G, Kissani N, Langdon D, Leite MI, Okuda DT, Palace J, Papais-Alvarenga RM, Mendes-Pinto I, Shi FD. State of the Art and Future Challenges in Multiple Sclerosis Research and Medical Management: An Insight into the 5th International Porto Congress of Multiple Sclerosis. Neurol Ther 2020; 9:281-300. [PMID: 32666470 PMCID: PMC7606370 DOI: 10.1007/s40120-020-00202-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Indexed: 02/07/2023] Open
Abstract
The 5th International Porto Congress of Multiple Sclerosis took place between the 14th and 16th of February 2019 in Porto, Portugal. Its intensive programme covered a wide-range of themes-including many of the hot topics, challenges, pitfalls and yet unmet needs in the field of multiple sclerosis (MS)-led by a number of well-acknowledged world experts. This meeting review summarizes the talks that took place during the congress, which focussed on issues in MS as diverse as the development and challenges of progressive MS, epidemiology, differential diagnosis, medical management, molecular research and imaging tools.
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Affiliation(s)
- María José Sá
- Department of Neurology, Centro Hospitalar Universitário de São João, Alameda Prof. Hernáni Monteiro, Porto, Portugal.
- Faculty of Health Sciences, University Fernando Pessoa, Rua Carlos da Maia, Porto, Portugal.
| | - Ricardo Soares Dos Reis
- Department of Neurology, Centro Hospitalar Universitário de São João, Alameda Prof. Hernáni Monteiro, Porto, Portugal.
- Department of Clinical Neurosciences and Mental Health, Faculty of Medicine, University of Porto, Porto, Portugal.
| | - Ayse Altintas
- Department of Neurology, School of Medicine, Koç University, Istanbul, Turkey
| | - Elisabeth Gulowsen Celius
- Department of Neurology, Oslo University Hospital, Ullevål, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Claudia Chien
- NeuroCure Clinical Research Center, NeuroCure Cluster of Excellence, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Giancarlo Comi
- Department of Neurology, University Vita-Salute San Raffaele, Milan, Italy
| | - Francesc Graus
- Department of Neurology, August Pi i Sunyer Biomedical Research Institute (IDIBAPS) Hospital Clínic, Barcelona, Spain
| | - Jan Hillert
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Jeremy Hobart
- Department of Neurology, University Hospitals Plymouth, Plymouth, UK
- Peninsula Schools of Medicine and Dentistry, University of Plymouth, Plymouth, UK
| | - Gulfaraz Khan
- Department of Microbiology and Immunology, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Najib Kissani
- Neurology Department, Marrakech University Hospital Mohammed VI, Marrakech, Morocco
- Neuroscience Research Laboratory, Marrakesh Medical School, Cadi Ayyad University, Marrakech, Morocco
| | - Dawn Langdon
- Department of Psychology, Royal Holloway, University of London, London, UK
| | - Maria Isabel Leite
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Darin T Okuda
- Department of Neurology and Neurotherapeutics, UT Southwestern Medical Center, Dallas, TX, USA
| | - Jacqueline Palace
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | | | | | - Fu-Dong Shi
- Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
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Guger M, Traxler G, Drabauer M, Leitner-Pohn D, Enzinger C, Leutmezer F, Oel D, Di Pauli F, Berger T, Ransmayr G. Pregnancy Outcomes in Patients With Multiple Sclerosis Exposed to Natalizumab-A Retrospective Analysis From the Austrian Multiple Sclerosis Treatment Registry. Front Neurol 2020; 11:676. [PMID: 32849179 PMCID: PMC7417297 DOI: 10.3389/fneur.2020.00676] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 06/05/2020] [Indexed: 11/16/2022] Open
Abstract
Objectives: To analyze safety and impact of natalizumab (NTZ) exposure on the disease course, pregnancy, and newborn outcomes of relapsing-remitting multiple sclerosis (RRMS) patients from the Austrian Multiple Sclerosis Treatment Registry (AMSTR). Materials and Methods: Twelve pregnancies of 11 women with RRMS exposed to treatment with NTZ were identified from the AMSTR. Exposure to NTZ was defined as treatment with NTZ from 8 weeks prior to the start of the last menstrual period and onward. All patients completed a standardized questionnaire regarding pregnancy and newborn outcomes until the postpartum period for up to 12 months. Results: NTZ was stopped on average 46 days after the last menstrual period. There were 11 live births and one elective termination due to ectopic pregnancy. Mean gestational age of live born individuals was 39.0 weeks [standard deviation (SD) ± 1.1]. Mean birth weight and length were 3,426 g (SD ± 348) and 51.9 cm (SD ± 1.9), respectively. Apgar scores 1 min after birth were normal, with 9.2 points on average. One child displayed hip dysplasia as the only congenital malformation documented in this cohort. Three patients experienced relapses during pregnancy and three patients in the postpartum period, resulting in confirmed Expanded Disability Status Scale (EDSS) progression in four of them. Conclusion: In this cohort, there was no increased risk concerning pregnancy and newborn outcomes due to NTZ exposure. However, relapses occurring during pregnancy and postpartum period resulted in confirmed disability.
