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Potential Protective Role of Pregnancy and Breastfeeding in Delaying Onset Symptoms Related to Multiple Sclerosis. Medicina (B Aires) 2023; 59:medicina59030619. [PMID: 36984620 PMCID: PMC10057678 DOI: 10.3390/medicina59030619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 03/04/2023] [Accepted: 03/09/2023] [Indexed: 03/22/2023] Open
Abstract
The impact of pregnancy and breastfeeding on the development and outcomes of Multiple sclerosis (MS) has been debated for decades. Since several factors can influence the evolution of the disease, the protective role of multiparity and breastfeeding remains uncertain, as well the role of hormone replacement therapy in the perimenopausal period. We report two cases of relatively late-onset MS in two parous women, who developed their first neurological symptoms after six and nine pregnancies, respectively. Both women breastfed each of their children for 3 to 12 months. One of them underwent surgical menopause and received hormone replacement therapy for 7 years before MS onset. We performed a systematic literature review to highlight the characteristics shared by women who develop the disease in similar conditions, after unique hormonal imbalances, and to collect promising evidence on this controversial issue. Several studies suggest that the beneficial effects of pregnancy and breastfeeding on MS onset and disability accumulation may only be realized when several pregnancies occur. However, these data on pregnancy and breastfeeding and their long-term benefits on MS outcomes suffer from the possibility of reverse causality, as women with milder impairment might choose to become pregnant more readily than those with a higher level of disability. Thus, the hypothesis that multiparity might have a protective role on MS outcomes needs to be tested in larger prospective cohort studies of neo-diagnosed women, evaluating both clinical and radiological features at presentation.
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The Impact of Reproductive Issues on Preferences of Women with Relapsing Multiple Sclerosis for Disease-Modifying Treatments. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2021; 13:583-597. [PMID: 32588337 DOI: 10.1007/s40271-020-00429-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Relapsing-remitting multiple sclerosis (RRMS) is an incurable disease characterised by relapses (periods of function loss) followed by full or partial recovery, and potential permanent disability over time. Many disease-modifying treatments (DMTs) exist that help reduce relapses and slow disease progression. Most are contraindicated during conception/pregnancy and some require a discontinuation period before trying to conceive. Although around three-quarters of people with RRMS are women, there is limited knowledge about how reproductive issues impact DMT preference. OBJECTIVE The aim of this study was to measure the preferences for DMTs of women with RRMS who are considering pregnancy. DESIGN An online discrete choice experiment (DCE). METHODS Participants chose between two hypothetical DMTs characterised by a set of attributes, then indicated if they preferred their choice to no treatment. Attributes were identified from interviews and focus groups with people with RRMS and MS professionals, as well as literature reviews, and included the probability of problems with pregnancy, discontinuation of DMTs, and breastfeeding safety. In each DCE task, participants were asked to imagine making decisions in three scenarios: now; when trying to conceive; and when pregnant. ANALYSIS Two mixed logit models were estimated, one to assess the statistical significance between scenarios and one in maximum acceptable risk space to allow comparison of the magnitudes of parameters between scenarios. SAMPLE Women with RRMS who were considering having a child in the future, recruited from a UK MS patient register. RESULTS Sixty respondents completed the survey. Participants preferred no treatment in 12.6% of choices in the 'now' scenario, rising significantly to 37.6% in the 'trying to conceive' scenario and 60.3% in the 'pregnant' scenario (Kruskal-Wallis p < 0.001). This pattern corresponds with results from models that included a no-treatment alternative-specific constant (ASC) capturing differences between taking and not taking a DMT not specified by the attributes. The ASC was lower in the trying to conceive scenario than in the now scenario, and lower still in the pregnant scenario, indicating an intrinsic preference for no treatment. Participants also placed relatively less preference on reducing relapses and avoiding disease progression in the trying to conceive and pregnant scenarios compared with a lower risk of problems with pregnancy. In the trying to conceive scenario, participants' preference for treatments with shorter washout periods increased. CONCLUSION Women with RRMS considering having a child prefer DMTs with more favourable reproduction-related attributes, even when not trying to conceive. Reproductive issues also influenced preferences for DMT attributes not directly related to pregnancy, with preferences dependent on the life circumstances in which choices were made. The design of the DCE highlights the benefits of considering the scenario in which participants make choices, as they may change over time.
