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Singer BA, Feng J, Chiong-Rivero H. Early use of high-efficacy therapies in multiple sclerosis in the United States: benefits, barriers, and strategies for encouraging adoption. J Neurol 2024; 271:3116-3130. [PMID: 38615277 PMCID: PMC11136864 DOI: 10.1007/s00415-024-12305-4] [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: 12/19/2023] [Revised: 03/04/2024] [Accepted: 03/04/2024] [Indexed: 04/15/2024]
Abstract
Multiple sclerosis (MS) is characterized by progressive neuroinflammation and neurodegeneration from disease onset that, if left untreated, can result in the accumulation of irreversible neurological disability. Early intervention with high-efficacy therapies (HETs) is increasingly recognized as the best strategy to delay or mitigate disease progression from the earliest stages of the disease and to prevent long-term neurodegeneration. Although there is growing clinical and real-world evidence supporting early HET intervention, foregoing this strategy in favor of a traditional escalation approach prioritizing lower-efficacy disease-modifying therapies remains a common approach in clinical practice. This review explores potential health care professional- and patient-related barriers to the early use of HETs in patients with MS in the United States. Barriers can include regulatory and reimbursement restrictions; knowledge gaps and long-term safety concerns among health care professionals; and various individual, cultural, and societal factors affecting patients. Potential strategies for overcoming these barriers and encouraging early HET use are proposed.
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Affiliation(s)
- Barry A Singer
- The MS Center for Innovations in Care, Missouri Baptist Medical Center, St Louis, MO, USA.
| | - Jenny Feng
- Ochsner Medical Center, New Orleans, LA, USA
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2
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Yamout B, Al-Jumah M, Sahraian MA, Almalik Y, Khaburi JA, Shalaby N, Aljarallah S, Bohlega S, Dahdaleh M, Almahdawi A, Khoury SJ, Koussa S, Slassi E, Daoudi S, Aref H, Mrabet S, Zeineddine M, Zakaria M, Inshasi J, Gouider R, Alroughani R. Consensus recommendations for diagnosis and treatment of Multiple Sclerosis: 2023 revision of the MENACTRIMS guidelines. Mult Scler Relat Disord 2024; 83:105435. [PMID: 38245998 DOI: 10.1016/j.msard.2024.105435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 12/21/2023] [Accepted: 01/06/2024] [Indexed: 01/23/2024]
Abstract
With evolving diagnostic criteria and the advent of new oral and parenteral therapies for Multiple Sclerosis (MS), most current diagnostic and treatment algorithms need revision and updating. The diagnosis of MS relies on incorporating clinical and paraclinical findings to prove dissemination in space and time and exclude alternative diseases that can explain the findings at hand. The differential diagnostic workup should be guided by clinical and laboratory red flags to avoid unnecessary tests. Appropriate selection of MS therapies is critical to maximize patient benefit. The current guidelines review the current diagnostic criteria for MS and the scientific evidence supporting treatment of acute relapses, radiologically isolated syndrome, clinically isolated syndrome, relapsing remitting MS, progressive MS, pediatric cases and pregnant women. The purpose of these guidelines is to provide practical recommendations and algorithms for the diagnosis and treatment of MS based on current scientific evidence and clinical experience.
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Affiliation(s)
- B Yamout
- Neurology Institute and Multiple Sclerosis Center, Harley Street Medical Center, Abu Dhabi, United Arab Emirates.
