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Yu D, Luo L, Wang H, Shyh-Chang N. Pregnancy-induced metabolic reprogramming and regenerative responses to pro-aging stresses. Trends Endocrinol Metab 2024:S1043-2760(24)00192-9. [PMID: 39122601 DOI: 10.1016/j.tem.2024.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 07/12/2024] [Accepted: 07/17/2024] [Indexed: 08/12/2024]
Abstract
Pregnancy is associated with physiological adaptations that affect virtually all organs, enabling the mother to support the growing fetus and placenta while withstanding the demands of pregnancy. As a result, mammalian pregnancy is a unique state that exerts paradoxical effects on maternal health. On one hand, the metabolic stress induced by pregnancy can accelerate aging and functional decline in organs. On the other hand, pregnancy activates metabolic programming and tissue regenerative responses that can reverse age-related impairments. In this sense, the oocyte-to-blastocyst transition is not the only physiological reprogramming event in the mammalian body, as pregnancy-induced regeneration could constitute a second physiological reprogramming event. Here, we review findings on how pregnancy dualistically leads to aging and rejuvenation in the maternal body.
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Affiliation(s)
- Dainan Yu
- Key Laboratory of Organ Regeneration and Reconstruction, State Key Laboratory of Stem Cell and Reproductive Biology, Institute of Zoology, Chinese Academy of Sciences, Beijing 100101, China; Beijing Institute for Stem Cell and Regenerative Medicine, Beijing 100101, China
| | - Lanfang Luo
- Key Laboratory of Organ Regeneration and Reconstruction, State Key Laboratory of Stem Cell and Reproductive Biology, Institute of Zoology, Chinese Academy of Sciences, Beijing 100101, China; Beijing Institute for Stem Cell and Regenerative Medicine, Beijing 100101, China; School of Biological Engineering, Zhuhai Campus of Zunyi Medical University, Guangdong 519000, China
| | - Hongmei Wang
- Key Laboratory of Organ Regeneration and Reconstruction, State Key Laboratory of Stem Cell and Reproductive Biology, Institute of Zoology, Chinese Academy of Sciences, Beijing 100101, China; Beijing Institute for Stem Cell and Regenerative Medicine, Beijing 100101, China; University of Chinese Academy of Sciences, Beijing 100049, China.
| | - Ng Shyh-Chang
- Key Laboratory of Organ Regeneration and Reconstruction, State Key Laboratory of Stem Cell and Reproductive Biology, Institute of Zoology, Chinese Academy of Sciences, Beijing 100101, China; Beijing Institute for Stem Cell and Regenerative Medicine, Beijing 100101, China; University of Chinese Academy of Sciences, Beijing 100049, China.
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Juriol L, Valeff N, Dibo M, Ventimiglia MS, Correale J, Jensen F. Human chorionic gonadotropin regulates cytokine production by lymphocytes from patients with multiple sclerosis. J Reprod Immunol 2024; 164:104280. [PMID: 38908336 DOI: 10.1016/j.jri.2024.104280] [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: 11/09/2023] [Revised: 06/09/2024] [Accepted: 06/10/2024] [Indexed: 06/24/2024]
Abstract
Multiple sclerosis (MS) is a chronic inflammatory demyelinating disease of the central nervous system (CNS) that primarily affects young adults, predominantly females. This was partially attributed to sex differences in immunity, which are influenced by changes in sex hormones occurring during women's life, among other factors. Furthermore, MS patients experience significant improvement in their symptoms during pregnancy when levels of female sex-hormones significantly increase. This phenomenon was attributed to immune adaptations occurring during gestation which are regulated by paternal antigens and sex hormones. The human chorionic gonadotropin (hCG) was shown to have strong immunosuppressive abilities. We aimed to analyze here the capacity of the hCG to regulate pro- and anti-inflammatory cytokine production by PBMC from MS patients. PBMC isolated from 17 MS patients receiving IFNβ1a treatment were cultured with or without recombinant or urinary hCG. Cytokine production in the supernatants was assessed using a CBA array and cytokine production by lymphocytes and expression of co-stimulatory molecules in B-lymphocytes were evaluated by flow cytometry. hCG reduced the production of TNF by PBMC from MS patients while lowering the percentages of TNF producing T cells and diminishing the production of TNF by B cells. hCG significantly boosted the production of IL-10 by regulatory T cells and CD19high B cells from MS patients. Furthermore, hCG treatment lowered the percentages of CD80+CD86+ expressing B cells within PBMC from MS patients. Overall, our results described a novel and not yet explored mechanisms of action of hCG in the context of MS.
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Affiliation(s)
- Lorena Juriol
- Center for Pharmacological and Botanical Studies (CEFYBO-UBA-CONICET), Graduate School of Medicine, University of Buenos Aires, 2155 Paraguay St. 16th Floor, Ciudad Autónoma de Buenos Aires C1121ABG, Argentina
| | - Natalín Valeff
- Center for Pharmacological and Botanical Studies (CEFYBO-UBA-CONICET), Graduate School of Medicine, University of Buenos Aires, 2155 Paraguay St. 16th Floor, Ciudad Autónoma de Buenos Aires C1121ABG, Argentina
| | - Marcos Dibo
- Center for Pharmacological and Botanical Studies (CEFYBO-UBA-CONICET), Graduate School of Medicine, University of Buenos Aires, 2155 Paraguay St. 16th Floor, Ciudad Autónoma de Buenos Aires C1121ABG, Argentina
| | - María Silvia Ventimiglia
- Center for Pharmacological and Botanical Studies (CEFYBO-UBA-CONICET), Graduate School of Medicine, University of Buenos Aires, 2155 Paraguay St. 16th Floor, Ciudad Autónoma de Buenos Aires C1121ABG, Argentina
| | - Jorge Correale
- Fleni, 2325 Montañeses St., Ciudad Autónoma de Buenos Aires C1428AQK, Argentina; Instituto de Química y Fisicoquímica Biológicas (IQUIFIB CONICET-UBA), Graduate School of Pharmacy and Biochemistry, University of Buenos Aires, 956 Junin St., Ciudad Autónoma de Buenos Aires C1113AAD, Argentina
| | - Federico Jensen
- Center for Pharmacological and Botanical Studies (CEFYBO-UBA-CONICET), Graduate School of Medicine, University of Buenos Aires, 2155 Paraguay St. 16th Floor, Ciudad Autónoma de Buenos Aires C1121ABG, Argentina; Centro Integrativo de Biología Y Química Aplicada, Universidad Bernardo O'Higgins, Santiago 8307993, Chile.
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Bove R, Applebee A, Bawden K, Fine C, Shah A, Avila RL, Belviso N, Branco F, Fong K, Lewin JB, Liu J, England SM, Vignos M. Patterns of disease-modifying therapy utilization before, during, and after pregnancy and postpartum relapses in women with multiple sclerosis. Mult Scler Relat Disord 2024; 88:105738. [PMID: 38959591 DOI: 10.1016/j.msard.2024.105738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 05/13/2024] [Accepted: 06/19/2024] [Indexed: 07/05/2024]
Abstract
BACKGROUND Pregnancy is a common consideration for people with multiple sclerosis (pwMS); MS onset is typically between 20 and 45 years of age, during potential child-bearing years. Pregnancy and postpartum care are a significant factor influencing disease-modifying therapy (DMT) selection for many pwMS. To date, few DMTs are considered safe to continue during pregnancy and real-world treatment patterns before, during, and after pregnancy remain uncharacterized. Evolving guidance is needed regarding how to optimize management of the pregnancy and postpartum periods considering the changing DMT landscape. This analysis in two large claims databases describes DMT utilization for the treatment of MS before, during, and after pregnancy and relapse patterns during pregnancy and postpartum. METHODS In this retrospective, observational study, the US MarketScan Commercial and Medicaid claims database was assessed for female patients aged 18-55 years with ≥1 insurance claim submitted under the diagnosis code of MS from 01 January 2016-30 April 2021 and continuous enrollment eligibility from ≥6 months prior to pregnancy date (preconception) through 6 months of follow-up following delivery (postpartum period). Comorbid conditions were examined preconception and postpartum, including anxiety and depression. Moderate/severe relapse was defined as MS-related hospitalization, or an outpatient visit and one claim within 7 days of the visit with steroids or total plasma exchange. RESULTS A total of 944 patients (mean [standard deviation] age, 32.4 [5.0] years) were eligible; 688 (73%) were commercially insured and 256 (27%) received Medicaid. Compared with commercially-insured patients, use of DMTs was lower among Medicaid patients at 6 months preconception (25.4% vs 40.4%; p < 0.001), with similar patterns observed both during pregnancy and postpartum. Overall, prevalence of DMT use declined sharply during pregnancy, from 36.3% of patients in the 6 months preconception to 17.9%, 5.3%, and 5.8% in trimesters 1, 2 and 3, respectively. Postpartum DMT utilization increased to 20.9% at 0-3 months and 24.4% at 4-6 months. Of all patients in the preconception period, the most frequently used DMTs were glatiramer acetate (14.3%), dimethyl fumarate (6.0%), interferon (5.2%), and natalizumab (4.9%). Due to small sample size, information was limited for anti-CD20s and alemtuzumab. The proportion of patients with any moderate/severe relapse declined over pregnancy (preconception, n = 82 [8.7%]; pregnancy, n = 25 [2.6%]), but increased postpartum (n = 94 [10.0%]). Of the 889 patients who stopped DMT during pregnancy, the risk of postpartum relapses was lower in the patients who resumed DMT postpartum (10/192) than in patients who did not (76/697) (5.2% vs 10.9%; odds ratio, 0.455 [95% confidence interval 0.216-0.860], p = 0.018). Cases of postpartum depression and anxiety were significantly lower in commercially-insured patients vs Medicaid patients (postpartum depression, 13.7% vs 27.0%, p < 0.01; postpartum anxiety, 16.3% vs 30.5%, p < 0.01). CONCLUSION DMT utilization declined sharply during pregnancy; it gradually increased postpartum but remained below pre-pregnancy use. The proportion of pwMS experiencing a moderate/severe relapse and number of relapses declined over pregnancy but increased postpartum. Reinitiation of DMT during the postpartum period was associated with lower risk of relapses, supporting a role for early reinitiation of DMT postpartum. STUDY SUPPORTED BY Biogen.
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Affiliation(s)
- Riley Bove
- Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
| | - Angela Applebee
- Department of Neurology, St. Peter's Multiple Sclerosis and Headache Center, Albany, NY, USA
| | - Katrina Bawden
- Rocky Mountain Multiple Sclerosis Clinic and Research Group, Salt Lake City, UT, USA
| | | | - Anna Shah
- Rocky Mountain Multiple Sclerosis Center, University of Colorado, Aurora, CO, USA
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Perillan C, Coto A, Arguelles J, Nuñez P. Study of the impact of multiple sclerosis on the reproductive life of Spanish women: An online survey. Mult Scler Relat Disord 2024; 90:105789. [PMID: 39096667 DOI: 10.1016/j.msard.2024.105789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Revised: 06/29/2024] [Accepted: 07/25/2024] [Indexed: 08/05/2024]
Abstract
BACKGROUND Women have a higher risk of developing multiple sclerosis (MS) than men. The natural reproductive period from menarche to menopause corresponds to the period of active inflammatory disease in MS. Mothers and pregnant women with MS need information about how their disease may affect pregnancy and breastfeeding. AIM The aim was to explore the reproductive factors in an MS-diagnosed population and to identify ways to support patients and their decision-making process. METHODS We conducted a cross-sectional, Web-based survey of women living with MS in Asturias (Spain) using a community-based participatory approach. FINDINGS Early menarche may predict the onset of MS. Pregnancy improves the general health of patients and reduces the number of relapses. Breastfeeding is often not practised and may cause concern in women. MS does not affect the age of menopause, but it can worsen symptoms. However, menopause does not increase the number of MS relapses. CONCLUSIONS MS is increasingly diagnosed at an earlier age, which increases the number of women who become pregnant after being diagnosed with MS. The decrease in MS relapses during pregnancy and the increase during the postpartum period are consistent with previous reports. Women who choose to breastfeed are in the minority due to treatment incompatibility, although some currently used treatments are compatible with breastfeeding. However, there is a lack of information on this which should be investigated.
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Affiliation(s)
- Carmen Perillan
- Department of Functional Biology, Physiology, Faculty of Medicine and Health Sciences, University of Oviedo, Oviedo, Spain
| | - Aroa Coto
- Department of Functional Biology, Physiology, Faculty of Medicine and Health Sciences, University of Oviedo, Oviedo, Spain
| | - Juan Arguelles
- Department of Functional Biology, Physiology, Faculty of Medicine and Health Sciences, University of Oviedo, Oviedo, Spain
| | - Paula Nuñez
- Department of Functional Biology, Physiology, Faculty of Medicine and Health Sciences, University of Oviedo, Oviedo, Spain.
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Saito S, Ikeguchi R, Kitagawa K, Shimizu Y. Clinical Experience with Dimethyl Fumarate and Natalizumab in Pregnant Women with Multiple Sclerosis: A Four-Patient Case Series. Case Rep Neurol Med 2024; 2024:7808140. [PMID: 39044765 PMCID: PMC11265946 DOI: 10.1155/2024/7808140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Revised: 05/12/2024] [Accepted: 07/04/2024] [Indexed: 07/25/2024] Open
Abstract
Interferon β and glatiramer acetate are the disease-modifying drugs (DMDs) considered relatively safe for use in pregnant women with multiple sclerosis (MS); however, the safety profile of dimethyl fumarate (DMF) and natalizumab (NTZ) in this population remains inconclusive. Here, we present four cases of pregnant women with MS who were treated with DMF and NTZ (n = 2 patients, each) during their pregnancy and discuss our observations with the use of these drugs and the clinical courses of the patients. We retrospectively examined relapse of MS during pregnancy and after delivery; duration of exposure to DMDs; maternal, fetal, and neonatal adverse events; breastfeeding; and timing of resumption of DMDs. The two patients treated with DMF discontinued treatment 5 or 6 weeks after the discovery of pregnancy. DMF was resumed 1 week postpartum, and mixed breastfeeding was initiated. Brain magnetic resonance imaging in one patient 9 months after delivery revealed a new lesion; however, it was not classified as a clinical relapse. In two patients treated with NTZ, the dosing interval was extended to 6 weeks after the discovery of pregnancy. One patient discontinued NTZ at 30 weeks and the other at 25 weeks of gestation, as a slight restriction in fetal growth was observed owing to hyperemesis gravidarum. Both patients opted for formula feeding, and no relapse was observed within 1 year postpartum. Additionally, no abnormalities were observed in any of the patients during the perinatal period, and their development was normal. Investigation of drug safety in pregnant and parturient women primarily relies on registries, postmarketing surveillance, and case reports due to ethical limitations on conducting randomized controlled trials. Our findings demonstrated that DMF and NTZ were not contraindicated during pregnancy or the perinatal period in women with MS; nevertheless, vigilant monitoring is essential to ensure the safety of these drugs.