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Lamaita R, Melo C, Laranjeira C, Barquero P, Gomes J, Silva-Filho A. Multiple Sclerosis in Pregnancy and its Role in Female Fertility: A Systematic Review. JBRA Assist Reprod 2021; 25:493-499. [PMID: 34061482 PMCID: PMC8312296 DOI: 10.5935/1518-0557.20210022] [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: 11/24/2022] Open
Abstract
Multiple sclerosis (MS) is a neurological disease that typically affects young women of reproductive age. There are still many questions and heterogeneous clinical approaches partly due to the lack of consensus and guidelines. For many years, women with MS have been discouraged from getting pregnant for fears that the disease might negatively affect the fetus or increase their obstetric risk or for claims that the disease might decrease fertility. However, fertility does not seem to be impaired to a larger extent in women with MS. Therefore, all healthcare providers involved in the follow-up of multiple sclerosis patients must be prepared to discuss future fertility, pregnancy, and others matters, in addition to providing them with the best possible counseling. This study presents data based on updated evidence and discusses fertility and pregnancy in patients with MS with respect to the impacts of pregnancy on the risk and prognostic factors tied to MS, and the impact of MS on pregnancy outcomes and fertility treatments administered to females with MS. In conclusion, a clear relationship between infertility and MS has not been established. There seems to exist a link between disease aggressiveness and progression with several processes that might impair fertility. However, MS does not stand as a contraindication to assisted reproductive technology. From the several studies analyzed, it is possible to conclude that pregnancy is possible in women with MS. It is important to discuss and plan the ideal moment to start treatment and managing pregnancy and contraception aiming at better results.
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Affiliation(s)
- Rivia Lamaita
- Federal University of Minas Gerais School of Medicine Department of Gynecology and Obstetrics Belo Horizonte Minas Gerais Brazil Department of Gynecology and Obstetrics of the School of Medicine of the Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Carolina Melo
- Rede Mater Dei de Saúde Belo Horizonte Minas Gerais Brazil Rede Mater Dei de Saúde, Belo Horizonte, Minas Gerais, Brazil
| | - Cláudia Laranjeira
- Federal University of Minas Gerais School of Medicine Department of Gynecology and Obstetrics Belo Horizonte Minas Gerais Brazil Department of Gynecology and Obstetrics of the School of Medicine of the Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | | | | | - Agnaldo Silva-Filho
- Federal University of Minas Gerais School of Medicine Department of Gynecology and Obstetrics Belo Horizonte Minas Gerais Brazil Department of Gynecology and Obstetrics of the School of Medicine of the Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
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Alhomoud MA, Khan AS, Alhomoud I. The Potential Preventive Effect of Pregnancy and Breastfeeding on Multiple Sclerosis. Eur Neurol 2021; 84:71-84. [PMID: 33744881 DOI: 10.1159/000514432] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 01/09/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Multiple sclerosis (MS) is an inflammatory demyelinating chronic neurological disease that affects the central nervous system of young adults and their quality of life. Several studies have investigated the effects of pregnancy and breastfeeding on MS. However, the evidence regarding the influence of pregnancy and breastfeeding on MS is still accumulating. This review aimed to summarize the current evidence regarding the effects of pregnancy and breastfeeding on MS. SUMMARY A systematic electronic literature search of the PubMed and Embase databases was conducted to determine relevant published articles. The eligible studies were summarized and evaluated in tables. Key Messages: The majority of the studies indicated that pregnancy appears to lower the rate of MS relapses, particularly in the third trimester. The evidence regarding the effect of breastfeeding on MS remains inconsistent. Despite reports of negative obstetric outcomes in some pregnant women with MS, pregnancies in women with MS should not be categorized as high-risk pregnancies.
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Affiliation(s)
- Mohsen Ali Alhomoud
- Department of Public Health, Ministry of Health, Eastern Province, Al Qatif, Saudi Arabia,
| | - Abdul Sattar Khan
- Family and Community Medicine Department, King Faisal University, Eastern Province, Al Ahsa, Saudi Arabia
| | - Iftetah Alhomoud
- Neurosciences Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
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Modrego PJ, Urrea MA, de Cerio LD. The effects of pregnancy on relapse rates, disability and peripartum outcomes in women with multiple sclerosis: a systematic review and meta-analysis. J Comp Eff Res 2021; 10:175-186. [PMID: 33565886 DOI: 10.2217/cer-2020-0211] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background: Although previous cohort studies of women with multiple sclerosis (MS) yielded a reduction in relapse rate during pregnancy, the effect size has not been quantified in a comprehensive manner. In addition, the effects on disability progression and peripartum outcomes have been controversial. The purpose of this work is to assess the effect of pregnancy on disease activity, and to assess the effects of MS on pregnancy as well. Materials & methods: We searched in PubMed, Cochrane Library and EMBASE for cohort studies dealing with the effects of pregnancy on relapse rates, disability progression and peripartum outcomes in women with MS. The evaluated outcomes were: changes in the annualized relapse rate (ARR) in pregnancy and puerperium, disability worsening compared with the year before pregnancy, and peripartum outcomes, which were compared with the ones of non-MS women. In the majority of cohorts included here, the women were not under disease modifying therapies during pregnancy. Results: We found 23 cohort studies measuring changes in the ARR during pregnancy and puerperium; 12 were prospective and 11 retrospective. In 17 cohorts there was significant reduction in the ARR during pregnancy compared with prepregnancy period. The pooled mean reduction in the ARR was -0.5 (95% CI: 0.67-0.38), p < 0.001, from 15 cohorts included in meta-analysis. In 18 cohorts the ARR increased in the 3-month puerperium relative to prepregnancy year period; the pooled mean increase in the ARR was 0.22 (95% CI: 0.11-0.33), p < 0.001, from 14 cohorts included in meta-analysis. Disability worsening was addressed in 18 cohorts, and in 14 of them there were no significant changes. Peripartum complications and obstetrical outcomes were assessed in 16 cohorts, of whom 13 were retrospective, without finding significant differences. Conclusion: Pregnancy is associated with lower disease activity, and puerperium with higher disease activity. Disability does not change significantly after pregnancy. The obstetrical outcomes are not very different from those of non-MS women in most cohorts.