| | - M Al-Jumah
- InterHealth hospital, Multiple Sclerosis Center, Riyadh, Saudi Arabia
| | - M A Sahraian
- Multiple Sclerosis Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Y Almalik
- Division of Neurology, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, National Guard Health Affairs, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - J Al Khaburi
- Department of Neurology, The Royal Hospital, Sultanate of Oman
| | - N Shalaby
- Neurology Department, Kasr Al-Ainy School of Medicine, Cairo University, Cairo, Egypt
| | | | - S Bohlega
- King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | | | - A Almahdawi
- Consultant Neurologist, Neurology Unit, Baghdad Teaching Hospital, Medical City Complex, Iraq
| | - S J Khoury
- Nehme and Therese Tohme Multiple Sclerosis Center, American University of Beirut Medical Center, Beirut, Lebanon
| | - S Koussa
- Multiple Sclerosis Center, Geitaoui Lebanese University Hospital, Beirut, Lebanon
| | - E Slassi
- Hôpital Cheikh Khalifa Ibn Zaid, Casablanca, Morocco
| | - S Daoudi
- Hospital Center Nedir Mohamed, Faculty of Medicine, University Mouloud Mammeri Tizi-Ouzou, Algeria
| | - H Aref
- Neurology Department, Ain Shams University, Cairo, Egypt
| | - S Mrabet
- Department of Neurology, CIC, Razi Universitary Hospital, University of Tunis El Manar, Tunis, Tunisia
| | - M Zeineddine
- Middle East and North Africa Committee for Treatment and Research in Multiple Sclerosis (MENACTRIMS), Beirut, Lebanon
| | | | - J Inshasi
- Department of Neurology, Rashid Hospital and Dubai Medical College, Dubai Health Authority, Dubai, United Arab Emirates
| | - R Gouider
- Department of Neurology, CIC, Razi Universitary Hospital, University of Tunis El Manar, Tunis, Tunisia
| | - R Alroughani
- Amiri Hospital, Arabian Gulf Street, Sharq, Kuwait
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3
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Bove R, Sutton P, Nicholas J. Women's Health and Pregnancy in Multiple Sclerosis. Neurol Clin 2024; 42:275-293. [PMID: 37980119 DOI: 10.1016/j.ncl.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2023]
Abstract
Multiple sclerosis has a 3:1 female-to-male predominance and commonly presents in young adult women. The hormonal changes in women throughout their lifetime do affect the underlying pathology of multiple sclerosis, and the needs of women therefore change with age. Although multiple sclerosis does not adversely affect fertility or pregnancy, there are many factors to consider when caring for women throughout family planning, pregnancy, and the postpartum period. The care of these women and complex decisions regarding disease-modifying therapy use in family planning should be individualized and comprehensive.
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Affiliation(s)
- Riley Bove
- UCSF Weill Institute for Neurosciences, 1651 Fourth Street, San Francisco, CA 94158, USA
| | - Paige Sutton
- OhioHealth Multiple Sclerosis Center, 3535 Olentangy River Road, Columbus, OH 43214, USA.
| | - Jacqueline Nicholas
- OhioHealth Multiple Sclerosis Center, 3535 Olentangy River Road, Columbus, OH 43214, USA
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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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Marulanda E, Tornes L. Obstetric and Gynecologic Disorders and the Nervous System. Continuum (Minneap Minn) 2023; 29:763-796. [PMID: 37341330 DOI: 10.1212/con.0000000000001237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Abstract
OBJECTIVE This article discusses obstetric and gynecologic associations with common neurologic disorders. LATEST DEVELOPMENTS Neurologic complications of obstetric and gynecologic disorders can arise throughout the lifespan. Caution should be exercised when prescribing fingolimod and natalizumab to patients with multiple sclerosis who are of childbearing potential because of the risk of disease rebound when they are discontinued. OnabotulinumtoxinA is considered safe in pregnancy and lactation based on long-term observational data. Hypertensive disorders of pregnancy are associated with higher subsequent cerebrovascular risk, likely via multiple mechanisms. ESSENTIAL POINTS Neurologic disorders may present in a variety of obstetric and gynecologic contexts, with meaningful implications for recognition and treatment. These interactions must be considered when treating women with neurologic conditions.
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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: 18] [Impact Index Per Article: 18.0] [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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7
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Graham EL. Neuroimmunological Disorders. Neurol Clin 2023; 41:315-330. [PMID: 37030960 DOI: 10.1016/j.ncl.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
Multiple sclerosis is a disease that tends to affect women during their childbearing years. Although relapse risk decreases during pregnancy, patients should still be optimized on disease-modifying therapy before and after pregnancy to minimize gaps in treatment. Exclusive breastfeeding may reduce the chances of disease relapse postpartum, and many disease-modifying therapies are considered to be safe while breastfeeding. Treatments for other neuroimmunologic disorders such as neuromyelitis optica spectrum disorder, myelin oligodendrocyte glycoprotein antibody-associated disease, neurosarcoidosis, and central nervous system vasculitis may require rituximab before and prednisone or intravenous immunoglobulin therapy during pregnancy.