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Affiliation(s)
- Satoshi Saito
- Department of NeurologyTokyo Women's Medical University School of Medicine, 8-1, Kawadacho, Shinjukuku, Tokyo, Japan
| | - Ryotaro Ikeguchi
- Department of NeurologyTokyo Women's Medical University School of Medicine, 8-1, Kawadacho, Shinjukuku, Tokyo, Japan
| | - Kazuo Kitagawa
- Department of NeurologyTokyo Women's Medical University School of Medicine, 8-1, Kawadacho, Shinjukuku, Tokyo, Japan
| | - Yuko Shimizu
- Department of NeurologyTokyo Women's Medical University School of Medicine, 8-1, Kawadacho, Shinjukuku, Tokyo, Japan
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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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Andersen ML, Jølving LR, Iachina M, Anru PL, Stenager E, Knudsen T, Nørgård BM. Neonatal outcomes in women with Multiple Sclerosis - Influence of disease activity: A Danish nationwide cohort study. Mult Scler Relat Disord 2024; 85:105549. [PMID: 38518505 DOI: 10.1016/j.msard.2024.105549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 02/20/2024] [Accepted: 03/10/2024] [Indexed: 03/24/2024]
Abstract
BACKGROUND Maternal Multiple Sclerosis (MS) has been associated with an increased risk of adverse birth outcomes. We hypothesized that active disease during conception and pregnancy plays an important role in this context, which this study aims to address. METHODS We used the Danish registers to conduct a nationwide cohort study. Information on maternal disease activity during pregnancy was retrieved using proxies from the linked registers (hospitalization, magnetic resonance imaging of the brain, and use of systemic corticosteroids during pregnancy). Neonates, exposed in utero to maternal disease activity constituted the exposed cohort and the unexposed cohort constituted neonates without in utero exposure to maternal disease activity. The examined outcomes were preterm birth, small for gestational age, low 5-minute Apgar score, and major congenital anomalies. In logistic regression models we estimated the odds ratios (OR) with adjustment for confounders such as maternal age, comorbidities, parity, smoking, calendar year of birth, and disease-modifying treatment. RESULTS Among the study population of 2492 children of mothers with MS we identified 273 (11 %) neonates exposed to maternal disease activity during pregnancy, and 2219 (89 %) neonates without exposure to disease activity. The adjusted odds ratios (aOR) for preterm birth, small for gestational age, low 5-minute Apgar score, and major congenital anomalies among children born to women with disease activity during pregnancy were 0.92 (95 % confidence interval (95 % CI) 0.53-1.60), aOR 1.19 (95 % CI 0.62-2.26), aOR 2.57 (95 % CI 0.93-7.15) and aOR 0.93 (95 % CI 0.48-1.83), respectively. CONCLUSIONS Women with MS having disease activity during pregnancy did not have a statistically significantly increased risk of adverse neonatal outcomes compared to women with MS without disease activity, which is overall reassuring results. We believe, that this will be useful knowledge for patients and clinicians in planning a pregnancy and preparing a birth plan.
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Affiliation(s)
- Mette Louise Andersen
- Center for Clinical Epidemiology, Odense University Hospital, Kløvervænget 30, entrance 216, Odense DK-5000, Denmark; Department of Clinical Research, Research Unit of Clinical Epidemiology, University of Southern Denmark, Denmark; Department of Gynecology and Obstetrics, University Hospital of Sothern Denmark, Esbjerg, Denmark.
| | - Line Riis Jølving
- Center for Clinical Epidemiology, Odense University Hospital, Kløvervænget 30, entrance 216, Odense DK-5000, Denmark; Department of Clinical Research, Research Unit of Clinical Epidemiology, University of Southern Denmark, Denmark
| | - Maria Iachina
- Center for Clinical Epidemiology, Odense University Hospital, Kløvervænget 30, entrance 216, Odense DK-5000, Denmark
| | - Pavithra Laxsen Anru
- Center for Clinical Epidemiology, Odense University Hospital, Kløvervænget 30, entrance 216, Odense DK-5000, Denmark
| | - Egon Stenager
- Department of Regional Research, University of Southern Denmark, Denmark; Multiple Sclerosis Clinic of Southern Jutland, University Hospital of Southern Jutland, Denmark
| | - Torben Knudsen
- Department of Regional Research, University of Southern Denmark, Denmark; Department of Gastroenterology, University Hospital of Southern Jutland, Denmark
| | - Bente Mertz Nørgård
- Center for Clinical Epidemiology, Odense University Hospital, Kløvervænget 30, entrance 216, Odense DK-5000, Denmark; Department of Clinical Research, Research Unit of Clinical Epidemiology, University of Southern Denmark, Denmark
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Witt L, Thiel S, Hellwig K. [Pregnancy and breastfeeding in women with multiple sclerosis]. DER NERVENARZT 2024; 95:329-334. [PMID: 38393359 DOI: 10.1007/s00115-024-01621-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/19/2024] [Indexed: 02/25/2024]
Abstract
The diagnosis of multiple sclerosis (MS) in women of reproductive age is associated with many uncertainties regarding childbearing and lactation. Pregnancies of MS patients are not usually considered high-risk pregnancies per se. The likelihood of pregnancy complications or adverse pregnancy outcomes is not increased by the disease; however, a careful planning of pregnancy is important in order to choose the treatment option with the greatest benefit for the mother and the least possible risk for the baby. For highly active courses of the disease, anti-CD20 antibodies, cladribine, or continued administration of natalizumab show the best data. Patients with MS can be supported in their desire to breastfeed. If women have had a very active disease course, it is recommended that treatment should be started as soon as possible postpartum. Interferon-beta preparations, glatiramer acetate and ofatumumab are also approved for use during breastfeeding but off-label breastfeeding is also possible with other monoclonal antibodies.
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Affiliation(s)
- Laura Witt
- Neurologische Klinik St. Josef Hospital, Ruhr-Universität Bochum, Gudrunstraße 56, 44791, Bochum, Deutschland
| | - Sandra Thiel
- Neurologische Klinik St. Josef Hospital, Ruhr-Universität Bochum, Gudrunstraße 56, 44791, Bochum, Deutschland
| | - Kerstin Hellwig
- Neurologische Klinik St. Josef Hospital, Ruhr-Universität Bochum, Gudrunstraße 56, 44791, Bochum, Deutschland.
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Graham EL, Bove R, Costello K, Crayton H, Jacobs DA, Shah S, Sorrell F, Stoll SS, Houtchens MK. Practical Considerations for Managing Pregnancy in Patients With Multiple Sclerosis: Dispelling the Myths. Neurol Clin Pract 2024; 14:e200253. [PMID: 38585436 PMCID: PMC10996912 DOI: 10.1212/cpj.0000000000200253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 11/27/2023] [Indexed: 04/09/2024]
Abstract
Purpose of Review Lack of consistent data and guidance have led to variations between clinicians in the management of pregnancy in women with multiple sclerosis (MS). Pregnant and/or lactating women are often excluded from clinical trials conducted in MS, and thus, the labeling for most disease-modifying therapies (DMTs) excludes use during pregnancy. This has led to heterogeneity in interpretation and labeling regarding the safety of DMTs during pregnancy and lactation and the required preconception washout periods. This review identifies key themes where there is conflicting information surrounding family planning and pregnancy in MS, focusing on the most common discussion points between physicians and patients during preconception planning, pregnancy, postpartum, and lactation. The goal was to inform the patient-physician conversation and provide best practice recommendations based on expert clinical expertise and experience. Recent Findings We outline the latest evidence-based data for DMT use during pregnancy and lactation, the effect of MS on fertility and fertility treatments, the risk of adverse pregnancy and delivery outcomes, the risk of postpartum relapse, and immunization and clinical imaging safety during pregnancy and breastfeeding. Summary Management of family planning and pregnancy in patients with MS requires the most current information. Health care providers should discuss family planning early and frequently with patients with MS, and partners where practicable. Because management of pregnant people with MS will often require a risk/benefit analysis of their needs, shared decision-making in family planning discussions is emphasized. Additional data are needed for specific and underrepresented populations with MS (e.g., single parents or those from the LGBTQ+ community) and those at risk of racial and socioeconomic disparities in care. Pregnancy registries and the design and conduct of clinical trials focused on pregnant and lactating patients should provide additional data to guide the ongoing management of patients with MS.
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Affiliation(s)
- Edith L Graham
- Department of Neurology (ELG), Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Neurology (RB), UCSF Weill Institute for Neurosciences, University of California, San Francisco; Can Do Multiple Sclerosis (KC), Avon, CO; Multiple Sclerosis Center of Greater Washington (HC), Vienna, VA; Department of Neurology (DAJ), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Neurology (SS), Duke University School of Medicine, Durham, NC; Envision Pharma Group (FS), Glasgow, UK; Stoll Medical Group (SSS), Philadelphia, PA; and Brigham Multiple Sclerosis Center (MKH), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Riley Bove
- Department of Neurology (ELG), Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Neurology (RB), UCSF Weill Institute for Neurosciences, University of California, San Francisco; Can Do Multiple Sclerosis (KC), Avon, CO; Multiple Sclerosis Center of Greater Washington (HC), Vienna, VA; Department of Neurology (DAJ), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Neurology (SS), Duke University School of Medicine, Durham, NC; Envision Pharma Group (FS), Glasgow, UK; Stoll Medical Group (SSS), Philadelphia, PA; and Brigham Multiple Sclerosis Center (MKH), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Kathleen Costello
- Department of Neurology (ELG), Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Neurology (RB), UCSF Weill Institute for Neurosciences, University of California, San Francisco; Can Do Multiple Sclerosis (KC), Avon, CO; Multiple Sclerosis Center of Greater Washington (HC), Vienna, VA; Department of Neurology (DAJ), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Neurology (SS), Duke University School of Medicine, Durham, NC; Envision Pharma Group (FS), Glasgow, UK; Stoll Medical Group (SSS), Philadelphia, PA; and Brigham Multiple Sclerosis Center (MKH), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Heidi Crayton
- Department of Neurology (ELG), Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Neurology (RB), UCSF Weill Institute for Neurosciences, University of California, San Francisco; Can Do Multiple Sclerosis (KC), Avon, CO; Multiple Sclerosis Center of Greater Washington (HC), Vienna, VA; Department of Neurology (DAJ), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Neurology (SS), Duke University School of Medicine, Durham, NC; Envision Pharma Group (FS), Glasgow, UK; Stoll Medical Group (SSS), Philadelphia, PA; and Brigham Multiple Sclerosis Center (MKH), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Dina A Jacobs
- Department of Neurology (ELG), Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Neurology (RB), UCSF Weill Institute for Neurosciences, University of California, San Francisco; Can Do Multiple Sclerosis (KC), Avon, CO; Multiple Sclerosis Center of Greater Washington (HC), Vienna, VA; Department of Neurology (DAJ), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Neurology (SS), Duke University School of Medicine, Durham, NC; Envision Pharma Group (FS), Glasgow, UK; Stoll Medical Group (SSS), Philadelphia, PA; and Brigham Multiple Sclerosis Center (MKH), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Suma Shah
- Department of Neurology (ELG), Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Neurology (RB), UCSF Weill Institute for Neurosciences, University of California, San Francisco; Can Do Multiple Sclerosis (KC), Avon, CO; Multiple Sclerosis Center of Greater Washington (HC), Vienna, VA; Department of Neurology (DAJ), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Neurology (SS), Duke University School of Medicine, Durham, NC; Envision Pharma Group (FS), Glasgow, UK; Stoll Medical Group (SSS), Philadelphia, PA; and Brigham Multiple Sclerosis Center (MKH), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Francesca Sorrell
- Department of Neurology (ELG), Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Neurology (RB), UCSF Weill Institute for Neurosciences, University of California, San Francisco; Can Do Multiple Sclerosis (KC), Avon, CO; Multiple Sclerosis Center of Greater Washington (HC), Vienna, VA; Department of Neurology (DAJ), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Neurology (SS), Duke University School of Medicine, Durham, NC; Envision Pharma Group (FS), Glasgow, UK; Stoll Medical Group (SSS), Philadelphia, PA; and Brigham Multiple Sclerosis Center (MKH), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Sharon S Stoll
- Department of Neurology (ELG), Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Neurology (RB), UCSF Weill Institute for Neurosciences, University of California, San Francisco; Can Do Multiple Sclerosis (KC), Avon, CO; Multiple Sclerosis Center of Greater Washington (HC), Vienna, VA; Department of Neurology (DAJ), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Neurology (SS), Duke University School of Medicine, Durham, NC; Envision Pharma Group (FS), Glasgow, UK; Stoll Medical Group (SSS), Philadelphia, PA; and Brigham Multiple Sclerosis Center (MKH), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Maria K Houtchens
- Department of Neurology (ELG), Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Neurology (RB), UCSF Weill Institute for Neurosciences, University of California, San Francisco; Can Do Multiple Sclerosis (KC), Avon, CO; Multiple Sclerosis Center of Greater Washington (HC), Vienna, VA; Department of Neurology (DAJ), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Neurology (SS), Duke University School of Medicine, Durham, NC; Envision Pharma Group (FS), Glasgow, UK; Stoll Medical Group (SSS), Philadelphia, PA; and Brigham Multiple Sclerosis Center (MKH), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Renaud J, Buissonnière P, Dulau C, Deloire M, Hontarrede F, Montcuquet A, Chansel-Debordeaux L, Hocké C, Ouallet JC, Ruet A, Bernard V. Gynaecological follow-up for women of reproductive age with multiple sclerosis: The GYNESEP study. Mult Scler Relat Disord 2024; 83:105448. [PMID: 38277979 DOI: 10.1016/j.msard.2024.105448] [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: 09/14/2023] [Revised: 12/21/2023] [Accepted: 01/13/2024] [Indexed: 01/28/2024]
Abstract
BACKGROUND The gynaecological care of women with Multiple Sclerosis has received little attention; most reports focussed on pregnancy or sexuality. The objective of the present study was to evaluate if gynaecological follow-up for women of reproductive age with Multiple Sclerosis was adequate. METHODS We performed a cross-sectional study on a large cohort of women with Multiple Sclerosis aged 18-40 years. All participants completed online questionnaires on general health status, gynaecological follow-up, and sexuality. Expanded Disability Status Scale (EDSS) scores were extracted from medical records. The study was registered in clinicaltrials.gov with the number NCT05248438, and in the European database ID-RCB with the number 2021-A02912-39. RESULTS Of the 192 patients who completed questionnaires, 157 (82.2%) reported gynaecological follow-up. Of the 155 patients on immunosuppressive treatments, only 31 (20%) underwent annual cervical screening. Of the 140 patients who met the French papillomavirus vaccination age recommendations, only 50 (35.7%) were vaccinated. A total of 128 (66.7%) patients used contraception. However, 16 (8.3%) patients reported unplanned pregnancies since the time of diagnosis. CONCLUSION Women with Multiple Sclerosis require more information on reproductive health and prevention of cancer. Better contraceptive advice would reduce the number of unplanned pregnancies and avoid foetal exposure to potentially teratogenic treatment.
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Affiliation(s)
- Juliette Renaud
- Department of Gynecology and Reproductive Medicine, CHU de Bordeaux, Bordeaux F-33000, France
| | | | - Cécile Dulau
- Department of Neurology, CHU de Bordeaux, Bordeaux F-33000, France
| | - Mathilde Deloire
- Department of Neurology, CHU de Bordeaux, Bordeaux F-33000, France
| | | | | | - Lucie Chansel-Debordeaux
- Department of Reproductive Biology-CECOS, CHU de Bordeaux, Bordeaux F- 33000, France; Bordeaux Institute of Oncology-BRIC-BioGo Team, INSERM U1312, University of Bordeaux, Bordeaux F-33000, France
| | - Claude Hocké
- Department of Gynecology and Reproductive Medicine, CHU de Bordeaux, Bordeaux F-33000, France
| | | | - Aurélie Ruet
- Department of Neurology, CHU de Bordeaux, Bordeaux F-33000, France; Neurocentre Magendie, INSERM U1215, University Bordeaux, Bordeaux F-33000, France
| | - Valérie Bernard
- Department of Gynecology and Reproductive Medicine, CHU de Bordeaux, Bordeaux F-33000, France; Bordeaux Institute of Oncology-BRIC-BioGo Team, INSERM U1312, University of Bordeaux, Bordeaux F-33000, France.