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Affiliation(s)
- Michael Guger
- Department of Neurology 2, Kepler University Hospital GmbH, Linz, Austria.,Medical Faculty, Johannes Kepler University Linz, Linz, Austria
| | - Gerhard Traxler
- Department of Neurology 2, Kepler University Hospital GmbH, Linz, Austria
| | - Martina Drabauer
- Department of Neurology 2, Kepler University Hospital GmbH, Linz, Austria
| | - Doris Leitner-Pohn
- Department of Neurology 2, Kepler University Hospital GmbH, Linz, Austria
| | | | - Fritz Leutmezer
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Dierk Oel
- Department of Neurology, Academic Teaching Hospital Wels-Grieskirchen, Wels, Austria
| | - Franziska Di Pauli
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Thomas Berger
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Gerhard Ransmayr
- Department of Neurology 2, Kepler University Hospital GmbH, Linz, Austria.,Medical Faculty, Johannes Kepler University Linz, Linz, Austria
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Krysko KM, Graves JS, Dobson R, Altintas A, Amato MP, Bernard J, Bonavita S, Bove R, Cavalla P, Clerico M, Corona T, Doshi A, Fragoso Y, Jacobs D, Jokubaitis V, Landi D, Llamosa G, Longbrake EE, Maillart E, Marta M, Midaglia L, Shah S, Tintore M, van der Walt A, Voskuhl R, Wang Y, Zabad RK, Zeydan B, Houtchens M, Hellwig K. Sex effects across the lifespan in women with multiple sclerosis. Ther Adv Neurol Disord 2020; 13:1756286420936166. [PMID: 32655689 PMCID: PMC7331774 DOI: 10.1177/1756286420936166] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 05/28/2020] [Indexed: 02/06/2023] Open
Abstract
Multiple sclerosis (MS) is an autoimmune inflammatory demyelinating central nervous system disorder that is more common in women, with onset often during reproductive years. The female:male sex ratio of MS rose in several regions over the last century, suggesting a possible sex by environmental interaction increasing MS risk in women. Since many with MS are in their childbearing years, family planning, including contraceptive and disease-modifying therapy (DMT) counselling, are important aspects of MS care in women. While some DMTs are likely harmful to the developing fetus, others can be used shortly before or until pregnancy is confirmed. Overall, pregnancy decreases risk of MS relapses, whereas relapse risk may increase postpartum, although pregnancy does not appear to be harmful for long-term prognosis of MS. However, ovarian aging may contribute to disability progression in women with MS. Here, we review sex effects across the lifespan in women with MS, including the effect of sex on MS susceptibility, effects of pregnancy on MS disease activity, and management strategies around pregnancy, including risks associated with DMT use before and during pregnancy, and while breastfeeding. We also review reproductive aging and sexual dysfunction in women with MS.