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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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Siracusano M, Carloni E, Riccioni A, Ferrara M, Scoppola C, Arturi L, Niolu C, Marfia GA, Mazzone L. Maternal Multiple Sclerosis and Offspring's Cognitive and Behavioral Development: What Do We Know until Now? CHILDREN (BASEL, SWITZERLAND) 2022; 9:1716. [PMID: 36360444 PMCID: PMC9689039 DOI: 10.3390/children9111716] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 11/03/2022] [Accepted: 11/05/2022] [Indexed: 11/26/2023]
Abstract
Multiple Sclerosis (MS) is a chronic pathological condition representing one of the main causes of neurological disability in the female young population. MS, as an immune disorder, could impact fetus development, and, considering the need for and the possibility of pharmacological treatment during pregnancy, the possible influence of medication on developmental trajectories represents a topic of great interest. We provide an overview of the available literature on the influence of maternal Multiple Sclerosis on offspring cognitive and behavioral development. A study was conducted on Pubmed, Medline and Google Scholar, considering empirical studies and reviews exclusively in the English language. Maternal MS appears not to be associated with emotional and behavioral problems, as evaluated through retrospective studies. However, a specific cognitive and behavioral phenotype, through the administration of standardized instruments, has not been delineated yet. Available studies on the topic are characterized by poor methodology and do not lead to conclusions. This overview highlights implications for further longitudinal studies which should delineate offspring developmental trajectories, taking into consideration maternal confounding factors and the exposure to pharmacological treatment in pregnancy.
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Affiliation(s)
- Martina Siracusano
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Via Montpellier 1, 00133 Rome, Italy
- Child Neurology and Psychiatry Unit, Department of Neurosciences, Policlinico Tor Vergata Foundation Hospital, Viale Oxford 81, 00133 Rome, Italy
| | - Elisa Carloni
- Child Neurology and Psychiatry Unit, Department of Neurosciences, Policlinico Tor Vergata Foundation Hospital, Viale Oxford 81, 00133 Rome, Italy
| | - Assia Riccioni
- Child Neurology and Psychiatry Unit, Department of Neurosciences, Policlinico Tor Vergata Foundation Hospital, Viale Oxford 81, 00133 Rome, Italy
- Systems Medicine Department, University of Rome Tor Vergata, Montpellier Street 1, 00133 Rome, Italy
| | - Marialaura Ferrara
- Child Neurology and Psychiatry Unit, Department of Neurosciences, Policlinico Tor Vergata Foundation Hospital, Viale Oxford 81, 00133 Rome, Italy
| | - Chiara Scoppola
- Child Neurology and Psychiatry Unit, Department of Neurosciences, Policlinico Tor Vergata Foundation Hospital, Viale Oxford 81, 00133 Rome, Italy
- Systems Medicine Department, University of Rome Tor Vergata, Montpellier Street 1, 00133 Rome, Italy
| | - Lucrezia Arturi
- Child Neurology and Psychiatry Unit, Department of Neurosciences, Policlinico Tor Vergata Foundation Hospital, Viale Oxford 81, 00133 Rome, Italy
- Systems Medicine Department, University of Rome Tor Vergata, Montpellier Street 1, 00133 Rome, Italy
| | - Cinzia Niolu
- Systems Medicine Department, University of Rome Tor Vergata, Montpellier Street 1, 00133 Rome, Italy
- Psychiatry and Clinical Psychology Unit, Department of Neurosciences, Policlinico Tor Vergata Foundation Hospital, Viale Oxford 81, 00133 Rome, Italy
| | - Girolama Alessandra Marfia
- MS Clinical and Research Unit, Department of Systems Medicine, Tor Vergata University, 00133 Rome, Italy
| | - Luigi Mazzone
- Child Neurology and Psychiatry Unit, Department of Neurosciences, Policlinico Tor Vergata Foundation Hospital, Viale Oxford 81, 00133 Rome, Italy
- Systems Medicine Department, University of Rome Tor Vergata, Montpellier Street 1, 00133 Rome, Italy
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10
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Russell MD, Dey M, Flint J, Davie P, Allen A, Crossley A, Frishman M, Gayed M, Hodson K, Khamashta M, Moore L, Panchal S, Piper M, Reid C, Saxby K, Schreiber K, Senvar N, Tosounidou S, van de Venne M, Warburton L, Williams D, Yee CS, Gordon C, Giles I, Roddy E, Armon K, Astell L, Cotton C, Davidson A, Fordham S, Jones C, Joyce C, Kuttikat A, McLaren Z, Merrison K, Mewar D, Mootoo A, Williams E. British Society for Rheumatology guideline on prescribing drugs in pregnancy and breastfeeding: immunomodulatory anti-rheumatic drugs and corticosteroids. Rheumatology (Oxford) 2022; 62:e48-e88. [PMID: 36318966 PMCID: PMC10070073 DOI: 10.1093/rheumatology/keac551] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 09/15/2022] [Indexed: 11/07/2022] Open