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11
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Liu H, Zhang X, Chen W, Xu Y, Lin X, Lin A. The relationship between plasma prolactin levels and clinical manifestations with neuromyelitis optica spectrum disorders. Neurol Sci 2024; 45:699-707. [PMID: 37620730 DOI: 10.1007/s10072-023-07008-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 08/04/2023] [Indexed: 08/26/2023]
Abstract
INTRODUCTION Systemic prolactin levels have been found to increase in 19 patients diagnosed with neuromyelitis optica spectrum disorders (NMOSD). However, the relationship between plasma prolactin levels and clinical manifestations in NMOSD patients remains unclear. METHODS This cross-sectional study was conducted as part of a Registered Cohort Study of Inflammatory Demyelination Disease (NCT04386018). A total of 95 patients diagnosed with central nervous system demyelinating diseases and 43 healthy controls were recruited between May 2020 and February 2022 at the First Affiliated Hospital of Fujian Medical University. Plasma samples were collected from all participants and analyzed for prolactin levels using electrochemiluminescence immunoassay. The study aimed to investigate the correlation between plasma prolactin levels and clinical features in patients with central nervous system demyelinating diseases. RESULTS Plasma prolactin levels in NMOSD patients were significantly higher than those in multiple sclerosis/myelin oligodendrocyte glycoprotein antibody-associated diseases patients and controls (p<0.05, respectively), and were found to be correlated with disease activity, sensory abnormalities, thoracic spinal cord lesions, and MR lesion enhancement (p<0.05). A total of 16.28% of NMOSD patients exhibited macroprolactinemia. However, there was no correlation found between macroprolactin levels and disease activity (p>0.05). CONCLUSION Prolactin may play a role in the pro-inflammatory regulation mechanism of NMOSD.
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Affiliation(s)
- Hanchen Liu
- Fujian Key Laboratory of Molecular Neurology, Institute of Neuroscience, Fujian Medical University, Fuzhou, 350004, Fujian, China
| | - Xianxing Zhang
- Department of Neurology, the First Affiliated Hospital of Fujian Medical University, Fuzhou, 350005, Fujian, China
- Department of Neurology, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital of Fujian Medical University, Fuzhou, 350212, Fujian, China
| | - Wei Chen
- Fujian Key Laboratory of Molecular Neurology, Institute of Neuroscience, Fujian Medical University, Fuzhou, 350004, Fujian, China
- Department of Neurology, the First Affiliated Hospital of Fujian Medical University, Fuzhou, 350005, Fujian, China
- Department of Neurology, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital of Fujian Medical University, Fuzhou, 350212, Fujian, China
| | - Yiwen Xu
- Department of Neurology, the First Affiliated Hospital of Fujian Medical University, Fuzhou, 350005, Fujian, China
| | - Xiaoting Lin
- Department of Neurology, the First Affiliated Hospital of Fujian Medical University, Fuzhou, 350005, Fujian, China
| | - Aiyu Lin
- Fujian Key Laboratory of Molecular Neurology, Institute of Neuroscience, Fujian Medical University, Fuzhou, 350004, Fujian, China.
- Department of Neurology, the First Affiliated Hospital of Fujian Medical University, Fuzhou, 350005, Fujian, China.
- Department of Neurology, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital of Fujian Medical University, Fuzhou, 350212, Fujian, China.
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12
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Vukusic S, Bourre B, Casey R, Deiva K, Guennoc AM, Lebrun-Frenay C, Leray E, Rollot F, Benyahya L, Girod C, Marignier R, Maillart E. The Response Study: A French registry on pregnancy in women with MS and related disorders and their children up to 6 years-Protocol, recruitment status, and baseline characteristics. Mult Scler 2024; 30:216-226. [PMID: 38205811 DOI: 10.1177/13524585231223390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Abstract
BACKGROUND Counseling on pregnancy is still challenging, particularly regarding the use of disease-modifying treatments (DMTs). We are lacking long-term outcomes in children exposed to DMTs. OBJECTIVES This study aimed to set up a French pregnancy registry for women with multiple sclerosis (MS) and related disorders nested within the Observatoire Français de la Sclérose en Plaques (OFSEP) cohort. METHODS Prospective, observational, multicentric, epidemiological study in France. Neurological visits are organized according to routine practice. Data are collected on the OFSEP minimal datasheet. Auto-questionnaires on pregnancy are completed by patients at Months 5-6 and 8 during pregnancy, and Months 3, 6, and 12 postpartum. A specific survey on analgesia is completed by anesthesiologists. Pediatric data are collected from the child's health book, where visits on Day 8, Month 9, and 24 are mandatory. Parents complete neurodevelopmental questionnaires at Year 1, Years 2 and 6. RESULTS The RESPONSE study started in August 2019. On 7 April 2023, 515 women were included. Baseline demographics are presented. CONCLUSIONS RESPONSE will provide rich information on the global management of pregnancy in France and prospective data on children until the age of 6 years, exposed or not to a DMT, including data on neurodevelopment that can be compared to the general population. STUDY FUNDING EDMUS and ARSEP Foundation, Biogen, Roche.
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Affiliation(s)
- Sandra Vukusic
- Hospices Civils de Lyon, Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro-Inflammation-Hôpital Neurologique Pierre Wertheimer, Bron Cedex, France
- Observatoire Français de la Sclérose en Plaques, Centre de Recherche en Neurosciences de Lyon, INSERM 1028 et CNRS UMR 5292, Lyon, France
- Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
- Eugène Devic EDMUS Foundation Against Multiple Sclerosis, State-Approved Foundation, Bron Cedex, France
| | | | - Romain Casey
- Hospices Civils de Lyon, Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro-Inflammation-Hôpital Neurologique Pierre Wertheimer, Bron Cedex, France
- Observatoire Français de la Sclérose en Plaques, Centre de Recherche en Neurosciences de Lyon, INSERM 1028 et CNRS UMR 5292, Lyon, France
- Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
- Eugène Devic EDMUS Foundation Against Multiple Sclerosis, State-Approved Foundation, Bron Cedex, France
| | - Kumaran Deiva
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Paris Saclay, Site Bicêtre, Service de Neurologie Pédiatrique, CRMR Maladies Inflammatoires Rares du Cerveau et de la Moelle (MIRCEM), UMR 1184, Le Kremlin-Bicêtre, France
| | | | - Christine Lebrun-Frenay
- CRCSEP Côte d'Azur, CHU de Nice Pasteur 2, Nice, France
- UR2CA-URRIS, Université Nice Côte d'Azur, Nice, France
| | - Emmanuelle Leray
- Université de Rennes, EHESP, CNRS, Inserm, Arènes-UMR 6051, RSMS (Recherche sur les Services et Management en Santé)-U 1309, Rennes, France
| | - Fabien Rollot
- Hospices Civils de Lyon, Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro-Inflammation-Hôpital Neurologique Pierre Wertheimer, Bron Cedex, France
- Observatoire Français de la Sclérose en Plaques, Centre de Recherche en Neurosciences de Lyon, INSERM 1028 et CNRS UMR 5292, Lyon, France
- Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
- Eugène Devic EDMUS Foundation Against Multiple Sclerosis, State-Approved Foundation, Bron Cedex, France
| | - Lakhdar Benyahya
- Hospices Civils de Lyon, Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro-Inflammation-Hôpital Neurologique Pierre Wertheimer, Bron Cedex, France
- Hospices Civils de Lyon, Hôpital Neurologique Pierre Wertheimer, Centre de Référence des Maladies Inflammatoires Rares du Cerveau et de la Moelle (MIRCEM), Bron Cedex, France
| | - Catherine Girod
- Hospices Civils de Lyon, Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro-Inflammation-Hôpital Neurologique Pierre Wertheimer, Bron Cedex, France
| | - Romain Marignier
- Hospices Civils de Lyon, Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro-Inflammation-Hôpital Neurologique Pierre Wertheimer, Bron Cedex, France
- Hospices Civils de Lyon, Hôpital Neurologique Pierre Wertheimer, Centre de Référence des Maladies Inflammatoires Rares du Cerveau et de la Moelle (MIRCEM), Bron Cedex, France
- Centre des Neurosciences de Lyon-FORGETTING Team, INSERM 1028 et CNRS UMR5292, Lyon, France
- Université Claude Bernard Lyon 1, Lyon, France
| | - Elisabeth Maillart
- Department of Neurology, Pitié-Salpêtrière Hospital, APHP, Paris, France
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13
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Kelly EE, Engel C, Pearsall R, Brenton JN, Bove R, Oh U, Goldman MD. Multiple Sclerosis and Family Planning: A Survey Study of the Patient Experience. Neurol Clin Pract 2024; 14:e200222. [PMID: 38148835 PMCID: PMC10751018 DOI: 10.1212/cpj.0000000000200222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 11/04/2023] [Indexed: 12/28/2023]
Abstract
Background and Objectives Multiple sclerosis (MS) commonly affects women in their childbearing years, necessitating discussion between patients and their MS treatment team around the issues of family planning, pregnancy, and postpartum experiences. This study assessed the impact of a diagnosis of MS on women's reproductive decision-making and on their perception of counseling received surrounding pregnancy. It also sought to evaluate trends in pregnancy and postpartum experiences and determine whether experiences differed by race, ethnicity, and zip code. Methods Women with an MS diagnosis seen at the University of Virginia MS Clinic or at Virginia Commonwealth University (VCU) MS Clinic were invited to participate in a survey study. MS disease and pregnancy history, and, when appropriate, reasons for pregnancy avoidance were collected. Respondents who had >1 pregnancy following MS diagnosis were asked to evaluate the counseling they received from medical professionals and to share their pregnancy experiences including complications during pregnancy, delivery outcomes, and postpartum experience including breastfeeding. Results Of the 280 respondents, 76.6% were currently receiving MS specialty care. Most of them (79.3%) had not been pregnant following MS diagnosis. Of them, 20.1% indicated that this decision was driven by MS-related concerns: MS worsening with pregnancy (47%); ability to care for child secondary to MS (35%); passing MS onto child (19%); stopping disease-modifying therapies to attempt pregnancy (14%); lack of knowledge about options for pregnancy and MS (9%). Women with a more recent estimated decade of pregnancy were more likely to report neurologist counseling regarding MS and pregnancy (pregnancy before 2000: 40%, 2000-2010: 64.7%, 2010- present: 83.3%; χ2 0.020). Breastfeeding initiation was reported in 71.4% of postdiagnosis pregnancies (median duration 6 months, interquartile range 1.75-11). Discussion Over the past few decades, women with MS have received a wide range of evolving guidance surrounding family planning, pregnancy, and postpartum care. Survey data suggest improvements in MS/pregnancy counseling and medical management in recent years, which may be driven by an increase in research in the field. There remains an important need and opportunity to improve counseling of women with MS who are considering pregnancy.
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Affiliation(s)
- Erin E Kelly
- Virginia Commonwealth University School of Medicine (EEK), Richmond; Virginia Tech Carilion School of Medicine (CE), Roanoke; College of Arts and Sciences (RP); Division of Child Neurology (JNB), Department of Neurology, University of Virginia, Charlottesville; UCSF Weill Institute for Neurosciences (RB), University of California San Francisco; and Virginia Commonwealth University (UO, MDG)
| | - Casey Engel
- Virginia Commonwealth University School of Medicine (EEK), Richmond; Virginia Tech Carilion School of Medicine (CE), Roanoke; College of Arts and Sciences (RP); Division of Child Neurology (JNB), Department of Neurology, University of Virginia, Charlottesville; UCSF Weill Institute for Neurosciences (RB), University of California San Francisco; and Virginia Commonwealth University (UO, MDG)
| | - Rylan Pearsall
- Virginia Commonwealth University School of Medicine (EEK), Richmond; Virginia Tech Carilion School of Medicine (CE), Roanoke; College of Arts and Sciences (RP); Division of Child Neurology (JNB), Department of Neurology, University of Virginia, Charlottesville; UCSF Weill Institute for Neurosciences (RB), University of California San Francisco; and Virginia Commonwealth University (UO, MDG)
| | - J Nicholas Brenton
- Virginia Commonwealth University School of Medicine (EEK), Richmond; Virginia Tech Carilion School of Medicine (CE), Roanoke; College of Arts and Sciences (RP); Division of Child Neurology (JNB), Department of Neurology, University of Virginia, Charlottesville; UCSF Weill Institute for Neurosciences (RB), University of California San Francisco; and Virginia Commonwealth University (UO, MDG)
| | - Riley Bove
- Virginia Commonwealth University School of Medicine (EEK), Richmond; Virginia Tech Carilion School of Medicine (CE), Roanoke; College of Arts and Sciences (RP); Division of Child Neurology (JNB), Department of Neurology, University of Virginia, Charlottesville; UCSF Weill Institute for Neurosciences (RB), University of California San Francisco; and Virginia Commonwealth University (UO, MDG)
| | - Unsong Oh
- Virginia Commonwealth University School of Medicine (EEK), Richmond; Virginia Tech Carilion School of Medicine (CE), Roanoke; College of Arts and Sciences (RP); Division of Child Neurology (JNB), Department of Neurology, University of Virginia, Charlottesville; UCSF Weill Institute for Neurosciences (RB), University of California San Francisco; and Virginia Commonwealth University (UO, MDG)
| | - Myla D Goldman
- Virginia Commonwealth University School of Medicine (EEK), Richmond; Virginia Tech Carilion School of Medicine (CE), Roanoke; College of Arts and Sciences (RP); Division of Child Neurology (JNB), Department of Neurology, University of Virginia, Charlottesville; UCSF Weill Institute for Neurosciences (RB), University of California San Francisco; and Virginia Commonwealth University (UO, MDG)
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14
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Haben S, Ciplea AI, Tokic M, Timmesfeld N, Thiel S, Gold R, Langer-Gould AM, Hellwig K. Early postpartum treatment strategies and early postpartum relapses in women with active multiple sclerosis. J Neurol Neurosurg Psychiatry 2024; 95:151-157. [PMID: 37536925 PMCID: PMC10850706 DOI: 10.1136/jnnp-2023-331525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 07/20/2023] [Indexed: 08/05/2023]
Abstract
BACKGROUND Relapse risk after delivery is increased in women with active multiple sclerosis (MS), the best strategy to reduce it is unknown. We aimed to assess the association of four different postpartum strategies with relapses during the first 6 months post partum. METHODS This cohort study includes data prospectively collected through structured telephone interviews from the German Multiple Sclerosis and Pregnancy Registry. Pregnancies with active MS (fingolimod or natalizumab treatment OR relapse within 1 year before pregnancy) and postpartum follow-up of ≥6 months were included. We compared four strategies: (1) intention to breastfeed exclusively without disease-modifying therapy (DMT) (exclusive breast feeding ≥2 months or switching to non-exclusive/weaning within 2 weeks after a relapse during the first 2 months), (2) early treatment with natalizumab/fingolimod and (3) other DMT initiated within 6 weeks post partum before a relapse. If women did not or only partially breastfed, or started DMT≤6 weeks after delivery after a relapse or later, we assumed (4) no-DMT-no-exclusive- breastfeeding-strategy. Main outcome was time to postpartum MS relapses. RESULTS In 867 women with 911 pregnancies, most (n=416) intended to breastfeed exclusively or had no-DMT-no-exclusive-breastfeeding-strategy (n=290); fewer started fingolimod (n=38), natalizumab (n=74) or another DMT (n=93) early. Recurrent time-to-event analysis showed a statistically significant reduction in relapse hazard only with the natalizumab/fingolimod-strategy as of months 3-4 post partum compared with intention-to-breastfeed-exclusively-strategy. The very early relapse risk was highest in no-DMT-no-exclusive-breastfeeding-strategy. CONCLUSION In active MS, an early postpartum treatment strategy should be determined well before delivery. Natalizumab/fingolimod-strategy reduced postpartum relapse hazard from month 3, but none diminished the early postpartum relapse hazard.
