Exposure to natalizumab during pregnancy and lactation is safe - No

Disease-modifying therapies and hematological disorders: a systematic review of case reports and case series

Introduction

Disease modifying therapies (DMTs) used to treat multiple sclerosis (MS) can be associated to the occurrence of hematological disorders. This systematic review aims to provide an overview of these events occurring in real-life conditions, by describing case reports and series published in the literature.

Methods

A literature search of all publications up to January 5th 2024 on the Medline and Embase databases was carried out. The results were presented both in the text and in tables.

Results

Sixty-seven case reports/series were included in this review, of which more than half related to alemtuzumab, natalizumab and ocrelizumab. The publication date of included studies ranged from 2006 to 2024. The majority of case reports and series described the occurrence of late-onset hematological disorders (events that occurred more than 30 days after the first DMT administration), mainly represented by case of neutropenia, autoimmune hemolytic anemia and immune thrombocytopenia. All cases reported a favorable outcome, apart one case report that described a fatal case. Among included cases, 4 articles, all related to natalizumab, described the occurrence of myeloid disorders in 13 newborns from mother receiving the DMT.

Discussion

Considering the limitations identified in the majority of included studies, further ad hoc studies are strongly needed to better evaluate the hematological disorders of DMTs. Meantime, the strict monitoring of treated patients for the occurrence of these toxicities should be highly recommended.

Saudi Consensus Recommendations on the Management of Multiple Sclerosis: Family Planning within the Management of MS

This review article addresses the complex issues faced by individuals with Multiple Sclerosis (MS) who are planning a family, becoming pregnant, or wishing to breastfeed their baby. Recommendations and guidelines were discussed and agreed upon by neurologists, neuroradiologists, nurses, and pharmacists involved in the management of MS in the Kingdom of Saudi Arabia (KSA). MS itself does not harm a pregnancy, and people with MS of childbearing age can be encouraged to enjoy family life. Family planning should be a part of the initial conversation with a newly diagnosed patient of childbearing age. Interferons and glatiramer acetate can be continued throughout pregnancy and can be administered during breastfeeding if the benefits outweigh the risks. These DMTs may be considered for a woman with well-controlled MS who is planning a pregnancy or otherwise not using contraception, according to an individualized risk-benefit analysis. The use of contraception should be maintained during the administration of other disease-modifying therapies (DMTs). Natalizumab can be administered at a reduced administration frequency to women with high MS disease activity up to 30 weeks gestation (this agent may induce hematological abnormalities in the fetus). Other DMTs should be withdrawn for variable periods before contraception is stopped and immediately after the discovery of a pregnancy (beware of rebound disease activity after withdrawing natalizumab or fingolimod). Resumption of treatment should not be delayed in women at risk of relapse during the postpartum period and especially in those who do not wish to breastfeed.

Adverse Obstetric Outcomes in Pregnant Women Using Natalizumab for the Treatment of Multiple Sclerosis: A Systematic Review

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.

Natalizumab treatment during pregnancy in multiple sclerosis-clinical and bioethical aspects of an ongoing debate

BACKGROUND

Natalizumab is an approved treatment for relapsing remitting multiple sclerosis; however, its safety during pregnancy is not formally proven.

CASE PRESENTATION

We report a woman with multiple sclerosis being treated with natalizumab before pregnancy. After withdrawal of natalizumab, she suffered a severe, disabling rebound. In agreement with the patient, natalizumab was restarted during pregnancy. Our patient improved substantially and gave birth to a healthy boy.

CONCLUSION

Use of natalizumab during pregnancy may be an option in highly active multiple sclerosis.

Influence of Pregnancy in Multiple Sclerosis and Impact of Disease-Modifying Therapies

Purpose of this Review: This article is a systematic review on the influence pregnancy has on multiple sclerosis and the resulting impact of disease-modifying therapies.

Findings: Multiple sclerosis predominantly affects young women with a clinical onset most often during the child-bearing age. The impact of multiple sclerosis and disease-modifying therapies on fertility, pregnancy, fetal outcome, and breastfeeding is a pivotal topic when it comes to clinical practice. The introduction of disease-modifying therapies has changed not only the natural history of the disease but also the perspective of pregnancy in women with multiple sclerosis. Family planning requires careful consideration, especially because many disease-modifying drugs are contraindicated during pregnancy. In this article, we review current evidence collected from published literature and drug-specific pregnancy registers on the use of disease-modifying therapies. Additionally, we discuss safety profiles for each drug and correlate them to both risk for the exposed fetus and risk for the mothers interrupting treatments when seeking pregnancy.

Susac syndrome and pregnancy: a review of published cases and considerations for patient management

Susac syndrome (SuS) is a rare autoimmune endotheliopathy leading to hearing loss, branch retinal artery occlusions and encephalopathy. Young females are more frequently affected than males, making counselling for family planning an important issue. We reviewed published cases on SuS during pregnancy or in the postpartum period, and selected 27 reports describing the details of 33 patients with SuS. Treatment options and implications for pregnancy and breastfeeding are discussed. We propose new areas for research and suggest a management strategy.