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Affiliation(s)
- Pedro J Modrego
- Department of Neurology, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | | | - Leyre Diaz de Cerio
- Department of Neurology, Hospital Universitario Miguel Servet, Zaragoza, Spain
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Xie Y, Tian Z, Han F, Liang S, Gao Y, Wu D. Factors associated with relapses in relapsing-remitting multiple sclerosis: A systematic review and meta-analysis. Medicine (Baltimore) 2020; 99:e20885. [PMID: 32629678 PMCID: PMC7337585 DOI: 10.1097/md.0000000000020885] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND The relapse is character of relapsing-remitting multiple sclerosis. The therapeutic goal is to reduce the risk of relapse. Factors associated with relapses can help to manage and prevent relapses. In addition, patients and doctors all pay attention to it. However, there are differences between studies. Our aim is to summarize factors associated with relapses in relapsing-remitting multiple sclerosis (RRMS). METHODS PubMed, EMBASE, Web of science, Cochrane library, CNKI, Wanfang, SinoMed, and VIP were searched to identify risk factors about relapses in RRMS, which should be in cohort or case-control studies. This article was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The quality of studies was evaluated by the Newcastle-Ottawa Scale (NOS). Meta-analysis, subgroup and sensitivity analyses, and publication bias were all performed with Stata. This research has been registered on the international prospective register of systematic reviews (PROSPERO, CRD42019120502). RESULTS 43 articles were included. Infection, postpartum period, risk gene, stress, and vitamin D were risk factors for relapses in RRMS. Pregnancy period was the protective factor. Among those, infection increased the risk of relapses in infection period (relative risk [RR], 2.07 [confidence interval (CI), 1.64 to 2.60]). Women in the postpartum period increased the risk of relapses compared with women before pregnancy (RR, 1.43 [CI, 1.19 to 1.72]), or women in pregnancy period (RR, 2.07 [CI, 1.49 to 2.88]). Women in the pregnancy period decreased the risk of relapses (RR, 0.56 [CI, 0.37 to 0.84]) compared with women before pregnancy. However, fewer studies, heterogeneity, and sample size were the limitations. CONCLUSION It is reliable to adopt results about infection, pregnancy period, and postpartum period.
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Affiliation(s)
- Yao Xie
- Department of Neurology, Affiliated Hospital of Hunan Academy of Traditional Chinese Medicine, Changsha
- Department of Neurology, Dongzhimen Hospital affiliated to Beijing University of Chinese Medicine
| | - Ziyu Tian
- Department of Neurology, Dongzhimen Hospital affiliated to Beijing University of Chinese Medicine
- Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine
| | - Fang Han
- Office of Academic Research, Beijing Hospital of Traditional Chinese Medicine affiliated to Capital Medical University, Beijing
| | - Shibing Liang
- Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine
- College of Basic Medical Sciences, Shanxi University of Traditional Chinese Medicine, Taiyuan, China
| | - Ying Gao
- Department of Neurology, Dongzhimen Hospital affiliated to Beijing University of Chinese Medicine
| | - Dahua Wu
- Department of Neurology, Affiliated Hospital of Hunan Academy of Traditional Chinese Medicine, Changsha
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Zanghì A, D'Amico E, Callari G, Chisari CG, Borriello G, Grimaldi LME, Patti F. Pregnancy and the Postpartum Period in Women With Relapsing-Remitting Multiple Sclerosis Treated With Old and New Disease-Modifying Treatments: A Real-World Multicenter Experience. Front Neurol 2020; 11:105. [PMID: 32158424 PMCID: PMC7052127 DOI: 10.3389/fneur.2020.00105] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 01/30/2020] [Indexed: 01/29/2023] Open
Abstract
Introduction: Trends of disease activity during pregnancy, the postpartum period, and until 24 months from the delivery in the era of new drugs for the treatment of relapsing-remitting multiple sclerosis (RRMS) need to be investigated. Methods: In this cross-sectional Italian multicenter study, women with RRMS were included; the disease-modifying treatment (DMT) at the time of conception included were: interferons, glatiramer acetate, teriflunomide, dimethyl fumarate, fingolimod, and natalizumab. The main outcome of the study was to determine the rate of relapse occurrence during pregnancy and the postpartum period in all women grouped for each DMT. The secondary outcome was to determine the overall disease activity assessed by NEDA 3 (relapse, disability level, and radiological activity) at 24 months from the date of delivery. Results: Completed data were available for 81 pregnancies (in 74 women). Women on interferons and glatiramer had longer disease duration than women on dimethyl fumarate, fingolimod, and natalizumab (p < 0.05). Overall, we recorded 25 relapses during pregnancy (11 in 11 women) and the postpartum period (14 in 14 women). Natalizumab was the most commonly DMT in women (3) who experienced relapses during pregnancy. IFNs were the most commonly prescribed DMT in women (8) who experienced relapses during the postpartum period. At logistic regression analysis, specific treatment per se was not associated with relapse occurrence. No differences among the DMTs groups were recorded about NEDA 3 status at 24 months of follow-up. Conclusions: In our population, there was no difference in terms of relapses occurrence, disability status, and the overall disease activity during a follow up of 24 months.