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Affiliation(s)
- Sabrina Haben
- Department of Neurology, Katholisches Klinikum Bochum, Ruhr-Universität Bochum, Bochum, Germany
| | - Andrea I Ciplea
- Department of Neurology, Katholisches Klinikum Bochum, Ruhr-Universität Bochum, Bochum, Germany
| | - Marianne Tokic
- Medical Informatics, Biometry and Epidemiology, Ruhr-Universitat Bochum, Bochum, Germany
| | - Nina Timmesfeld
- Medical Informatics, Biometry and Epidemiology, Ruhr-Universitat Bochum, Bochum, Germany
| | - Sandra Thiel
- Department of Neurology, Katholisches Klinikum Bochum, Ruhr-Universität Bochum, Bochum, Germany
| | - Ralf Gold
- Department of Neurology, Katholisches Klinikum Bochum, Ruhr-Universität Bochum, Bochum, Germany
| | | | - Kerstin Hellwig
- Department of Neurology, Katholisches Klinikum Bochum, Ruhr-Universität Bochum, Bochum, Germany
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15
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Klehmet J, Begus-Nahrmann Y, Taipale K, Niemczyk G, Rehberg-Weber K. Pregnancy outcomes in female multiple sclerosis patients exposed to intramuscular interferon beta-1a or peginterferon beta-1a reported in a German Patient Support Programme - results from the non-interventional post-authorization safety study PRIMA. Ther Adv Neurol Disord 2023; 16:17562864231214041. [PMID: 38107443 PMCID: PMC10725088 DOI: 10.1177/17562864231214041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 10/27/2023] [Indexed: 12/19/2023] Open
Abstract
Background Based on data from two large cohort studies, a label update became applicable for the class of interferon beta therapies in 9/2019, allowing interferons during pregnancy and breastfeeding. Objective To assess pregnancy outcomes of women with multiple sclerosis (MS) exposed to peginterferon beta-1a or intramuscular interferon beta-1a therapy (IFN). Design Non-interventional post-authorization safety study. Methods PRIMA was conducted from April to October 2021 in Germany. Retrospective pregnancy data were retrieved from adult female patients diagnosed with relapsing-remitting MS or clinically isolated syndrome, exposed to IFN before or during pregnancy and registered in the patient support programme (PSP) of the marketing authorization holder's MS Service Centre. The primary endpoint was the outcome of pregnancy. Prospective postpartum data were collected from mothers reporting live births. Results In total, 426 women reporting 542 pregnancies between December 2001 and July 2020 (14 pregnancies after the label update) were enrolled. Among patients with confirmed exposure during pregnancy (N = 362), 306 pregnancies (84.5%) resulted in live births (77.6% without defects, 1.9% with defects and 4.4% preterm). Spontaneous abortion, elective termination and stillbirth were reported in 10.9%, 2.8% and 0.2% of the cases, respectively. Higher rates of spontaneous abortions were reported in women with continuous IFN use. A total of 162 women completed the questionnaire for 192 live births within the prospective study part. Mothers restarted IFN therapy or switched to another disease-modifying therapy postpartum in 51.0% and 14.1% of cases, respectively. 158/192 infants (82.3%) were breastfed [34/158 (21.5%)] during IFN therapy. Postpartum relapse activity was low (mothers of 87.3% of breastfed infants remained relapse-free during lactation). Conclusion Overall, the prevalence of spontaneous abortions and congenital anomalies of females exposed to IFN exposure before or during pregnancy was within the range reported for the general population. Most mothers paused IFN during pregnancy and breastfeeding. Relapse activity during pregnancy and lactation was observed to be low. These real-world data from a PSP corroborate European and Scandinavian registry data. Trial registration NCT04655222, EUPAS38347.
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Affiliation(s)
- Juliane Klehmet
- Jüdisches Krankenhaus Berlin, Heinz-Galinski-Straße 1, Berlin 13347, Germany
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16
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Dubuisson N, de Maere d'Aertrijcke O, Marta M, Gnanapavan S, Turner B, Baker D, Schmierer K, Giovannoni G, Verma V, Docquier MA. Anaesthetic management of people with multiple sclerosis. Mult Scler Relat Disord 2023; 80:105045. [PMID: 37866022 DOI: 10.1016/j.msard.2023.105045] [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: 02/09/2023] [Revised: 08/27/2023] [Accepted: 09/29/2023] [Indexed: 10/24/2023]
Abstract
There is a lack of published guidelines on the management of patients with multiple sclerosis (MS) undergoing procedures that require anaesthesia and respective advice is largely based on retrospective studies or case reports. The aim of this paper is to provide recommendations for anaesthetists and neurologists for the management of patients with MS requiring anaesthesia. This review covers issues related to the anaesthetic management of patients with MS, with a focus on preoperative assessment, choice of anaesthetic techniques and agents, side-effects of drugs used during anaesthesia and their potential impact on the disease evolution, drug interactions that may occur, and the need to use monitoring devices. A systematic PubMed research was performed to retrieve relevant articles.
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Affiliation(s)
- N Dubuisson
- Faculty of Medicine and Dentistry, Blizard Institute (Neuroscience), Queen Mary University London, 4 Newark Street, London E1 2AT, UK; Neuromuscular Reference Center, Department of Neurology, Cliniques Universitaires Saint-Luc, Avenue Hippocrate 10, Brussels 1200, Belgium.
| | - O de Maere d'Aertrijcke
- Department of Anesthesia and Perioperative Medicine, Cliniques Universitaires Saint-Luc, St Luc Hospital, Avenue Hippocrate 10, Brussels 1200, Belgium
| | - M Marta
- Faculty of Medicine and Dentistry, Blizard Institute (Neuroscience), Queen Mary University London, 4 Newark Street, London E1 2AT, UK; Clinical Board Medicine (Neuroscience), The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - S Gnanapavan
- Faculty of Medicine and Dentistry, Blizard Institute (Neuroscience), Queen Mary University London, 4 Newark Street, London E1 2AT, UK; Clinical Board Medicine (Neuroscience), The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - B Turner
- Faculty of Medicine and Dentistry, Blizard Institute (Neuroscience), Queen Mary University London, 4 Newark Street, London E1 2AT, UK; Clinical Board Medicine (Neuroscience), The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - D Baker
- Faculty of Medicine and Dentistry, Blizard Institute (Neuroscience), Queen Mary University London, 4 Newark Street, London E1 2AT, UK
| | - K Schmierer
- Faculty of Medicine and Dentistry, Blizard Institute (Neuroscience), Queen Mary University London, 4 Newark Street, London E1 2AT, UK; Clinical Board Medicine (Neuroscience), The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - G Giovannoni
- Faculty of Medicine and Dentistry, Blizard Institute (Neuroscience), Queen Mary University London, 4 Newark Street, London E1 2AT, UK; Clinical Board Medicine (Neuroscience), The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - V Verma
- Department of Anesthesia, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - M-A Docquier
- Department of Anesthesia and Perioperative Medicine, Cliniques Universitaires Saint-Luc, St Luc Hospital, Avenue Hippocrate 10, Brussels 1200, Belgium
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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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18
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Khan E, Kagzi Y, Elkhooly M, Surpur S, Wen S, Sharma K, Sriwastava S. Disease modifying therapy and pregnancy outcomes in multiple sclerosis: A systematic review and meta-analysis. J Neuroimmunol 2023; 383:578178. [PMID: 37672841 DOI: 10.1016/j.jneuroim.2023.578178] [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: 06/28/2023] [Revised: 08/13/2023] [Accepted: 08/17/2023] [Indexed: 09/08/2023]
Abstract
OBJECTIVES To report pregnancy outcomes among multiple sclerosis (MS) patients treated with disease-modifying therapies (DMTs). METHODS We performed a retrospective chart review of articles published from June 1996 to May 2023. Additional information was acquired from the drug registries of individual pharmaceutical companies. A comparison was also made with pregnancy data of the general population using the World Health Organization database. Summary analysis was achieved using R statistical software (v3.6), and the overall prevalence of outcomes was estimated using a random effects model. RESULTS A meta-analysis of 44 studies was conducted. Dimethyl fumarate had the highest prevalence of premature births at 0.6667% (SD:0.5236-0.7845). The highest rates of stillbirths and infant deaths (perinatal and neonatal) were observed with interferons at 0.004% (SD:0.001-0.010) and 0.009% (SD:0.005-0.0015), respectively. Cladribine had the majority of ectopic pregnancies (0.0234%, SD:0.0041-1217), while natalizumab had the highest prevalence of spontaneous abortions (0.1177%, SD:0.0931-0.1477) and live birth defects (0.0755%, SD:0.0643-0.0943).None of the outcomes were significantly different from those of the general population (p > 0.05), except ectopic pregnancy and spontaneous abortion (p < 0.001), where the odds were 0.665 (0.061-0.886) and 0.537(0.003-0.786), respectively. The pooled prevalence of MS relapses was 221% for a single episode (SD:0.001-0.714), 0.075% for more than one episode (SD:0.006-0.167), and 0.141% for at least one episode requiring steroids (SD:0.073-0.206) none of these reached clinical significance. CONCLUSION Existing research suggests that DMT use in MS patients during pregnancy is generally considered safe. This study supports their utilization on a case-by-case basis. However, further primary research on this topic with clinical trials is warranted.
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Affiliation(s)
- Erum Khan
- Department of Neurology, University of Alabama at Birmingham, AL,USA
| | - Yusuf Kagzi
- Mahatma Gandhi Memorial Medical College, Indore, India
| | - Mahmoud Elkhooly
- Department of Neurology, Wayne State University, Detroit, MI, USA; Department of Neurology, Southern Illinois University, Springfield, IL, USA; Department of Neuropsychiatry, Minia University, Egypt
| | | | - Sijin Wen
- West Virginia Clinical Transitional Science, Morgantown, WV, USA
| | - Kanika Sharma
- Division of Multiple Sclerosis and Neuroimmunology Department of Neurology, McGovern Medical School (UT Health), University of Texas Health Science Center at Houston, Houston, TX,USA
| | - Shitiz Sriwastava
- Division of Multiple Sclerosis and Neuroimmunology Department of Neurology, McGovern Medical School (UT Health), University of Texas Health Science Center at Houston, Houston, TX,USA.
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19
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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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20
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McGuire J, Muto C, Marcello C. Multiple sclerosis: Implications for the primary care NP. Nurse Pract 2023; 48:38-47. [PMID: 37487047 DOI: 10.1097/01.npr.0000000000000083] [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: 07/26/2023]
Abstract
ABSTRACT Multiple sclerosis is a demyelinating disease of the central nervous system. It contributes to a variety of symptoms affecting different areas of the body. The primary care NP must be familiar with the disease, therapies, and social impact to provide proper care to affected patients.
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21
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Ciplea AI, Kurzeja A, Thiel S, Haben S, Adamus E, Hellwig K. Safety evaluations of offspring breastfed by mothers receiving glatiramer acetate for relapsing multiple sclerosis. Mult Scler Relat Disord 2023; 75:104771. [PMID: 37245349 DOI: 10.1016/j.msard.2023.104771] [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: 02/22/2023] [Revised: 05/05/2023] [Accepted: 05/21/2023] [Indexed: 05/30/2023]
Abstract
BACKGROUND Although the relapse risk is increased after birth in women with relapsing multiple sclerosis (RMS), only a very few disease-modifying therapies (DMTs) are approved during breastfeeding. Glatiramer acetate (GA, Copaxone®) is one of three DMTs that can be used in breastfeeding. The real-world safety of Copaxone® in Offsprings of Breastfeeding and treated RMS pAtients (COBRA) study demonstrated that offspring parameters (hospitalisations, antibiotic use, developmental delays, growth parameters) were similar between offspring breastfed by mothers taking GA or no DMT (control) during breastfeeding. COBRA data analyses were extended to provide further safety data on the impact of maternal GA treatment during breastfeeding on offspring. METHODS COBRA was a non-interventional, retrospective study using German Multiple Sclerosis and Pregnancy Registry data. Participants had RMS, gave birth and had GA or no DMT during breastfeeding. Offspring total adverse events (AEs), non-serious AEs (NAEs) and serious AEs (SAEs) up to 18 months postpartum were assessed. Reasons for offspring hospitalisations and antibiotic treatments were explored. RESULTS Baseline maternal demographics and disease characteristics were similar between cohorts. Each cohort had 60 offspring. Numbers of offspring AEs were comparable between cohorts; total AEs: 82 (GA) vs 83 (control); NAEs: 59 vs 61; SAEs: 23 vs 22. AEs in both cohorts were diverse with no specific patterns. Duration of GA-exposed breastfeeding was 6 to >574 days for offspring with any AE. For all-cause hospitalisations, 11 offspring had 12 hospitalisations (GA cohort) and 12 control offspring had 16 hospitalisations. Most common reason for hospitalisation was infection: 5/12 (41.7%; GA) vs 4/16 (25.0%, control). Two out of 12 (16.7%) hospitalisations due to infection occurred during GA-exposed breastfeeding; the others occurred 70, 192 and 257 days after discontinuation of GA-exposed breastfeeding. Median (range) duration of GA-exposed breastfeeding was 110 (56 to ≥285) days for offspring hospitalised for infections and 137 (88-396) days for those hospitalised for other reasons. Nine offspring had 13 antibiotic treatments (GA cohort) and nine control offspring had 10 treatments. Ten out of 13 (76.9%) antibiotic treatments occurred during GA-exposed breastfeeding, of which four were primarily due to double kidney with reflux. Other antibiotic treatments occurred 193, 229 and 257 days after discontinuation of GA-exposed breastfeeding. CONCLUSIONS GA treatment of mothers with RMS during breastfeeding did not increase AEs, hospitalisations or antibiotic use in their offspring versus control offspring. These data support previous COBRA data that the benefit of maternal RMS treatment with GA during breastfeeding outweighs the potential, apparently low risk of untoward events, in their breastfed offspring.
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Affiliation(s)
- Andrea I Ciplea
- Department of Neurology, St Josef Hospital, Katholisches Klinikum Bochum gGmbH, Ruhr University Bochum, Bochum, Germany
| | - Anna Kurzeja
- European Medical Affairs, Teva Pharmaceuticals Europe B.V., Amsterdam, the Netherlands
| | - Sandra Thiel
- Department of Neurology, St Josef Hospital, Katholisches Klinikum Bochum gGmbH, Ruhr University Bochum, Bochum, Germany
| | - Sabrina Haben
- Department of Neurology, St Josef Hospital, Katholisches Klinikum Bochum gGmbH, Ruhr University Bochum, Bochum, Germany
| | - Evelyn Adamus
- Department of Neurology, St Josef Hospital, Katholisches Klinikum Bochum gGmbH, Ruhr University Bochum, Bochum, Germany
| | - Kerstin Hellwig
- Department of Neurology, St Josef Hospital, Katholisches Klinikum Bochum gGmbH, Ruhr University Bochum, Bochum, Germany.