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Affiliation(s)
- Kristen M Krysko
- Department of Neurology, UCSF Weill Institute for Neurosciences, University of California San Francisco, 675 Nelson Rising Lane, Suite 221, San Francisco, CA 94158, USA
| | - Jennifer S Graves
- Department of Neurosciences, University of California San Diego, UCSD ACTRI, La Jolla, CA, USA
| | - Ruth Dobson
- Preventive Neurology Unit, Wolfson Institute of Preventive Neurology, Queen Mary University of London, London, UK
| | - Ayse Altintas
- Department of Neurology, School of Medicine, Koc University, Istanbul, Turkey
| | - Maria Pia Amato
- Department NEUROFARBA, Section of Neurosciences, University of Florence, Florence, Italy
| | - Jacqueline Bernard
- Department of Neurology, Oregon Health Science University, Portland, OR, USA
| | - Simona Bonavita
- Department of Advanced Medical and Surgical Sciences, University of Campania, "Luigi Vanvitelli", Naples, Italy
| | - Riley Bove
- Department of Neurology, UCSF Weill Institute for Neurosciences, University of California San Francisco, San Francisco CA, USA
| | - Paola Cavalla
- Department of Neuroscience and Mental Health, City of Health and Science University Hospital of Torino, Turin, Italy
| | - Marinella Clerico
- Department of Clinical and Biological Sciences, University of Torino, San Luigi Gonzaga Hospital, Orbassano, Turin, Italy
| | - Teresa Corona
- Clinical Laboratory of Neurodegenerative Disease, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico
| | - Anisha Doshi
- Department of Neuroinflammation, Queen Square Multiple Sclerosis Centre, University College London (UCL) Institute of Neurology, London, UK
| | - Yara Fragoso
- Multiple Sclerosis & Headache Research Institute, Santos, SP, Brazil
| | - Dina Jacobs
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Vilija Jokubaitis
- Department of Neuroscience, Monash University, Melbourne, VIC, Australia
| | - Doriana Landi
- Department of Systems Medicine, Multiple Sclerosis Center and Research Unit, Tor Vergata University and Hospital, Rome, Italy
| | | | | | | | - Monica Marta
- Neurosciences and Trauma Centre, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Luciana Midaglia
- Department of Neurology-Neuroimmunology, Multiple Sclerosis Centre of Catalonia, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Suma Shah
- Department of Neurology, Duke University, Durham, NC, USA
| | - Mar Tintore
- Department of Neurology-Neuroimmunology, Multiple Sclerosis Centre of Catalonia, Vall d'Hebron University Hospital, Barcelona, Spain
| | | | - Rhonda Voskuhl
- Department of Neurology, University of California Los Angeles, Los Angeles, CA, USA
| | - Yujie Wang
- Department of Neurology, Johns Hopkins University, Baltimore, MD, USA
| | - Rana K Zabad
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, USA
| | - Burcu Zeydan
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Maria Houtchens
- Department of Neurology, Partners MS Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kerstin Hellwig
- Department of Neurology, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
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Andersen JB, Magyari M. Pharmacotherapeutic considerations in women with multiple sclerosis. Expert Opin Pharmacother 2020; 21:1591-1602. [PMID: 32521172 DOI: 10.1080/14656566.2020.1774554] [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: 01/01/2023]
Abstract
INTRODUCTION Multiple sclerosis (MS) is a chronically progressive disease of the central nervous system. The relapsing form of the disease predominantly affects women with onset between the ages 20 to 40 years. Therefore, timing, choice, and treatment options should take pregnancy planning into consideration to accommodate both the needs and safety of the mother and health of the fetus. AREAS COVERED In this review, the authors discuss and summarize the recent evidence of different pharmacotherapeutic possibilities in the treatment of women with MS. EXPERT OPINION There is evidence that disease modifying therapy reduces the risk of relapses and diminishes disability progression in people with relapsing MS. The disease is often diagnosed in the childbearing years, and thus pregnancy planning can possibly be a part of the pharmacotherapeutic considerations. The management of women planning pregnancy requires a balancing of risks. The clinician must consider the risks related to treatment discontinuation versus the risk of exposing the developing fetus to drugs that are potential fetotoxic. Randomized controlled trials of medication safety - if used during pregnancy, are prohibited for ethical reasons; hence, the evidence is continuously gathered from observational data, post-authorization studies and pregnancy registries.