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Affiliation(s)
- Aurora Zanghì
- Department "G. F. Ingrassia", University of Catania, Catania, Italy
| | - Emanuele D'Amico
- Department "G. F. Ingrassia", University of Catania, Catania, Italy
| | | | | | | | | | - Francesco Patti
- Department "G. F. Ingrassia", University of Catania, Catania, Italy
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Belarmino ADC, Azevedo LJM, Teixeira AKM, Sousa BAT, Alves LC, Ferreira junior AR. Gestante com esclerose múltipla: reflexão fenomenológica da mulher quanto ao parto. AVANCES EN ENFERMERÍA 2020. [DOI: 10.15446/av.enferm.v38n1.81405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Objetivo: descrever o parto e o nascimento na perspectiva da portadora de esclerose múltipla.Materiais e método: estudo fenomenológico alicerçado na fenomenologia descritiva de Husserl e na fenomenologia social de Alfred Schütz. A descrição foi obtida por meio de entrevista fenomenológica efetuada com puérpera em agosto de 2018 em um hospital do Nordeste, Brasil. Foi aplicada a redução fenomenológica eidética para analisar os discursos da mulher com esclerose no pós-parto.Resultados: da análise dos depoimentos, emergiram as categorias: Medo de engravidar com esclerose múltipla (EM), Dor terrível e medo do parto, e Felicidade com o bebê. Conclusões: a maternidade em condições crônicas como a EM proporciona novos significados no mundo da vida, em que o nascimento do bebê projeta novas perspectivas positivaspara o futuro da mulher.
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Fragoso YD, Adoni T, Brooks JBB, Finkelsztejn A, da Gama PD, Grzesiuk AK, Marques VD, Parolin MFK, Sato HK, Varela DL, Vasconcelos CCF. Practical Evidence-Based Recommendations for Patients with Multiple Sclerosis Who Want to Have Children. Neurol Ther 2018; 7:207-232. [PMID: 30167914 PMCID: PMC6283793 DOI: 10.1007/s40120-018-0110-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Indexed: 12/14/2022] Open
Abstract
Multiple sclerosis (MS) management presently aims to reach a state of no (or minimal) evidence of disease activity. The development and commercialization of new drugs has led to a renewed interest in family planning, since patients with MS may face a future with reduced (or no) disease-related neurological disability. The advice of neurologists is often sought by patients who want to have children and need to know more about disease control at conception and during pregnancy and the puerperium. When MS is well controlled, the simple withdrawal of drugs for patients who intend to conceive is not an option. On the other hand, not all treatments presently recommended for MS are considered safe during conception, pregnancy and/or breastfeeding. The objective of the present study was to summarize the practical and evidence-based recommendations for family planning when our patients (women and men) have MS.Funding TEVA Pharmaceutical Brazil.
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Affiliation(s)
| | - Tarso Adoni
- Hospital Sirio-Libanes de Sao Paulo, São Paulo, SP, Brazil
| | | | | | | | | | | | | | - Henry K Sato
- Instituto de Neurologia de Curitiba, Curitiba, PR, Brazil
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McCombe PA. The Short and Long-Term Effects of Pregnancy on Multiple Sclerosis and Experimental Autoimmune Encephalomyelitis. J Clin Med 2018; 7:jcm7120494. [PMID: 30486504 PMCID: PMC6306813 DOI: 10.3390/jcm7120494] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 11/21/2018] [Accepted: 11/21/2018] [Indexed: 02/07/2023] Open
Abstract
The role of pregnancy in multiple sclerosis (MS) is of importance because many patients with MS are young women in the childbearing age who require information to inform their reproductive decisions. Pregnancy is now well-known to be associated with fewer relapses of MS and reduced activity of autoimmune encephalomyelitis (EAE). However, in women with multiple sclerosis, this benefit is not always sufficient to protect against a rebound of disease activity if disease-modulating therapy is ceased for pregnancy. There is concern that use of assisted reproductive therapies can be associated with relapses of MS, but more data are required. It is thought that the beneficial effects of pregnancy are due to the pregnancy-associated changes in the maternal immune system. There is some evidence of this in human studies and studies of EAE. There is also evidence that having been pregnant leads to better long-term outcome of MS. The mechanism for this is not fully understood but it could result from epigenetic changes resulting from pregnancy or parenthood. Further studies of the mechanisms of the beneficial effects of pregnancy could provide information that might be used to produce new therapies.