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22
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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: 28] [Impact Index Per Article: 28.0] [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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23
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Milosevic A, Lavrnja I, Savic D, Milosevic K, Skuljec J, Bjelobaba I, Janjic MM. Rat Ovarian Function Is Impaired during Experimental Autoimmune Encephalomyelitis. Cells 2023; 12:cells12071045. [PMID: 37048118 PMCID: PMC10093247 DOI: 10.3390/cells12071045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 03/21/2023] [Accepted: 03/28/2023] [Indexed: 04/14/2023] Open
Abstract
Multiple sclerosis (MS) is an autoimmune disease affecting the CNS and occurring far more prevalently in women than in men. In both MS and its animal models, sex hormones play important immunomodulatory roles. We have previously shown that experimental autoimmune encephalomyelitis (EAE) affects the hypothalamic-pituitary-gonadal axis in rats of both sexes and induces an arrest in the estrous cycle in females. To investigate the gonadal status in female rats with EAE, we explored ovarian morphometric parameters, circulating and intraovarian sex steroid levels, and the expression of steroidogenic machinery components in the ovarian tissue. A prolonged state of diestrus was recorded during the peak of EAE, with maintenance of the corpora lutea, elevated intraovarian progesterone levels, and increased gene and protein expression of StAR, similar to the state of pseudopregnancy. The decrease in CYP17A1 protein expression was followed by a decrease in ovarian testosterone and estradiol levels. On the contrary, serum testosterone levels were slightly increased. With unchanged serum estradiol levels, these results point at extra-gonadal sites of sex steroid biosynthesis and catabolism as important regulators of their circulating levels. Our study suggests alterations in the function of the female reproductive system during central autoimmunity and highlights the bidirectional relationships between hormonal status and EAE.
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Affiliation(s)
- Ana Milosevic
- Institute for Biological Research "Siniša Stanković"-National Institute of Republic of Serbia, University of Belgrade, 11000 Belgrade, Serbia
| | - Irena Lavrnja
- Institute for Biological Research "Siniša Stanković"-National Institute of Republic of Serbia, University of Belgrade, 11000 Belgrade, Serbia
| | - Danijela Savic
- Institute for Biological Research "Siniša Stanković"-National Institute of Republic of Serbia, University of Belgrade, 11000 Belgrade, Serbia
| | - Katarina Milosevic
- Institute for Biological Research "Siniša Stanković"-National Institute of Republic of Serbia, University of Belgrade, 11000 Belgrade, Serbia
| | - Jelena Skuljec
- Department of Neurology, University Medicine Essen, 45147 Essen, Germany
- Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, 45147 Essen, Germany
| | - Ivana Bjelobaba
- Institute for Biological Research "Siniša Stanković"-National Institute of Republic of Serbia, University of Belgrade, 11000 Belgrade, Serbia
| | - Marija M Janjic
- Institute for Biological Research "Siniša Stanković"-National Institute of Republic of Serbia, University of Belgrade, 11000 Belgrade, Serbia
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24
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Aigner S, Huhn K, Cepek L, Hellwig K, Nickel FT, Bayas A. Breastfeeding in Mothers with Multiple Sclerosis: The German Experience. Breastfeed Med 2023; 18:241-245. [PMID: 36795995 DOI: 10.1089/bfm.2022.0279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
Background: Many female people with multiple sclerosis (pwMS) are in childbearing age; however, only few data exist about the situation of breastfeeding in pwMS. Objective: Our study analyzed breastfeeding rate and duration, reasons for weaning, and the impact of disease severity on successful breastfeeding in pwMS. Methods: The study included pwMS giving birth within 3 years before study participation. Data were collected by structured questionnaire. Results: Compared to published data, we found a significant difference (p = 0.0007) between the nursing rate in the general population (96.6%) and females with MS (85.9%). However, a higher rate of exclusive breastfeeding could be observed in our study population for 5-6 months in 40.6% of pwMS versus 9% for 6 months in the general population. In contrast, total breastfeeding duration in our study population was shorter (18.8% for 11-12 months) than in the general population (41.1% for 12 months). Reasons for weaning were predominantly (68.7%) related to breastfeeding barriers based on MS. No significant impact of prepartum or postpartum education on the breastfeeding rate could be observed. Prepartum relapse rate and prepartum disease-modifying drugs had no effect on breastfeeding success. Conclusion: Our survey provides an insight into the situation of breastfeeding in pwMS in Germany.
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Affiliation(s)
- Stefanie Aigner
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Konstantin Huhn
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | | | - Kerstin Hellwig
- Department of Neurology, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | | | - Antonios Bayas
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany.,Department of Neurology, Medical Faculty, University of Augsburg, Augsburg, Germany
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25
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Hassoun HK, Almahdawi A, Al-Bajalan SJ, Sheaheed NM, Kamil MA, Saeed Ridha SM, Al-Owath MM, Abd MF, Al-Khammasi B, Hasan ZN, Hatem AO, Al-Naqshbandi M, Rieckmann P. Expert opinion on the pharmacological management of multiple sclerosis in women of childbearing age in Iraq. Heliyon 2023; 9:e13350. [PMID: 36816245 PMCID: PMC9932647 DOI: 10.1016/j.heliyon.2023.e13350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 01/02/2023] [Accepted: 01/26/2023] [Indexed: 02/01/2023] Open
Abstract
Background Multiple sclerosis (MS) is often diagnosed in women of childbearing age (WCBA), with a mean age of onset of 30 years. Women with MS have long been cautioned to carefully plan their pregnancies and, traditionally, disease-modifying therapies (DMTs) have not been recommended for use in patients engaged in family planning. In 2020, the United States Food and Drug Administration (FDA) approved a label update for interferon beta (IFN ß) by adding new safety data on pregnancy and breastfeeding. Because current management guidelines do not yet reflect the recent label update, a panel of neurology experts from Iraq decided to discuss the potential need for changes in treatment strategies in Iraq. Methods A panel of experts consisting of 8 neurologists from Iraq and one international neurology expert from Germany convened to develop an expert opinion that would provide practical guidance for the pharmacological management of WCBA with MS in Iraq. They considered the latest label update and relevant published literature, along with local clinical practice and available resources. Results Interferon and Glatiramer acetate have no evidence of harm during pregnancy. IFN β can be continued safely through pregnancy. Switching treatment during pregnancy is generally not recommended. Short-term intravenous methylprednisolone can be used to treat disabling relapses. Conclusion Given the complexity of managing MS in pregnant women, it is the opinion of the expert panel that family planning should be discussed early in the disease course, planned pregnancy should be encouraged, and open communication with patient for her treatment decisions is paramount. Patients who are engaged in family planning are no longer discouraged from treatment with some of the currently available DMTs.
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Affiliation(s)
- Hayder K. Hassoun
- Kufa University, Kufa College of Medicine, Al-Najaf, Iraq
- Corresponding author.
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26
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Collorone S, Kodali S, Toosy AT. The protective role of breastfeeding in multiple sclerosis: Latest evidence and practical considerations. Front Neurol 2023; 13:1090133. [PMID: 36761920 PMCID: PMC9902945 DOI: 10.3389/fneur.2022.1090133] [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: 11/04/2022] [Accepted: 12/23/2022] [Indexed: 01/25/2023] Open
Abstract
The immunoprotective role of pregnancy in multiple sclerosis (MS) has been known for decades. Conversely, there has been rich debate on the topic of breastfeeding and disease activity in MS. In clinical practice, women are often offered to restart their disease-modifying drug (DMD) soon after delivery to maintain their relapse risk protection. Limited available information about peri-partum DMD safety can discourage women to choose breastfeeding, despite the World Health Organization's recommendation to breastfeed children for the first 6 months of life exclusively. New evidence is emerging about the protective role of exclusive breastfeeding on relapse rate. Research studies shed light on the hormonal and immunological mechanisms driving the risk of relapses during pregnancy and postpartum. Finally, case reports, real-world data, and clinical trials are increasing our knowledge of the safety of DMDs for the fetus and infant. While some DMDs must be avoided, others may be considered in highly active pregnant or lactating women with MS. This mini-review conveys recent evidence regarding the protective role of exclusive breastfeeding in MS and offers clinicians practical considerations for a patient-tailored approach.
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Affiliation(s)
- Sara Collorone
- NMR Research Unit, Department of Neuroinflammation, Queen Square MS Centre, Faculty of Brain Sciences, UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
| | - Srikirti Kodali
- NMR Research Unit, Department of Neuroinflammation, Queen Square MS Centre, Faculty of Brain Sciences, UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
| | - Ahmed T Toosy
- NMR Research Unit, Department of Neuroinflammation, Queen Square MS Centre, Faculty of Brain Sciences, UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
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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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Stamatellos VP, Papazisis G. Safety and Monitoring of the Treatment with Disease-Modifying Therapies (DMTs) for Multiple Sclerosis (MS). Curr Rev Clin Exp Pharmacol 2023; 18:39-50. [PMID: 35418296 DOI: 10.2174/2772432817666220412110720] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 01/08/2022] [Accepted: 01/27/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND Disease-Modifying Therapies (DMTs) for Multiple Sclerosis (MS) are widely used given their proven efficacy in the relapsing form of the disease, while recently, Siponimod and Ocrelizumab have been approved for the progressive forms of the disease. Currently, 22 diseasemodifying drugs are approved by the FDA, while in 2012, only nine were present in the market. From March 2019 until August 2020, six new drugs were approved. This rapid development of new DMTs highlighted the need to update our knowledge about their short and long-term safety. OBJECTIVE This review summarizes the available safety data for all the Disease-Modifying Therapies for Multiple Sclerosis and presents the monitoring plan before and during the treatment. METHODS A literature search was conducted using PUBMED and COCHRANE databases. Key journals and abstracts from major annual meetings of Neurology, references of relevant reviews, and relative articles were also manually searched. We prioritized systematic reviews, large randomized controlled trials (RCTs), prospective cohort studies, and other observational studies. Special attention was paid to guidelines and papers focusing on the safety and monitoring of DMTs. CONCLUSION Data for oral (Sphingosine 1-phosphate (S1P) receptor modulators, Fumarates, Teriflunomide, Cladribine), injectables (Interferons, Glatiramer acetate, Ofatumumab), and infusion therapies (Natalizumab, Ocrelizumab, Alemtuzumab) are presented.
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Affiliation(s)
| | - Georgios Papazisis
- Clinical Trials Unit, Special Unit for Biomedical Research and Education & Department of Clinical Pharmacology School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
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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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Mainguy M, Tillaut H, Degremont A, Le Page E, Mainguy C, Duros S, Polard E, Leray E. Assessing the Risk of Relapse Requiring Corticosteroids After In Vitro Fertilization in Women With Multiple Sclerosis. Neurology 2022; 99:e1916-e1925. [PMID: 35953288 DOI: 10.1212/wnl.0000000000201027] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 06/13/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Several studies have shown an increased risk of relapse after in vitro fertilization (IVF) in women with multiple sclerosis (MS), especially when a gonadotrophin-releasing hormone (GnRH) agonist stimulation protocol was used. Our objective was to investigate the risk of relapse after IVF in women with MS, overall and according to stimulation protocol (GnRH agonists vs antagonists), using data from the French national health insurance database. METHODS This retrospective cohort study included all women with MS who have benefited from IVF between January 1, 2010, and December 31, 2015, in France. Three-month exposed periods after IVF were compared with unexposed periods before IVF, each woman being her own control. Four outcomes were considered: annualized relapse rate (ARR), proportion of IVF with relapse, difference in the number of relapses "after-before," and the delay from IVF to the first relapse. Relapses were identified by an algorithm based on MS-related hospital admissions and the use of corticosteroid therapy. Stimulation protocols and disease-modifying therapies (DMTs) were identified using drug claims. Zero-inflated Poisson regression models adjusted for age at IVF and the presence of DMT were used. A random effect on women was included because women may undergo multiple IVF procedures. Subgroup analyses by stimulation protocol and IVF outcome (pregnancy or failure) were conducted. RESULTS A total of 225 women accounting for 338 IVF procedures were included (the mean age at the first IVF 34.6 ± 4.5 years; 36% of women underwent at least 2 IVF procedures during the period). No increase in the risk of relapse after IVF was found overall (before vs after IVF: 0.20 vs 0.18 relapse per patient-year; 7.7% vs 7.1% of IVF with women having at least one relapse) and in subgroups. A lower ARR before and after IVF was observed among women who remained treated until IVF. DISCUSSION The maintenance of DMT until IVF seemed to be a determining factor in reducing the risk of relapse. Women with MS should be reassured because we did not show an increased risk of relapse requiring the use of corticosteroid therapy after IVF neither with GnRH agonists nor with GnRH antagonists.
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Affiliation(s)
- Marie Mainguy
- From the Univ Rennes (M.M., E.L.), EHESP, CNRS, Inserm, ARENES-UMR, France; Univ Rennes (H.T.), Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail)-UMR, Rennes, France; Pharmacovigilance (A.D., E.P.), Pharmacoepidemiology and Drug Information Centre, Department of Clinical Pharmacology, Rennes University Hospital, France; Neurology Department CRCSEP (E.L.P.), Rennes Clinical Investigation Centre CIC-P, Rennes University Hospital Rennes University INSERM, France; and Department of Gynecology Obstetric and Reproductive Medecine (C.M., S.D.), University Hospital, Rennes, France
| | - Hélène Tillaut
- From the Univ Rennes (M.M., E.L.), EHESP, CNRS, Inserm, ARENES-UMR, France; Univ Rennes (H.T.), Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail)-UMR, Rennes, France; Pharmacovigilance (A.D., E.P.), Pharmacoepidemiology and Drug Information Centre, Department of Clinical Pharmacology, Rennes University Hospital, France; Neurology Department CRCSEP (E.L.P.), Rennes Clinical Investigation Centre CIC-P, Rennes University Hospital Rennes University INSERM, France; and Department of Gynecology Obstetric and Reproductive Medecine (C.M., S.D.), University Hospital, Rennes, France
| | - Adeline Degremont
- From the Univ Rennes (M.M., E.L.), EHESP, CNRS, Inserm, ARENES-UMR, France; Univ Rennes (H.T.), Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail)-UMR, Rennes, France; Pharmacovigilance (A.D., E.P.), Pharmacoepidemiology and Drug Information Centre, Department of Clinical Pharmacology, Rennes University Hospital, France; Neurology Department CRCSEP (E.L.P.), Rennes Clinical Investigation Centre CIC-P, Rennes University Hospital Rennes University INSERM, France; and Department of Gynecology Obstetric and Reproductive Medecine (C.M., S.D.), University Hospital, Rennes, France
| | - Emmanuelle Le Page
- From the Univ Rennes (M.M., E.L.), EHESP, CNRS, Inserm, ARENES-UMR, France; Univ Rennes (H.T.), Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail)-UMR, Rennes, France; Pharmacovigilance (A.D., E.P.), Pharmacoepidemiology and Drug Information Centre, Department of Clinical Pharmacology, Rennes University Hospital, France; Neurology Department CRCSEP (E.L.P.), Rennes Clinical Investigation Centre CIC-P, Rennes University Hospital Rennes University INSERM, France; and Department of Gynecology Obstetric and Reproductive Medecine (C.M., S.D.), University Hospital, Rennes, France
| | - Christelle Mainguy
- From the Univ Rennes (M.M., E.L.), EHESP, CNRS, Inserm, ARENES-UMR, France; Univ Rennes (H.T.), Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail)-UMR, Rennes, France; Pharmacovigilance (A.D., E.P.), Pharmacoepidemiology and Drug Information Centre, Department of Clinical Pharmacology, Rennes University Hospital, France; Neurology Department CRCSEP (E.L.P.), Rennes Clinical Investigation Centre CIC-P, Rennes University Hospital Rennes University INSERM, France; and Department of Gynecology Obstetric and Reproductive Medecine (C.M., S.D.), University Hospital, Rennes, France
| | - Solène Duros
- From the Univ Rennes (M.M., E.L.), EHESP, CNRS, Inserm, ARENES-UMR, France; Univ Rennes (H.T.), Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail)-UMR, Rennes, France; Pharmacovigilance (A.D., E.P.), Pharmacoepidemiology and Drug Information Centre, Department of Clinical Pharmacology, Rennes University Hospital, France; Neurology Department CRCSEP (E.L.P.), Rennes Clinical Investigation Centre CIC-P, Rennes University Hospital Rennes University INSERM, France; and Department of Gynecology Obstetric and Reproductive Medecine (C.M., S.D.), University Hospital, Rennes, France
| | - Elisabeth Polard
- From the Univ Rennes (M.M., E.L.), EHESP, CNRS, Inserm, ARENES-UMR, France; Univ Rennes (H.T.), Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail)-UMR, Rennes, France; Pharmacovigilance (A.D., E.P.), Pharmacoepidemiology and Drug Information Centre, Department of Clinical Pharmacology, Rennes University Hospital, France; Neurology Department CRCSEP (E.L.P.), Rennes Clinical Investigation Centre CIC-P, Rennes University Hospital Rennes University INSERM, France; and Department of Gynecology Obstetric and Reproductive Medecine (C.M., S.D.), University Hospital, Rennes, France
| | - Emmanuelle Leray
- From the Univ Rennes (M.M., E.L.), EHESP, CNRS, Inserm, ARENES-UMR, France; Univ Rennes (H.T.), Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail)-UMR, Rennes, France; Pharmacovigilance (A.D., E.P.), Pharmacoepidemiology and Drug Information Centre, Department of Clinical Pharmacology, Rennes University Hospital, France; Neurology Department CRCSEP (E.L.P.), Rennes Clinical Investigation Centre CIC-P, Rennes University Hospital Rennes University INSERM, France; and Department of Gynecology Obstetric and Reproductive Medecine (C.M., S.D.), University Hospital, Rennes, France.