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Affiliation(s)
- Johanna B Andersen
- Danish Multiple Sclerosis Registry, Department of Neurology, Copenhagen University Hospital , Copenhagen, Denmark
| | - Melinda Magyari
- Danish Multiple Sclerosis Registry, Department of Neurology, Copenhagen University Hospital , Copenhagen, Denmark.,Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital , Copenhagen, Denmark
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Zanghì A, D'Amico E, Callari G, Chisari CG, Borriello G, Grimaldi LME, Patti F. Pregnancy and the Postpartum Period in Women With Relapsing-Remitting Multiple Sclerosis Treated With Old and New Disease-Modifying Treatments: A Real-World Multicenter Experience. Front Neurol 2020; 11:105. [PMID: 32158424 PMCID: PMC7052127 DOI: 10.3389/fneur.2020.00105] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 01/30/2020] [Indexed: 01/29/2023] Open
Abstract
Introduction: Trends of disease activity during pregnancy, the postpartum period, and until 24 months from the delivery in the era of new drugs for the treatment of relapsing-remitting multiple sclerosis (RRMS) need to be investigated. Methods: In this cross-sectional Italian multicenter study, women with RRMS were included; the disease-modifying treatment (DMT) at the time of conception included were: interferons, glatiramer acetate, teriflunomide, dimethyl fumarate, fingolimod, and natalizumab. The main outcome of the study was to determine the rate of relapse occurrence during pregnancy and the postpartum period in all women grouped for each DMT. The secondary outcome was to determine the overall disease activity assessed by NEDA 3 (relapse, disability level, and radiological activity) at 24 months from the date of delivery. Results: Completed data were available for 81 pregnancies (in 74 women). Women on interferons and glatiramer had longer disease duration than women on dimethyl fumarate, fingolimod, and natalizumab (p < 0.05). Overall, we recorded 25 relapses during pregnancy (11 in 11 women) and the postpartum period (14 in 14 women). Natalizumab was the most commonly DMT in women (3) who experienced relapses during pregnancy. IFNs were the most commonly prescribed DMT in women (8) who experienced relapses during the postpartum period. At logistic regression analysis, specific treatment per se was not associated with relapse occurrence. No differences among the DMTs groups were recorded about NEDA 3 status at 24 months of follow-up. Conclusions: In our population, there was no difference in terms of relapses occurrence, disability status, and the overall disease activity during a follow up of 24 months.
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Affiliation(s)
- Aurora Zanghì
- Department "G. F. Ingrassia", University of Catania, Catania, Italy
| | - Emanuele D'Amico
- Department "G. F. Ingrassia", University of Catania, Catania, Italy
| | | | | | | | | | - Francesco Patti
- Department "G. F. Ingrassia", University of Catania, Catania, Italy
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Levin S, Rimmer K, Vargas WS. Neuroimmunologic disorders in pregnancy. HANDBOOK OF CLINICAL NEUROLOGY 2020; 172:105-123. [PMID: 32768083 DOI: 10.1016/b978-0-444-64240-0.00006-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Pregnancy influences the course of neuroimmunologic conditions, which include multiple sclerosis (MS), neuromyelitis optica spectrum disorder, and autoimmune encephalitis. The outcomes differ significantly for each disorder, reflecting the impact of hormonal changes, T-cell subsets, and placental factors on disease pathogenesis. In recent years, numerous data have emerged regarding MS activity throughout pregnancy and postpartum. Historically, the misconception that pregnancy worsens MS outcomes led patients to abstain from childbearing. Now, more women with these disorders, empowered by up-to-date information and better baseline disease control, are choosing to conceive. Nevertheless, the management of MS and related disorders in the pregnancy and postpartum period is complicated and requires a nuanced approach. Since standardized treatment guidelines around pregnancy are currently lacking, neurologists, together with obstetricians, must engage patients in a shared decision-making process that weighs the benefits to the mother and risks to the fetus. This chapter outlines the pathophysiology of neuroimmunologic disorders during pregnancy and postpartum, the impact of these diseases on childbearing, including fertility, pregnancy, delivery, and peurperium, as well as existing recommendations for treatment.
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Affiliation(s)
- Seth Levin
- Department of Neurology, Columbia University Multiple Sclerosis Center, New York, NY, United States
| | - Kathryn Rimmer
- Department of Neurology, Columbia University Multiple Sclerosis Center, New York, NY, United States
| | - Wendy S Vargas
- Department of Neurology, Columbia University Multiple Sclerosis Center, New York, NY, United States; Department of Neurology, Division of Child Neurology, Columbia University Irving Medical Center, New York, NY, United States.
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