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Affiliation(s)
- Pamela A McCombe
- The University of Queensland, Centre for Clinical Research, Brisbane, QLD 4029, Australia.
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11
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Houtchens MK, Edwards NC, Phillips AL. Relapses and disease-modifying drug treatment in pregnancy and live birth in US women with MS. Neurology 2018; 91:e1570-e1578. [PMID: 30266887 PMCID: PMC6205686 DOI: 10.1212/wnl.0000000000006382] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 07/16/2018] [Indexed: 11/17/2022] Open
Abstract
Objective To evaluate relapse rates and disease-modifying drug (DMD) treatment in US women with multiple sclerosis (MS) and a live birth. Methods This retrospective administrative claims database study used US commercial health plan data from women with MS and a live birth from January 1, 2006, to June 30, 2015. Relapses and DMD treatment were evaluated 1-year prepregnancy, during pregnancy, during puerperium (6 weeks postpregnancy), and 1-year postpregnancy. Relapse was defined as MS-related hospitalization, emergency room visit, or outpatient visit with corticosteroid prescription within 7 days. Generalized estimating equation models for longitudinal data tested for differences between prepregnancy vs the other time periods. Results A total of 2,158 patients were eligible. The odds of relapse declined during pregnancy (odds ratio [OR] 0.623, 95% confidence interval [CI] 0.521–0.744; p < 0.0001), increased during puerperium (OR 1.710, 95% CI 1.358–2.152; p < 0.0001), and ended at a higher level during the last 3 postpartum quarters (OR 1.216, 95% CI 1.052–1.406; p = 0.0081). The proportion of women with DMD treatment was rather low overall: approximately 20% prepregnancy, bottoming to 1.9% during the second trimester, and peaking at 25.5% 9 to 12 months postpartum. DMD treatment declined significantly during pregnancy (OR 0.171, 95% CI 0.144–0.203; p < 0.0001), remained lower during puerperium (OR 0.361, 95% CI 0.312–0.418; p < 0.0001), and ended at a higher level during the last 3 postpartum quarters (OR 1.259, 95% CI 1.156–1.371; p < 0.0001). Conclusions The rate of MS relapse decreased during pregnancy, increased 6 months postpartum, and decreased 6 to 12 months postpartum. DMD treatment was uncommon in the year before pregnancy, further decreased immediately prepregnancy and during pregnancy, and increased postpartum.
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Affiliation(s)
- Maria K Houtchens
- From the Partners MS Center (M.K.H.), Brigham and Women's Hospital, Harvard Medical School, Boston; Health Services Consulting Corporation (N.C.E.), Boxborough; and EMD Serono, Inc. (A.L.P.), Rockland, MA.
| | - Natalie C Edwards
- From the Partners MS Center (M.K.H.), Brigham and Women's Hospital, Harvard Medical School, Boston; Health Services Consulting Corporation (N.C.E.), Boxborough; and EMD Serono, Inc. (A.L.P.), Rockland, MA
| | - Amy L Phillips
- From the Partners MS Center (M.K.H.), Brigham and Women's Hospital, Harvard Medical School, Boston; Health Services Consulting Corporation (N.C.E.), Boxborough; and EMD Serono, Inc. (A.L.P.), Rockland, MA
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12
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Vaughn C, Bushra A, Kolb C, Weinstock-Guttman B. An Update on the Use of Disease-Modifying Therapy in Pregnant Patients with Multiple Sclerosis. CNS Drugs 2018; 32:161-178. [PMID: 29508244 DOI: 10.1007/s40263-018-0496-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
The active management of multiple sclerosis (MS) has been made possible during the last two decades with the advent of disease-modifying therapies (DMTs), leading to improved clinical outcomes for many patients. Furthermore, with the realization that MS does not adversely affect pregnancy outcome and that pregnancy does not have an overall negative impact on the long-term disease course of MS, the importance of appropriate counseling and discussion of future pregnancy plans with women of childbearing age is greater than ever. Although several DMTs are licensed for the treatment of MS, none are specifically approved for use during pregnancy or breastfeeding and the use of DMTs during these periods frequently gives rise to concerns regarding potential risks to the fetus. The outcomes of studies in patients with MS treated with DMTs during pregnancy and immediately postpartum have been the focus of several recently published papers. Given the high level of interest surrounding the prescribing of DMTs for MS patients of childbearing age, and the lack of clear guidance in this respect, the current review presents an up-to-date overview of new data, including observational data on real-world outcomes, that have been published during the last 2 years, and could inform future prescribing decisions.
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Affiliation(s)
- Caila Vaughn
- Department of Neurology, Jacobs MS Center for Treatment and Research, University at Buffalo, Buffalo, NY, USA.
| | - Aisha Bushra
- Department of Neurology, Jacobs MS Center for Treatment and Research, University at Buffalo, Buffalo, NY, USA
| | - Channa Kolb
- Department of Neurology, Jacobs MS Center for Treatment and Research, University at Buffalo, Buffalo, NY, USA
| | - Bianca Weinstock-Guttman
- Department of Neurology, Jacobs MS Center for Treatment and Research, University at Buffalo, Buffalo, NY, USA.