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The Rate of Hospitalization of Pregnant Women with Multiple Sclerosis in Poland. J Clin Med 2022; 11:jcm11195615. [PMID: 36233482 PMCID: PMC9572960 DOI: 10.3390/jcm11195615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 09/07/2022] [Accepted: 09/20/2022] [Indexed: 11/28/2022] Open
Abstract
Multiple sclerosis (MS) is most often diagnosed in women of childbearing age. Therefore, it is important to examine the impact of pregnancy on the course of MS and to enable patients to make decisions about motherhood based on reliable data. The main objective of this study was to assess the impact of pregnancy on the course of MS by comparing the frequency of MS-related hospitalizations during pregnancy and 40 weeks postpartum versus 40 weeks before pregnancy. We used administrative health claims to identify female patients with MS, their deliveries, and their MS-related hospital admissions and calculated the frequency of MS-related hospital admissions before, during, and after pregnancy. We observed that MS is diagnosed approximately three times less often during pregnancy than before or after pregnancy. The number of MS-related hospital admissions decreased during pregnancy, especially in the third trimester. In contrast with other studies, we did not observe an increased level of MS-related admissions postpartum. The number of hospitalizations reported with steroid injections and emergency department visits also decreased during pregnancy. Our results show that pregnancy has a protective effect on the course of MS.
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Diem L, Hammer H, Hoepner R, Pistor M, Remlinger J, Salmen A. Sex and gender differences in autoimmune demyelinating CNS disorders: Multiple sclerosis (MS), neuromyelitis optica spectrum disorder (NMOSD) and myelin-oligodendrocyte-glycoprotein antibody associated disorder (MOGAD). INTERNATIONAL REVIEW OF NEUROBIOLOGY 2022; 164:129-178. [PMID: 36038203 DOI: 10.1016/bs.irn.2022.06.011] [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: 06/15/2023]
Abstract
Multiple sclerosis (MS), Neuromyelitis optica spectrum disorder (NMOSD) and Myelin-Oligodendrocyte-Glycoprotein antibody associated disorder (MOGAD) are demyelinating disorders of the central nervous system (CNS) of autoimmune origin. Here, we summarize general considerations on sex-specific differences in the immunopathogenesis and hormonal influences as well as key clinical and epidemiological elements. Gender-specific issues are widely neglected starting with the lacking separation of sex as a biological variable and gender comprising the sociocultural components. As for other autoimmune diseases, female preponderance is common in MS and NMOSD. However, sex distribution in MOGAD seems equal. As in MS, immunotherapy in NMOSD and MOGAD is crucial to prevent further disease activity. Therefore, we assessed data on sex differences of the currently licensed disease-modifying treatments for efficacy and safety. This topic seems widely neglected with only fragmented information resulting from post-hoc analyses of clinical trials or real-world post-marketing studies afflicted with lacking power and/or inherent sources of bias. In summary, biological hypotheses of sex differences including genetic factors, the constitution of the immune system and hormonal influences are based upon human and preclinical data, especially for the paradigmatic disease of MS whereas specific data for NMOSD and MOGAD are widely lacking. Epidemiological and clinical differences between men and women are well described for MS and to some extent for NMOSD, yet, with remaining contradictory findings. MOGAD needs further detailed investigation. Sex-specific analyses of safety and efficacy of long-term immunotherapies need to be addressed in future studies designed and powered to answer the pressing questions and to optimize and individualize treatment.
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Affiliation(s)
- Lara Diem
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Freiburgstrasse, Bern, Switzerland
| | - Helly Hammer
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Freiburgstrasse, Bern, Switzerland
| | - Robert Hoepner
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Freiburgstrasse, Bern, Switzerland
| | - Max Pistor
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Freiburgstrasse, Bern, Switzerland
| | - Jana Remlinger
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Freiburgstrasse, Bern, Switzerland; Department of Biomedical Research and Graduate School for Cellular and Biomedical Sciences, University of Bern, Bern, Switzerland
| | - Anke Salmen
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Freiburgstrasse, Bern, Switzerland.
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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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Pregnancy and Family Planning Considerations in Multiple Sclerosis. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2022. [DOI: 10.1007/s13669-022-00329-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Capone F, Albanese A, Quadri G, Di Lazzaro V, Falato E, Cortese A, De Giglio L, Ferraro E. Disease-Modifying Drugs and Breastfeeding in Multiple Sclerosis: A Narrative Literature Review. Front Neurol 2022; 13:851413. [PMID: 35493841 PMCID: PMC9051389 DOI: 10.3389/fneur.2022.851413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 02/15/2022] [Indexed: 11/16/2022] Open
Abstract
Pregnancy-related issues in women with multiple sclerosis (MS) have been receiving increasing attention, with particular interest for the use of disease-modifying therapies (DMTs) before conception, during pregnancy, and postpartum, including breastfeeding. The risk of relapse is higher in the early postpartum period, especially in cases of significant disease activity prior to pregnancy, and thus treatment resumption and/or switching strategies might be necessary. Moreover, breastfeeding provides unmatched health benefits for babies and mothers, and is recommended as the best source of nutrition for infants. Furthermore, a protective role of breastfeeding on MS disease course has not been fully demonstrated and it remains debatable. At the same time, a source of concern is the potential transfer of DMTs into breastmilk and the resulting infant exposure. The use of most DMTs is unlicensed during breastfeeding mainly due to the limited data available on the excretion in human milk and on the effects on infants' exposure. Consequently, women have to face the difficult challenge of choosing between breastfeeding and DMT resumption. The present narrative review summarizes and discusses the available evidence on the safety of DMTs during breastfeeding and the relative approved labels. At the time of diagnosis of MS, specific counseling should be offered to women of childbearing age, making them aware of the possible therapeutic options and their impact on pregnancy and breastfeeding. Women can be encouraged to breastfeed, if clinically feasible, following a review of their medications and clinical status, with a personalized approach.
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Affiliation(s)
- Fioravante Capone
- Neurology, Neurophysiology and Neurobiology Unit, Department of Medicine, Università Campus Bio-Medico, Rome, Italy
- *Correspondence: Fioravante Capone
| | - Angela Albanese
- Merck Serono S.p.A., An Affiliate of Merck KGaA, Rome, Italy
| | - Giorgia Quadri
- Merck Serono S.p.A., An Affiliate of Merck KGaA, Rome, Italy
| | - Vincenzo Di Lazzaro
- Neurology, Neurophysiology and Neurobiology Unit, Department of Medicine, Università Campus Bio-Medico, Rome, Italy
| | - Emma Falato
- Neurology, Neurophysiology and Neurobiology Unit, Department of Medicine, Università Campus Bio-Medico, Rome, Italy
| | - Antonio Cortese
- Multiple Sclerosis Centre, S. Filippo Neri Hospital, Rome, Italy
| | - Laura De Giglio
- Multiple Sclerosis Centre, S. Filippo Neri Hospital, Rome, Italy
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Ines Ciplea A, Kurzeja A, Thiel S, Haben S, Alexander J, Adamus E, Hellwig K. Eighteen-month safety analysis of offspring breastfed by mothers receiving glatiramer acetate therapy for relapsing multiple sclerosis - COBRA study. Mult Scler 2022; 28:1641-1650. [PMID: 35362346 PMCID: PMC9315183 DOI: 10.1177/13524585221083982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Safety data on disease-modifying therapies (DMTs) for relapsing multiple
sclerosis (RMS) during breastfeeding are limited. Objective: Assess safety outcomes for offspring breastfed by mothers undergoing
glatiramer acetate (GA; Copaxone®) treatment. Methods: This non-interventional, retrospective study used German Multiple Sclerosis
and Pregnancy Registry data. Participants had RMS, a live birth, and
received GA or no DMT during breastfeeding. Results: GA cohort: 58 mothers/60 offspring; matched controls: 60 mothers/60
offspring; 86.7% (GA) and 25% (control) of offspring were born to mothers
who had GA at some point during pregnancy. Maternal demographics and disease
activity were comparable. Annualized number of hospitalizations was similar
for breastfed offspring: 0.20 (95% confidence interval: 0.09–0.31; GA) and
0.25 (0.12–0.38, controls). Proportion of offspring requiring
hospitalization was comparable between cohorts (18.33% vs. 20.00%).
Annualized number of antibiotic uses was similar in both cohorts (0.22,
0.10–0.33 (GA) vs. 0.17, 0.06–0.27 (controls)) The proportion of offspring
requiring antibiotics was 15.00% (both cohorts). More developmental delays
were identified in controls versus the GA cohort (3 (5.36%) vs. 0). Growth
parameters were comparable between cohorts. Conclusion: Maternal intake of GA during breastfeeding did not adversely affect offspring
safety outcomes assessed during the first 18 months of life.
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Affiliation(s)
- Andrea Ines Ciplea
- Department of Neurology, St. Josef Hospital - Katholisches Klinikum Bochum, Ruhr University Bochum, Bochum, Germany
| | - Anna Kurzeja
- European Medical Affairs, Teva Pharmaceuticals Europe B.V., Amsterdam, The Netherlands
| | - Sandra Thiel
- Department of Neurology, St. Josef Hospital - Katholisches Klinikum Bochum, Ruhr University Bochum, Bochum, Germany
| | - Sabrina Haben
- Department of Neurology, St. Josef Hospital - Katholisches Klinikum Bochum, Ruhr University Bochum, Bochum, Germany
| | | | - Evelyn Adamus
- Department of Neurology, St. Josef Hospital - Katholisches Klinikum Bochum, Ruhr University Bochum, Bochum, Germany
| | - Kerstin Hellwig
- Department of Neurology, St. Josef Hospital - Katholisches Klinikum Bochum, Ruhr University Bochum, Bochum, Germany
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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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Pregnancy, Fetal, and Infant Outcomes Following Maternal Exposure to Glatiramer Acetate During Pregnancy and Breastfeeding. Drug Saf 2022; 45:345-357. [PMID: 35297004 DOI: 10.1007/s40264-022-01168-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2022] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Published data support the safety of glatiramer acetate in patients with multiple sclerosis who are pregnant or breastfeeding, but long-term data are limited. OBJECTIVE We aimed to assess pregnancy, fetal, and infant outcomes following maternal exposure to glatiramer acetate. METHODS In-utero glatiramer acetate-exposed postmarketing pregnancy reports from 2019 to 2021 were extracted from Teva's pharmacovigilance database. Pregnancy data acquired prior to knowledge of pregnancy outcome or detection of congenital malformation (prospective reports) were used to estimate pregnancy and infant outcome rates for glatiramer acetate 20- and 40-mg/mL exposure. A subgroup of cases completed follow-up questionnaires and were analyzed separately. RESULTS Prospective cases with 702 fetuses had known outcomes with 647 (92.2%) live births, 47 (6.7%) spontaneous abortions, 4 (0.6%) induced abortions, 2 (0.3%) ectopic pregnancies, and 2 (0.3%) fetal deaths. Rates of major congenital malformation (1.1%), preterm births (7.2%), and low/very low birth weight (4.8%), and parameters of growth were within background rates. No infant developmental delay was reported. Overall, pregnancy and infant outcomes were similar across glatiramer acetate doses. CONCLUSIONS Maternal exposure to glatiramer acetate does not appear to be related to adverse pregnancy, fetal, or infant outcomes. These data further support the safety of both glatiramer acetate 20-mg/mL and 40-mg/mL treatments during pregnancy and breastfeeding.
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Bove RM, Houtchens MK. Pregnancy Management in Multiple Sclerosis and Other Demyelinating Diseases. Continuum (Minneap Minn) 2022; 28:12-33. [DOI: 10.1212/con.0000000000001108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Bsteh G, Hegen H, Riedl K, Altmann P, Di Pauli F, Ehling R, Zulehner G, Rommer P, Leutmezer F, Deisenhammer F, Berger T. Estimating Risk of Multiple Sclerosis Disease Reactivation in Pregnancy and Postpartum: The VIPRiMS Score. Front Neurol 2022; 12:766956. [PMID: 35111123 PMCID: PMC8801570 DOI: 10.3389/fneur.2021.766956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 12/15/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Evidence guiding personalized decision-making with respect to disease-modifying therapy (DMT) around pregnancy in relapsing multiple sclerosis (RMS) is lacking. Objective: To generate and validate a risk score for disease reactivation intrapartum and postpartum in RMS. Methods: From the Vienna Innsbruck MS database (VIMSD), we included 343 pregnancies in patients with RMS. Primary endpoint was disease reactivation. Patients were randomly assigned 2:1 in a generation and validation dataset. A predictive score was calculated using the Cox regression and validated. Results: In the generation dataset, occurrence of relapse and type of DMT in the year before conception, DMT washout duration, the Expanded Disability Status Scale (EDSS) at conception, and time until DMT restart postpartum were identified as independent predictors of disease reactivation (p < 0.001). The resulting 10-point risk score robustly predicted reactivation (explaining 75% of variance, p < 0.001) identifying patients at high [≥6 points; mean risk 65%; range 50–100%; hazard ratio (HR) 14.5], intermediate (3–5 points; mean risk 24%; range 15–35%; HR 4.3), and low risk (≤2 points; mean risk 6%; range 0–8%) of disease reactivation in pregnancy and up to 6 months postpartum. Conclusion: The composite Vienna Innsbruck Pregnancy Risk in Multiple Sclerosis (VIPRiMS) score is a valuable clinical tool to support patients and neurologists in anticipating risk and, thus, individualizing treatment decision-making around pregnancy.