Affiliation(s)
- Mark D Russell
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Mrinalini Dey
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Julia Flint
- Department of Rheumatology, Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Shropshire, UK
| | - Philippa Davie
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Alexander Allen
- Clinical Affairs, British Society for Rheumatology, London, UK
| | | | - Margreta Frishman
- Rheumatology, North Middlesex University Hospital NHS Trust, London, UK
| | - Mary Gayed
- Rheumatology, Sandwell and West Birmingham Hospitals, Birmingham, UK
| | | | - Munther Khamashta
- Lupus Research Unit, Division of Women's Health, King's College London, London, UK
| | - Louise Moore
- Rheumatic and Musculoskeletal Disease Unit, Our Lady's Hospice and Care Service, Dublin, Ireland
| | - Sonia Panchal
- Department of Rheumatology, South Warwickshire NHS Foundation Trust, Warwickshire, UK
| | - Madeleine Piper
- Royal National Hospital for Rheumatic Diseases, Royal United Hospital, Bath, UK
| | | | - Katherine Saxby
- Pharmacy, University College London Hospitals NHS Foundation Trust, London, UK
| | - Karen Schreiber
- Thrombosis and Haemostasis, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Department of Rheumatology, Danish Hospital for Rheumatic Diseases, Sonderborg, Denmark.,Department of Regional Health Research (IRS), University of Southern Denmark, Odense, Denmark
| | - Naz Senvar
- Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Sofia Tosounidou
- Lupus UK Centre of Excellence, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | | | | | - David Williams
- Obstetrics, University College London Hospitals NHS Foundation Trust, London, UK
| | - Chee-Seng Yee
- Department of Rheumatology, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, Doncaster, UK
| | - Caroline Gordon
- Rheumatology Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Ian Giles
- Centre for Rheumatology, Division of Medicine, University College London, London, UK
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11
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Leflunomide Exposure and Teriflunomide Concentrations up to the Third Trimester of Pregnancy: A Case Report. Clin Drug Investig 2022; 42:787-789. [PMID: 35896855 DOI: 10.1007/s40261-022-01185-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2022] [Indexed: 11/03/2022]
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12
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LaHue SC, Gano D, Bove R. Reproductive Rights in Neurology-The Supreme Court's Impact on All of Us. JAMA Neurol 2022; 79:961-962. [PMID: 35830178 DOI: 10.1001/jamaneurol.2022.2347] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- Sara C LaHue
- Department of Neurology, School of Medicine, University of California, San Francisco.,UCSF Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco
| | - Dawn Gano
- Department of Neurology, School of Medicine, University of California, San Francisco.,Department of Pediatrics, School of Medicine, University of California, San Francisco
| | - Riley Bove
- Department of Neurology, School of Medicine, University of California, San Francisco.,UCSF Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco
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13
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Andersen JB, Wandall-Holm MF, Magyari M. Pregnancy outcomes following maternal or paternal exposure to teriflunomide in the Danish MS population. Mult Scler Relat Disord 2022; 59:103529. [DOI: 10.1016/j.msard.2022.103529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 01/05/2022] [Accepted: 01/14/2022] [Indexed: 11/27/2022]
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14