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Montalban X, Gold R, Thompson AJ, Otero-Romero S, Amato MP, Chandraratna D, Clanet M, Comi G, Derfuss T, Fazekas F, Hartung HP, Havrdova E, Hemmer B, Kappos L, Liblau R, Lubetzki C, Marcus E, Miller DH, Olsson T, Pilling S, Selmaj K, Siva A, Sorensen PS, Sormani MP, Thalheim C, Wiendl H, Zipp F. ECTRIMS/EAN Guideline on the pharmacological treatment of people with multiple sclerosis. Mult Scler 2018; 24:96-120. [PMID: 29353550 DOI: 10.1177/1352458517751049] [Citation(s) in RCA: 391] [Impact Index Per Article: 65.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Multiple sclerosis (MS) is a complex disease with new drugs becoming available in the past years. There is a need for a reference tool compiling current data to aid professionals in treatment decisions. OBJECTIVES To develop an evidence-based clinical practice guideline for the pharmacological treatment of people with MS. METHODS This guideline has been developed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology and following the updated EAN recommendations. Clinical questions were formulated in Patients-Intervention-Comparator-Outcome (PICO) format and outcomes were prioritized. The quality of evidence was rated into four categories according to the risk of bias. The recommendations with assigned strength (strong and weak) were formulated based on the quality of evidence and the risk-benefit balance. Consensus between the panelists was reached by use of the modified nominal group technique. RESULTS A total of 10 questions were agreed, encompassing treatment efficacy, response criteria, strategies to address suboptimal response and safety concerns and treatment strategies in MS and pregnancy. The guideline takes into account all disease-modifying drugs approved by the European Medicine Agency (EMA) at the time of publication. A total of 21 recommendations were agreed by the guideline working group after three rounds of consensus. CONCLUSION The present guideline will enable homogeneity of treatment decisions across Europe.
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Affiliation(s)
- Xavier Montalban
- Department of Neurology-Neuroimmunology, Multiple Sclerosis Centre of Catalonia (Cemcat), Vall d'Hebron University Hospital, Barcelona, Spain
| | - Ralf Gold
- Department of Neurology, Ruhr University, St. Josef-Hospital, Bochum, Germany
| | - Alan J Thompson
- Department of Brain Repair & Rehabilitation and Faculty of Brain Sciences, University College London Institute of Neurology, London, UK
| | - Susana Otero-Romero
- Department of Neurology-Neuroimmunology, Multiple Sclerosis Centre of Catalonia (Cemcat), Vall d'Hebron University Hospital, Barcelona, Spain/Preventive Medicine and Epidemiology Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Maria Pia Amato
- Department of Neurosciences, Psychology, Drugs and Child Health Area (NEUROFARBA), Section Neurosciences, University of Florence, Florence, Italy
| | | | - Michel Clanet
- Department of Neurology, Toulouse University Hospital, Toulouse, France
| | - Giancarlo Comi
- Neurological Department, Institute of Experimental Neurology (INSPE), Scientific Institute Hospital San Raffaele, Universita' Vita-Salute San Raffaele, Milan, Italy
| | - Tobias Derfuss
- Departments of Neurology and Biomedicine, University Hospital Basel, Basel, Switzerland
| | - Franz Fazekas
- Department of Neurology, Medical University of Graz, Graz, Austria
| | - Hans Peter Hartung
- Multiple Sclerosis Center, Department of Neurology, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Eva Havrdova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic
| | - Bernhard Hemmer
- Department of Neurology, Klinikum Rechts der Isar, Technische Universität München and Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | | | - Roland Liblau
- INSERM UMR U1043 - CNRS U5282, Université de Toulouse, UPS, Centre de Physiopathologie de Toulouse Purpan, Toulouse, France
| | - Catherine Lubetzki
- Sorbonne Universités, UPMC Univ Paris 06, UMR_S 1127, ICM-GHU Pitié-Salpêtrière, Paris, France
| | - Elena Marcus
- Centre for Outcomes Research and Effectiveness (CORE), Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | - David H Miller
- NMR Research Unit and Queen Square Multiple Sclerosis Centre, University College London Institute of Neurology, London, UK
| | - Tomas Olsson
- Neuroimmunology Unit, Center for Molecular Medicine, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Steve Pilling
- Centre for Outcomes Research and Effectiveness (CORE), Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | - Krysztof Selmaj
- Department of Neurology, Medical University of Lodz, Lodz, Poland
| | - Axel Siva
- Clinical Neuroimmunology Unit and MS Clinic, Department of Neurology, Cerrahpasa School of Medicine, Istanbul University, Istanbul, Turkey
| | - Per Soelberg Sorensen
- Department of Neurology, Danish Multiple Sclerosis Center, Copenhagen University Hospital, Rigshospitalet, Denmark
| | | | | | - Heinz Wiendl
- Department of Neurology, University of Münster, Münster, Germany
| | - Frauke Zipp
- Department of Neurology, Focus Program Translational Neuroscience (FTN) and Immunology (FZI), Rhine-Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
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14
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Montalban X, Gold R, Thompson AJ, Otero‐Romero S, Amato MP, Chandraratna D, Clanet M, Comi G, Derfuss T, Fazekas F, Hartung HP, Havrdova E, Hemmer B, Kappos L, Liblau R, Lubetzki C, Marcus E, Miller DH, Olsson T, Pilling S, Selmaj K, Siva A, Sorensen PS, Sormani MP, Thalheim C, Wiendl H, Zipp F. ECTRIMS
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EAN