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Affiliation(s)
- Gabriel Bsteh
- Department of Neurology, Medical University of Vienna, Vienna, Austria
- *Correspondence: Gabriel Bsteh
| | - Harald Hegen
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Katharina Riedl
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Patrick Altmann
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Franziska Di Pauli
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Rainer Ehling
- Department of Neurology, Clinic for Rehabilitation Münster, Münster, Austria
| | - Gudrun Zulehner
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Paulus Rommer
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Fritz Leutmezer
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | | | - Thomas Berger
- Department of Neurology, Medical University of Vienna, Vienna, Austria
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Villaverde-González R. Updated Perspectives on the Challenges of Managing Multiple Sclerosis During Pregnancy. Degener Neurol Neuromuscul Dis 2022; 12:1-21. [PMID: 35023987 PMCID: PMC8743861 DOI: 10.2147/dnnd.s203406] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 12/20/2021] [Indexed: 11/23/2022] Open
Abstract
Multiple sclerosis (MS) is a chronic immune-mediated, inflammatory, and degenerative disease that is up to three times more frequent in young women. MS does not alter fertility and has no impact on fetal development, the course of pregnancy, or childbirth. The Pregnancy in Multiple Sclerosis Study in 1998 showed that pregnancy, mostly in untreated women, did not adversely affect MS, as disease activity decreased during pregnancy (although it significantly increased in the first trimester postpartum). These findings, together with the limited information available on the potential risks of fetal exposure to disease modifying treatments (DMTs), meant that women were advised to delay the onset of DMTs, stop them prior to conception, or, in case of unplanned pregnancy, discontinue them when pregnancy was confirmed. Now, many women with MS receive DMTs before pregnancy and, despite being considered a period of MS stability, up to 30% of patients could relapse in the first trimester postpartum. Factors associated with an increased risk of relapse and disability during pregnancy and postpartum include relapses before and during pregnancy, a greater disability at the time of conception, the occurrence of relapses after DMT cessation before conception, and the use of high-efficacy DMTs before conception, especially natalizumab or fingolimod. Strategies to prevent postpartum activity are needed in some patients, but consensus is lacking regarding the therapeutic strategies for women with MS of a fertile age. This, along with the increasing number of DMTs, means that the decision-making processes in aspects related to family planning and therapeutic strategies before, during, and after pregnancy are increasingly more complex. The purpose of this review is to provide an update on pregnancy-related issues in women with MS, including recommendations for counseling, general management, use of DMTs in pre-pregnancy, pregnancy, and postpartum periods, and breastfeeding-related aspects of DMTs.
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Saposnik G, Andhavarapu S, Fernández Ó, Kim HJ, Wiendl H, Foss M, Zuo F, Havrdová EK, Celius EG, Caceres F, Magyari M, Bermel R, Costa A, Terzaghi M, Kalincik T, Popescu V, Amato MP, Montalban X, Oh J. Effect of desire for pregnancy on decisions to escalate treatment in multiple sclerosis care: Differences between MS specialists and non-MS specialists. Mult Scler Relat Disord 2022; 57:103389. [PMID: 35158479 DOI: 10.1016/j.msard.2021.103389] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 10/24/2021] [Accepted: 11/07/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Therapeutic inertia (TI) is a worldwide phenomenon that affects 60 to 90% of neurologists and up to 25% of daily treatment decisions during management of multiple sclerosis (MS) patients. A large volume of MS patients are women of childbearing age, and desire for pregnancy is a complex variable often affecting MS care. The objective of this study was to determine the effect of desire for pregnancy on decisions to escalate treatment during management of MS patients. METHODS 300 neurologists with expertise in MS from 20 countries were invited to participate in the study. Participants were presented with 12 pairs of simulated MS patient profiles reflective of case scenarios encountered in clinical practice. Participants were asked to select the ideal candidate for treatment escalation from modest to higher-efficacy therapies. Disaggregated discrete choice experiments were used to estimate the weight of factors and attributes affecting physicians' decisions when considering treatment selection. An excel calculator that provides estimates as the percentage of participants that would escalate treatment for a simulated case-scenario was constructed. RESULTS 229 (76.3%) completed the study. The mean age (SD) of study participants was 44 (±10) years. The mean (SD) number of MS patients seen per month by each neurologist was 18 (±16). Non-MS specialists were significantly less likely to escalate treatment than MS specialists across mild, moderate, and severe patient cases. These differences were accentuated when case scenarios introduced a desire for pregnancy. The findings were consistent when MRI-lesions, severity of symptoms, and number of relapses were included. CONCLUSIONS Desire for pregnancy differentially influences decisions to escalate treatment, suggesting knowledge-to-action gaps between MS and non-MS specialists. Our findings indicate the need for educational strategies to overcome these gaps and improve clinical outcomes for MS patients who desire pregnancy.
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Affiliation(s)
- Gustavo Saposnik
- Division of Neurology, Department of Medicine, St. Michael's Hospital, University of Toronto, Canada; Zurich Center for Neuroeconomics (ZNE), Department of Economics, University of Zurich, Switzerland; Clinical Outcomes and Decision Neuroscience Unit, St Michael's Hospital, University of Toronto, Toronto, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Canada.
| | - Sanketh Andhavarapu
- Clinical Outcomes and Decision Neuroscience Unit, St Michael's Hospital, University of Toronto, Toronto, Canada
| | - Óscar Fernández
- Department of Pharmacology, Faculty of Medicine, University of Malaga, Institute of Biomedical Research of Malaga (IBIMA), Regional University Hospital of Malaga, Spain
| | - Ho Jin Kim
- Department of Neurology, Research Institute and Hospital of National Cancer Center, Goyang, Korea (the Republic of)
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University of Münster, Germany
| | - Mona Foss
- Bootstrap Analytics, Calgary, Canada
| | - Fei Zuo
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Canada
| | - Eva Kubala Havrdová
- Department of Neurology and Center for Clinical Neuroscience, First Medical Faculty, Charles University in Prague, Prague, Czech Republic
| | - Elisabeth Gulowsen Celius
- Department of Neurology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Fernando Caceres
- Institute of Restorative Neurosciences (INERE), Buenos Aires, Argentina
| | - Melinda Magyari
- Danish Multiple Sclerosis Center, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Robert Bermel
- Mellen Center for Multiple Sclerosis, Cleveland Clinic, Cleveland, OH, United States
| | - Andreia Costa
- Neurology Department, Centro Hospitalar Universitário São João, Faculty of Medicine University of Porto, Portugal
| | - Maria Terzaghi
- Clinical Outcomes and Decision Neuroscience Unit, St Michael's Hospital, University of Toronto, Toronto, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Canada
| | - Tomas Kalincik
- MS Centre, Royal Melbourne Hospital, Melborne, Australia; CORe, Department of Medicine, University of Melbourne, SA
| | - Veronica Popescu
- University MS Centre, Noorderhart Hospital, Pelt, Belgium; Hasselt University, Hasselt, Belgium
| | - Maria Pia Amato
- Department NEUROFARBA, University of Florence, Italy; IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy
| | - Xavier Montalban
- Division of Neurology, Department of Medicine, St. Michael's Hospital, University of Toronto, Canada; Department of Neurology. Cemcat. Hospital Vall d´Hebron. Universitat Autonoma de Barcelona. Spain
| | - Jiwon Oh
- Division of Neurology, Department of Medicine, St. Michael's Hospital, University of Toronto, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Canada
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Hellwig K, Verdun di Cantogno E, Sabidó M. A systematic review of relapse rates during pregnancy and postpartum in patients with relapsing multiple sclerosis. Ther Adv Neurol Disord 2021; 14:17562864211051012. [PMID: 34876925 PMCID: PMC8645312 DOI: 10.1177/17562864211051012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 09/16/2021] [Indexed: 11/21/2022] Open
Abstract
Introduction: Pregnancy is widely accepted as a period when relapses of
multiple sclerosis (MS) are decreased, with an increased risk of relapse in
the first months postpartum. This systematic review evaluated relapses
during pregnancy and postpartum, according to disease-modifying therapy
(DMT) exposure before, during, and after pregnancy, and the influence of DMT
on these outcomes. Methods: We searched Medline and EMBASE to identify relevant
publications from November 2009 to 2019 along with references lists of
selected articles. Publications were filtered and assessed by two
independent reviewers to ensure appropriate data extraction. Results: Of 469 articles identified, 28 were included for analysis
including 4739 pregnancies in 5324 patients. All five studies comparing
natalizumab or fingolimod (high-efficacy DMTs) use preconception versus
interferon beta, glatiramer acetate, or dimethyl fumarate, or no DMT
suggested that there was a greater risk of relapse during pregnancy
following withdrawal of the high-efficacy DMTs. Of 10 studies evaluating
relapses during pregnancy, five studies found that continuing DMTs into
early pregnancy reduced relapses compared to discontinuing treatment. DMT
exposure preconception generally had no effect on postpartum relapses versus
no DMT; however, natalizumab or fingolimod use preconception was associated
with postpartum relapse versus no high-efficacy DMT in one study. DMT
exposure during pregnancy was associated with fewer postpartum relapses
versus no DMT exposure in four of seven studies, while three found no
difference between groups. Conclusion: Results of this systematic review concerning women with
relapsing MS show a complex and often conflicting picture regarding DMT
exposure and relapses during and after pregnancy. Although our data are
limited by variability between studies, there is some evidence suggesting
the use of natalizumab or fingolimod preconception is associated with
increased risk of relapses during pregnancy, highlighting the need for
effective disease-management strategies in these especially high-risk
patients.
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Affiliation(s)
- Kerstin Hellwig
- Department of Neurology, St. Josef Hospital, Ruhr-University Bochum, Gudrunstrasse 56, 44791 Bochum, Germany
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Thiel S, Ciplea AI, Gold R, Hellwig K. The German Multiple Sclerosis and Pregnancy Registry: rationale, objective, design, and first results. Ther Adv Neurol Disord 2021; 14:17562864211054956. [PMID: 34840606 PMCID: PMC8613898 DOI: 10.1177/17562864211054956] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 10/04/2021] [Indexed: 12/16/2022] Open
Abstract
Objectives: Multiple sclerosis (MS) and neuromyelitis optica spectrum disorders (NMOSD) predominantly affect women of reproductive age. During the last few decades many disease-modifying therapies (DMTs) have been approved. It is therefore important to provide epidemiological structures for the collection of safety information on exposed pregnancies. Data on disease activity after withdrawal of DMTs are in high demand especially as severe relapses have been described after ceasing highly effective DMTs. Although breastfeeding is recommended, it is still unclear if the early reintroduction, especially of highly effective DMTs, has a beneficial effect on postpartum relapse risk or a combination of both, however safety data are lacking. Methods: The German MS and Pregnancy Registry (DMSKW) is a nationwide, observational, cohort study of pregnant women with MS or NMOSD, founded in 2006. As the study procedure has undergone important adaptation in recent years, described here is the updated methodology including data source and acquisition as well as variables collected within the DMSKW. Results: As of December 2020, the DMSKW database comprises 2579 pregnancies, 2568 with MS and 11 with NMOSD. Women are enrolled at a median gestational week of 11 (range: 0.02–42.1), have a median postpartum follow up of 1.2 years (range: 0–9.2) with 76% of all pregnancies being exposed to a DMT, mostly in the first trimester. Spontaneous abortion and preterm birth occurred in 7% and 10%, respectively; 19% of all women suffered from at least one relapse during pregnancy, with a minimum of 6% during the third trimester of pregnancy. Conclusion: The DMSKW is a valuable structure in providing safety data on drug exposure during pregnancy and lactation in combination with information on disease activity up to 6 years postpartum. This article will be the reference for describing the methods of future publications from the DMSKW.
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Affiliation(s)
- Sandra Thiel
- Department of Neurology, St. Josef Hospital - Katholisches Klinikum Bochum GmbH, Ruhr University Bochum, Bochum, Germany
| | - Andrea I Ciplea
- Department of Neurology, St. Josef Hospital - Katholisches Klinikum Bochum GmbH, Ruhr University Bochum, Bochum, Germany
| | - Ralf Gold
- Department of Neurology, St. Josef Hospital - Katholisches Klinikum Bochum GmbH, Ruhr University Bochum, Bochum, Germany
| | - Kerstin Hellwig
- Department of Neurology, St. Josef Hospital - Katholisches Klinikum Bochum GmbH, Ruhr University Bochum, Gudrunstrasse 56, 44791 Bochum, Germany
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Andersen JB, Wandall-Holm MF, Andersen PK, Sellebjerg F, Magyari M. Pregnancy in women with MS: Impact on long-term disability accrual in a nationwide Danish Cohort. Mult Scler 2021; 28:1239-1247. [PMID: 34791952 DOI: 10.1177/13524585211057767] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Pregnancy is considered to influence the disease course in women with multiple sclerosis (MS). OBJECTIVE The aim of this study was to investigate the effect of pregnancy on long-term disability accrual in women with MS. METHODS The Danish Multiple Sclerosis Registry (DMSR) was used to identify women diagnosed with clinically isolated syndrome or relapsing-remitting MS. Cox models with pregnancy as a time-dependent exposure and propensity score (PS) models were used to evaluate time to reach confirmed Expanded Disability Status Scale (EDSS) score of 4 and 6. RESULTS A total of 425 women became parous and 840 remained nulliparous. When including pregnancy as a time-dependent exposure, a non-significant association with time to reach EDSS 4 (hazard ratio (HR) 0.86, 95% confidence interval (CI) 0.61-1.20) and EDSS 6 (HR 0.70, 95% CI 0.40-1.20) was found. Correspondingly, the PS model showed no association with pregnancy on time to reach EDSS 4 (HR 0.85, 95% CI 0.56-1.28). CONCLUSION This study concludes that pregnancy does not affect long-term disability accumulation.