guideline on the pharmacological treatment of people with multiple sclerosis. Eur J Neurol 2018; 25:215-237. [DOI: 10.1111/ene.13536] [Citation(s) in RCA: 113] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 11/27/2017] [Indexed: 01/21/2023]
Affiliation(s)
- X. Montalban
- Multiple Sclerosis Centre of Catalonia (Cemcat) Department of Neurology‐Neuroimmunology Vall d'Hebron University Hospital Barcelona Spain
| | - R. Gold
- Department of Neurology Ruhr University, St Josef‐Hospital Bochum Germany
| | - A. J. Thompson
- Department of Brain Repair and Rehabilitation Faculty of Brain Sciences University College London Institute of Neurology London UK
| | - S. Otero‐Romero
- Multiple Sclerosis Centre of Catalonia (Cemcat) Department of Neurology‐Neuroimmunology Vall d'Hebron University Hospital Barcelona Spain
- Preventive Medicine and Epidemiology Department Vall d'Hebron University Hospital Barcelona Spain
| | - M. P. Amato
- Department NEUROFARBA Section Neurosciences University of Florence Florence Italy
| | | | - M. Clanet
- Department of Neurology Toulouse University Hospital Toulouse France
| | - G. Comi
- Neurological Department Institute of Experimental Neurology (INSPE) Scientific Institute Hospital San Raffaele University Vita‐Salute San Raffaele Milan Italy
| | - T. Derfuss
- Departments of Neurology and Biomedicine University Hospital Basel Basel Switzerland
| | - F. Fazekas
- Department of Neurology Medical University of Graz Graz Austria
| | - H. P. Hartung
- Department of Neurology Medical Faculty, Multiple Sclerosis Heinrich‐Heine‐University Düsseldorf Germany
| | - E. Havrdova
- Department of Neurology and Centre of Clinical Neuroscience First Faculty of Medicine and General University Hospital Charles University Prague Czech Republic
| | - B. Hemmer
- Department of Neurology Klinikum Rechts der Isar Technische Universität München MunichGermany
- Munich Cluster for Systems Neurology (SyNergy) Munich Germany
| | - L. Kappos
- University Hospital Basel Basel Switzerland
| | - R. Liblau
- INSERM UMR U1043 – CNRS U5282 Centre de Physiopathologie de Toulouse Purpan Université de Toulouse, UPS ToulouseFrance
| | - C. Lubetzki
- ICM‐GHU Pitié‐Salpêtrière Sorbonne Universités UPMC Univ Paris 06, UMR_S 1127 Paris France
| | - E. Marcus
- Centre for Outcomes Research and Effectiveness (CORE) Research Department of Clinical, Educational and Health Psychology University College London LondonUK
| | - D. H. Miller
- NMR Research Unit Queen Square Multiple Sclerosis Centre University College London (UCL) Institute of Neurology London UK
| | - T. Olsson
- Neuroimmunology Unit Centre for Molecular Medicine, L8:04 Karolinska University Hospital (Solna) Stockholm Sweden
| | - S. Pilling
- Centre for Outcomes Research and Effectiveness (CORE) Research Department of Clinical, Educational and Health Psychology University College London LondonUK
| | - K. Selmaj
- Department of Neurology Medical University of Lodz Lodz Poland
| | - A. Siva
- Clinical Neuroimmunology Unit and MS Clinic Department of Neurology Cerrahpasa School of Medicine Istanbul University Istanbul Turkey
| | - P. S. Sorensen
- Danish Multiple Sclerosis Centre Department of Neurology Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
| | | | - C. Thalheim
- European Multiple Sclerosis Platform (EMSP) Schaerbeek/Brussels Belgium
| | - H. Wiendl
- Department of Neurology University of Münster MünsterGermany
| | - F. Zipp
- Department of Neurology Focus Program Translational Neuroscience (FTN) and Immunology (FZI) Rhine‐Main Neuroscience Network (rmn2) University Medical Centre of the Johannes Gutenberg University Mainz Mainz Germany
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15
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Amato MP, Bertolotto A, Brunelli R, Cavalla P, Goretti B, Marrosu MG, Patti F, Pozzilli C, Provinciali L, Rizzo N, Strobelt N, Tedeschi G, Trojano M, Comi G. Management of pregnancy-related issues in multiple sclerosis patients: the need for an interdisciplinary approach. Neurol Sci 2017; 38:1849-1858. [PMID: 28770366 DOI: 10.1007/s10072-017-3081-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 07/22/2017] [Indexed: 11/25/2022]
Abstract
Multiple sclerosis (MS) is a demyelinating and neurodegenerative disease of the central nervous system (CNS), most probably autoimmune in origin, usually occurring in young adults with a female/male prevalence of approximately 3:1. Women with MS in the reproductive age may face challenging issues in reconciling the desire for parenthood with their condition, owing to the possible influence both on the ongoing or planned treatment with the possible consequences on the disease course and on the potential negative effects of treatments on foetal and pregnancy outcomes. At MS diagnosis, timely counselling should promote informed parenthood, while disease evolution should be assessed before making therapeutic decisions. Current guidelines advise the discontinuation of any treatment during pregnancy, with possible exceptions for some treatments in patients with very active disease. Relapses decline during pregnancy but are more frequent during puerperium, when MS therapy should be promptly resumed in most of the cases. First-line immunomodulatory agents, such as interferon-β (IFN-β) and glatiramer acetate (GA), significantly reduce the post-partum risk of relapse. Due to substantial evidence of safety with the use of GA during pregnancy, a recent change in European marketing authorization removed the pregnancy contraindication for GA. This paper reports a consensus of Italian experts involved in MS management, including neurologists, gynaecologists and psychologists. This consensus, based on a review of the available scientific evidence, promoted an interdisciplinary approach to the management of pregnancy in MS women.
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Affiliation(s)
- Maria Pia Amato
- Department NEUROFARBA, Section Neurological Sciences, University of Florence, Largo Brambilla 3, 50134, Florence, Italy.
| | - Antonio Bertolotto
- Neurology 2-CRESM (Multiple Sclerosis Regional Reference Center), AOU San Luigi Gonzaga, Orbassano, Torino, Italy
| | - Roberto Brunelli
- Department of Gynecology, Obstetrics and Urology, Umberto I Hospital, Sapienza University of Rome, Rome, Italy
| | - Paola Cavalla
- Neurology 1 and Multiple Sclerosis Center, City of Health and Science Turin University Hospital, Turin, Italy
| | - Benedetta Goretti
- Department NEUROFARBA, Section Neurological Sciences, University of Florence, Largo Brambilla 3, 50134, Florence, Italy
| | - Maria Giovanna Marrosu
- Department of Medical Sciences and Public Health, Multiple Sclerosis Center, University of Cagliari, Cagliari, Italy
| | - Francesco Patti
- G.F. Ingrassia Department of Medical and Surgical Sciences and Advanced Technologies, Multiple Sclerosis Center, University of Catania, Catania, Italy
| | - Carlo Pozzilli
- Department of Neurology and Psychiatry, Sapienza University of Rome, Rome, Italy
| | - Leandro Provinciali
- Department of Experimental and Clinical Medicine, 1 Neurological Clinic, Marche Polytechnic University, Ancona, Italy
| | - Nicola Rizzo
- Department of Medical Surgical Sciences, Division of Obstetrics and Prenatal Medicine, St Orsola Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Nicola Strobelt
- Gynecology and Obstetrics Department, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Gioacchino Tedeschi
- Department of Medical, Surgical, Neurological, Metabolic and Aging Sciences, Università della Campania "L. Vanvitelli", Naples, Italy
| | - Maria Trojano
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari, Bari, Italy
| | - Giancarlo Comi
- Department of Neurology, INSPE, San Raffaele Scientific Institute, Milan, Italy
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16
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Pregnancy and the Use of Disease-Modifying Therapies in Patients with Multiple Sclerosis: Benefits versus Risks. Mult Scler Int 2016; 2016:1034912. [PMID: 28078140 PMCID: PMC5203912 DOI: 10.1155/2016/1034912] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 11/14/2016] [Indexed: 12/02/2022] Open
Abstract
The burden of multiple sclerosis (MS) in women of childbearing potential is increasing, with peak incidence around the age of 30 years, increasing incidence and prevalence, and growing female : male ratio. Guidelines recommend early use of disease-modifying therapies (DMTs), which are contraindicated or recommended with considerable caution, during pregnancy/breastfeeding. Many physicians are reluctant to prescribe them for a woman who is/is planning to be pregnant. Interferons are not absolutely contraindicated during pregnancy, since interferon-β appears to lack serious adverse effects in pregnancy, despite a warning in its labelling concerning risk of spontaneous abortion. Glatiramer acetate, natalizumab, and alemtuzumab also may not induce adverse pregnancy outcomes, although natalizumab may induce haematologic abnormalities in newborns. An accelerated elimination procedure is needed for teriflunomide if pregnancy occurs on treatment or if pregnancy is planned. Current evidence supports the contraindication for fingolimod during pregnancy; data on other DMTs remains limited. Increased relapse rates following withdrawal of some DMTs in pregnancy are concerning and require further research. The postpartum period brings increased risk of disease reactivation that needs to be carefully addressed through effective communication between treating physicians and mothers intending to breastfeed. We address the potential for use of the first- and second-line DMTs in pregnancy and lactation.
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