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Affiliation(s)
- Johanna Balslev Andersen
- The Danish Multiple Sclerosis Registry, Department of Neurology, Copenhagen University Hospital, Rigshospitalet, Glostrup, Denmark
| | - Malthe Faurschou Wandall-Holm
- The Danish Multiple Sclerosis Registry, Department of Neurology, Copenhagen University Hospital, Rigshospitalet, Glostrup, Denmark
| | | | - Finn Sellebjerg
- The Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital, Rigshospitalet, Glostrup, Denmark/Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Melinda Magyari
- The Danish Multiple Sclerosis Registry, Department of Neurology, Copenhagen University Hospital, Rigshospitalet, Glostrup, Denmark/The Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital, Rigshospitalet, Glostrup, Denmark/Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Abstract
BACKGROUND Multiple sclerosis (MS) is the most common neurological cause of disability in young adults. Off-label rituximab for MS is used in most countries surveyed by the International Federation of MS, including high-income countries where on-label disease-modifying treatments (DMTs) are available. OBJECTIVES: To assess beneficial and adverse effects of rituximab as 'first choice' and as 'switching' for adults with MS. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL, and trial registers for completed and ongoing studies on 31 January 2021. SELECTION CRITERIA We included randomised controlled trials (RCTs) and controlled non-randomised studies of interventions (NRSIs) comparing rituximab with placebo or another DMT for adults with MS. DATA COLLECTION AND ANALYSIS We followed standard Cochrane methodology. We used the Cochrane Collaboration's tool for assessing risk of bias. We rated the certainty of evidence using GRADE for: disability worsening, relapse, serious adverse events (SAEs), health-related quality of life (HRQoL), common infections, cancer, and mortality. We conducted separate analyses for rituximab as 'first choice' or as 'switching', relapsing or progressive MS, comparison versus placebo or another DMT, and RCTs or NRSIs. MAIN RESULTS We included 15 studies (5 RCTs, 10 NRSIs) with 16,429 participants of whom 13,143 were relapsing MS and 3286 progressive MS. The studies were one to two years long and compared rituximab as 'first choice' with placebo (1 RCT) or other DMTs (1 NRSI), rituximab as 'switching' against placebo (2 RCTs) or other DMTs (2 RCTs, 9 NRSIs). The studies were conducted worldwide; most originated from high-income countries, six from the Swedish MS register. Pharmaceutical companies funded two studies. We identified 14 ongoing studies. Rituximab as 'first choice' for relapsing MS Rituximab versus placebo: no studies met eligibility criteria for this comparison. Rituximab versus other DMTs: one NRSI compared rituximab with interferon beta or glatiramer acetate, dimethyl fumarate, natalizumab, or fingolimod in active relapsing MS at 24 months' follow-up. Rituximab likely results in a large reduction in relapses compared with interferon beta or glatiramer acetate (hazard ratio (HR) 0.14, 95% confidence interval (CI) 0.05 to 0.39; 335 participants; moderate-certainty evidence). Rituximab may reduce relapses compared with dimethyl fumarate (HR 0.29, 95% CI 0.08 to 1.00; 206 participants; low-certainty evidence) and natalizumab (HR 0.24, 95% CI 0.06 to 1.00; 170 participants; low-certainty evidence). It may make little or no difference on relapse compared with fingolimod (HR 0.26, 95% CI 0.04 to 1.69; 137 participants; very low-certainty evidence). The study reported no deaths over 24 months. The study did not measure disability worsening, SAEs, HRQoL, and common infections. Rituximab as 'first choice' for progressive MS One RCT compared rituximab with placebo in primary progressive MS at 24 months' follow-up. Rituximab likely results in little to no difference in the number of participants who have disability worsening compared with placebo (odds ratio (OR) 0.71, 95% CI 0.45 to 1.11; 439 participants; moderate-certainty evidence). Rituximab may result in little to no difference in recurrence of relapses (OR 0.60, 95% CI 0.18 to 1.99; 439 participants; low-certainty evidence), SAEs (OR 1.25, 95% CI 0.71 to 2.20; 439 participants; low-certainty evidence), common infections (OR 1.14, 95% CI 0.75 to 1.73; 439 participants; low-certainty evidence), cancer (OR 0.50, 95% CI 0.07 to 3.59; 439 participants; low-certainty evidence), and mortality (OR 0.25, 95% CI 0.02 to 2.77; 439 participants; low-certainty evidence). The study did not measure HRQoL. Rituximab versus other DMTs: no studies met eligibility criteria for this comparison. Rituximab as 'switching' for relapsing MS One RCT compared rituximab with placebo in relapsing MS at 12 months' follow-up. Rituximab may decrease recurrence of relapses compared with placebo (OR 0.38, 95% CI 0.16 to 0.93; 104 participants; low-certainty evidence). The data did not confirm or exclude a beneficial or detrimental effect of rituximab relative to placebo on SAEs (OR 0.90, 95% CI 0.28 to 2.92; 104 participants; very low-certainty evidence), common infections (OR 0.91, 95% CI 0.37 to 2.24; 104 participants; very low-certainty evidence), cancer (OR 1.55, 95% CI 0.06 to 39.15; 104 participants; very low-certainty evidence), and mortality (OR 1.55, 95% CI 0.06 to 39.15; 104 participants; very low-certainty evidence). The study did not measure disability worsening and HRQoL. Five NRSIs compared rituximab with other DMTs in relapsing MS at 24 months' follow-up. The data did not confirm or exclude a beneficial or detrimental effect of rituximab relative to interferon beta or glatiramer acetate on disability worsening (HR 0.86, 95% CI 0.52 to 1.42; 1 NRSI, 853 participants; very low-certainty evidence). Rituximab likely results in a large reduction in relapses compared with interferon beta or glatiramer acetate (HR 0.18, 95% CI 0.07 to 0.49; 1 NRSI, 1383 participants; moderate-certainty evidence); and fingolimod (HR 0.08, 95% CI 0.02 to 0.32; 1 NRSI, 256 participants; moderate-certainty evidence). The data did not confirm or exclude a beneficial or detrimental effect of rituximab relative to natalizumab on relapses (HR 1.0, 95% CI 0.2 to 5.0; 1 NRSI, 153 participants; very low-certainty evidence). Rituximab likely increases slightly common infections compared with interferon beta or glatiramer acetate (OR 1.71, 95% CI 1.11 to 2.62; 1 NRSI, 5477 participants; moderate-certainty evidence); and compared with natalizumab (OR 1.58, 95% CI 1.08 to 2.32; 2 NRSIs, 5001 participants; moderate-certainty evidence). Rituximab may increase slightly common infections compared with fingolimod (OR 1.26, 95% CI 0.90 to 1.77; 3 NRSIs, 5187 participants; low-certainty evidence). It may make little or no difference compared with ocrelizumab (OR 0.02, 95% CI 0.00 to 0.40; 1 NRSI, 472 participants; very low-certainty evidence). The data did not confirm or exclude a beneficial or detrimental effect of rituximab on mortality compared with fingolimod (OR 5.59, 95% CI 0.22 to 139.89; 1 NRSI, 136 participants; very low-certainty evidence) and natalizumab (OR 6.66, 95% CI 0.27 to 166.58; 1 NRSI, 153 participants; very low-certainty evidence). The included studies did not measure SAEs, HRQoL, and cancer. AUTHORS' CONCLUSIONS For preventing relapses in relapsing MS, rituximab as 'first choice' and as 'switching' may compare favourably with a wide range of approved DMTs. A protective effect of rituximab against disability worsening is uncertain. There is limited information to determine the effect of rituximab for progressive MS. The evidence is uncertain about the effect of rituximab on SAEs. They are relatively rare in people with MS, thus difficult to study, and they were not well reported in studies. There is an increased risk of common infections with rituximab, but absolute risk is small. Rituximab is widely used as off-label treatment in people with MS; however, randomised evidence is weak. In the absence of randomised evidence, remaining uncertainties on beneficial and adverse effects of rituximab for MS might be clarified by making real-world data available.
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Affiliation(s)
- Graziella Filippini
- Scientific Director's Office, Carlo Besta Foundation and Neurological Institute, Milan, Italy
| | - Jera Kruja
- Neurology, UHC Mother Theresa, University of Medicine, Tirana, Albania
| | - Cinzia Del Giovane
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Population Health Laboratory (#PopHealthLab), University of Fribourg, Fribourg, Switzerland
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Effects of Pregnancy and Breastfeeding on Clinical Outcomes and MRI Measurements of Women with Multiple Sclerosis: An Exploratory Real-World Cohort Study. Neurol Ther 2021; 11:39-49. [PMID: 34714518 PMCID: PMC8857366 DOI: 10.1007/s40120-021-00297-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 10/20/2021] [Indexed: 11/09/2022] Open
Abstract
Introduction Pregnancy represents an important event for women with multiple sclerosis (MS) and is often accompanied by post-partum disease reactivation. To date, the influence of this reproductive phase on long-term MS outcomes is still largely unexplored. The objective of the study was characterise a large real-world cohort of women with MS to evaluate the effects of pregnancy and breastfeeding on short- and long-term clinical and magnetic resonance imaging (MRI) outcomes while exploring the relationships with MRI measurements of brain atrophy. Methods MS patients with and without pregnancy were recruited. Clinical relapses and MRI activity of the year before conception versus the year after delivery were evaluated. Regression models were performed to investigate the relationships between long-term MS outcomes (EDSS score and MRI brain measurements obtained by SIENAX software) and pregnancy and breastfeeding duration. Results Two hundred ten women with MS were enrolled; of them, 129 (61.4%) had at least one pregnancy. Of all pregnancies (n = 212), those that occurred after MS onset (90 [42.4%]) were examined to evaluate the short-term outcomes. A higher annualised relapse rate in the post-partum year versus the pre-conception year (0.54 ± 0.84 vs. 0.45 ± 0.71; p = 0.04) was observed. A regression analysis showed that clinical activity after delivery was associated with clinical activity of the year before conception (p = 0.001) as well as duration of breastfeeding (p = 0.022). Similarly, post-partum MRI activity was associated with pre-conception MRI activity (p = 0.026) and shorter breastfeeding duration (p = 0.013). Regarding long-term outcomes, having had at least one pregnancy during MS was associated with a lower EDSS score (p = 0.021), while no relationships were reported with MRI measurements. Conversely, a breastfeeding duration > 6 months was associated with lower white matter volume (p = 0.008). Conclusions Our study underlines the importance of considering the effects of pregnancy and breastfeeding on short- and long-term MS outcomes. In the current therapeutic landscape, pregnancy planning and treatment optimisation in the post-partum period, in particular for women who choose to breastfeed, are fundamental for the management of these biological phases so central in a woman’s life.
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Coyle PK. What Can We Learn from Sex Differences in MS? J Pers Med 2021; 11:1006. [PMID: 34683148 PMCID: PMC8537319 DOI: 10.3390/jpm11101006] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 09/26/2021] [Indexed: 01/05/2023] Open
Abstract
Multiple sclerosis (MS) is the major acquired central nervous system disease of young adults. It is a female predominant disease. Multiple aspects of MS are influenced by sex-based differences. This has become an important area of research and study. It teaches us how the impact of sex on a disease can lead to new insights, guidelines, management, and treatments.
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Affiliation(s)
- Patricia K Coyle
- Department of Neurology, Stony Brook University, Stony Brook, NY 11794, USA
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Ahmed AM, Reda MABMG, Elsheshiny AH. Outcomes of pregnancy in Egyptian women with multiple sclerosis in the new treatment era: a multi-center retrospective observational study. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2021. [DOI: 10.1186/s41983-021-00386-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Pregnancy is a recent growing issue in multiple sclerosis (MS) and the update in the diagnostic criteria of MS and introduction of many disease-modifying therapies (DMTs) may cause changes in the relationship between MS, pregnancy, and breastfeeding. This study aimed to investigate the effect of pregnancy and breastfeeding on MS and vice versa. A retrospective observational study was conducted to include MS women with a history of at least one pregnancy during the last 7 years. Data were collected from the archived files in addition to a self-administrating questionnaire. The annualized relapsing rate (ARR) was calculated before, during, and after pregnancy.
Results
We included 116 successful pregnancies from 93 MS women with mean age 32.74 ± 5.12 years. Interferon-beta was the commonly used DMT during and after pregnancy. Despite the ARR during the two years preceding the conception was 0.36 (95% CI 0.32–0.41), this rate was significantly decreased during first, second, and third trimester (0.07; 95% CI 0.04–0.15, 0.10; 95% CI 0.03–0.17, and 0.15; 95% CI 0.08–0.24, respectively; P-value < 0.001 in all). Furthermore, this ARR was significantly decreased during the first and last three months after delivery (0.27; 95% CI 0.16–0.39; P-value = 0.037, and 0.24; 95% CI 0.17–0.38; P-value = 0.023). Exclusive breastfeeding was associated with deceased risk of postpartum relapse, with HR 0.31 (95% CI 0.12–0.67; P = 0.002).
Conclusions
Pregnancy is protective from MS relapse, with a significant decrease of ARR from the pre-pregnancy period. Postpartum reactivation of the disease occurs from the third month after labor, rather than the early postpartum period. Exclusive breastfeeding for at least 2 months decreased the risk of postpartum relapse.
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Proschmann U, Haase R, Inojosa H, Akgün K, Ziemssen T. Drug and Neurofilament Levels in Serum and Breastmilk of Women With Multiple Sclerosis Exposed to Natalizumab During Pregnancy and Lactation. Front Immunol 2021; 12:715195. [PMID: 34512637 PMCID: PMC8426350 DOI: 10.3389/fimmu.2021.715195] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 08/05/2021] [Indexed: 12/28/2022] Open
Abstract
Objective To determine the transfer of the monoclonal antibody natalizumab into breastmilk and to evaluate drug and serum neurofilament light chain ((s)NfL) levels in natalizumab exposed pregnancies and lactation periods. Methods Eleven women with relapsing remitting multiple sclerosis treated with natalizumab during pregnancy and lactation were included in this study. Breastmilk samples were collected up to 302 days after delivery and analyzed for natalizumab concentration and NfL. Additionally, maternal drug levels and sNfL were determined preconceptually, in each trimester, at delivery and postpartum. Clinical and radiological disease activity was systemically assessed across pregnancy and postpartum period. Results The mean average natalizumab concentration in breast milk was low at 0.06 µg/ml [standard deviation (SD) 0.05] in the eight patients who provided serial breastmilk samples with an estimated mean absolute infant dose of 0.007 mg/kg/d (SD 0.005). The relative infant dose (RID), a metric comparing the infant with maternal drug exposure was low as well with a mean of 0.04% (SD=0.03). Most patients had a maximum concentration in breast milk at one to eight days after infusion. Pregnancy was associated with a non-significant decline of the median natalizumab serum concentration. All patients exposed to natalizumab prior (n=10) and during pregnancy (n=11) kept free of disease activity during gestation. While pregnancy was associated with low sNfL levels in patients treated with natalizumab prior and during pregnancy, the postpartum period was linked to a transient sNfL increase in some patients without any evidence of clinical or radiological disease activity. NfL was detectable in the majority of breastmilk samples with a median concentration of 1.7 pg/ml (range 0.004-18.1). Conclusion We determined transfer of natalizumab into breastmilk with an RID far below the threshold of concern of 10%. Studies including childhood development assessment are needed in order to gain safety data about natalizumab-exposed breastfeeding. SNfL assessment might be a useful adjunct to monitor silent disease activity and therapeutic response during pregnancy and postpartum period. However, further investigations regarding transient postpartum sNfL increases are required to determine its association to parturition per se or to a silent disease activity in people with multiple sclerosis.
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Affiliation(s)
- Undine Proschmann
- Multiple Sclerosis Center, Center of Clinical Neuroscience, Department of Neurology, University Hospital Carl Gustav Carus, Dresden University of Technology, Dresden, Germany
| | - Rocco Haase
- Multiple Sclerosis Center, Center of Clinical Neuroscience, Department of Neurology, University Hospital Carl Gustav Carus, Dresden University of Technology, Dresden, Germany
| | - Hernan Inojosa
- Multiple Sclerosis Center, Center of Clinical Neuroscience, Department of Neurology, University Hospital Carl Gustav Carus, Dresden University of Technology, Dresden, Germany
| | - Katja Akgün
- Multiple Sclerosis Center, Center of Clinical Neuroscience, Department of Neurology, University Hospital Carl Gustav Carus, Dresden University of Technology, Dresden, Germany
| | - Tjalf Ziemssen
- Multiple Sclerosis Center, Center of Clinical Neuroscience, Department of Neurology, University Hospital Carl Gustav Carus, Dresden University of Technology, Dresden, Germany
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