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Guarnaccia JB, Cabot A, Garten LL, Napoli S, Hasbani MJ. Teriflunomide levels in women whose male sexual partner is on teriflunomide for relapsing multiple sclerosis. Mult Scler Relat Disord 2022; 57:103347. [PMID: 35158456 DOI: 10.1016/j.msard.2021.103347] [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: 06/29/2021] [Revised: 10/05/2021] [Accepted: 10/24/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND For small molecules such as teriflunomide, used to treat relapsing multiple sclerosis (MS), that are potentially embryotoxic, there is a theoretical risk of transmission of the medication from males on the drug to female sexual partners. However, that risk has been undefined up to now. METHODS Teriflunomide concentrations were assayed concomitantly in ten sexually active couples, not using barrier methods of contraception, in whom the male partner with MS was on treatment with teriflunomide 14 mg daily for at least two months. These results were compared by male and female age, teriflunomide concentrations and reported average number of incidences of sexual intercourse per month. The threshold level of detection of teriflunomide was 0.020 µg/ml in females. RESULTS The average age of the cohort was 46.70 for males and 47.10 for females. Four of ten females had detectible teriflunomide concentrations (mean 0.046 µg/ml (range 0.22-0.077, standard deviation 0.025). Male age and both female teriflunomide positive threshold and female teriflunomide concentration were inversely correlated (r = 0.67, R2=0.45, p = 0.034) for the former and (r = 0.62, R2=0.39, p = 0.05, ns) for the latter. No significant correlations were observed for female age, male teriflunomide concentrations, or reported mean monthly episodes of sexual intercourse. CONCLUSION This limited study suggests that the small risk that low levels of teriflunomide can be transmitted from male to female partners via sexual intercourse is related to male age. This supports the recommendations found in the United States Product Insert (USPI) stating that men taking teriflunomide who do not wish to father a child, and their female partners, should use reliable contraception. Men wishing to father a child should discontinue use of teriflunomide and undergo an accelerated elimination procedure to reduce the plasma concentrations of the medication to less than 0.02 mg/L (0.02 µg/ml1.
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Affiliation(s)
| | - Ann Cabot
- MS Specialty Care Program, Concord Hospital, NH, United States
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15
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Alroughani R, Inshasi J, Al Khawajah M, Ahmed SF, Al Malik Y, Alkhabouri J, Shatila A, Aljarallah S, Cupler EJ, Qureshi SA, Thakre M, Elhasin H, Ezzat A, Roushdy S. Real-world effectiveness and safety profile of teriflunomide in the management of multiple sclerosis in the Gulf Cooperation Council countries: An expert consensus narrative review. Mult Scler J Exp Transl Clin 2022; 8:20552173221077185. [PMID: 35284088 PMCID: PMC8915209 DOI: 10.1177/20552173221077185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 01/06/2022] [Accepted: 01/13/2022] [Indexed: 12/21/2022] Open
Abstract
Background The prevalence of multiple sclerosis (MS) is increasing in Gulf Cooperation Council (GCC) countries. Multiple sclerosis contributes to significant burden on patients and caregivers. The pharmacological treatment in MS involves treating acute exacerbations and preventing relapses and disability progression using disease-modifying therapies. Clinical evidence suggests that teriflunomide is one of the therapeutic choices for patients with relapsing–remitting MS (RRMS). However, genetic and cultural differences across different regions may contribute to variations in drug use. Therefore, it is necessary to consider real-world evidence for teriflunomide usage in GCC countries. Methods An expert group for MS gathered from GCC countries in December 2020. The consensus highlighting role of teriflunomide in MS management has been developed using clinical experiences and evidence-based approach. Results The expert-recommended patient profile for teriflunomide usage includes individuals aged 18 years and above, both men and women (on effective contraceptives) with clinically isolated syndrome or RRMS. The factors considered were cost-effectiveness of the drug, patient preference, adherence, monitoring, established safety profile, and coronavirus disease 2019 status. Conclusion Expert recommendations based on their clinical experience will be more helpful to clinicians in clinical settings regarding the usage of teriflunomide and provide valuable insights applicable in day-to-day practice.
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Affiliation(s)
- Raed Alroughani
- Division of Neurology, Department of Medicine, Al-Amiri Hospital, Kuwait City, Kuwait
| | - Jihad Inshasi
- Neurology Department, Rashid Hospital and Dubai Medical College, Dubai Health Authority, Dubai, UAE
| | | | | | - Yaser Al Malik
- College of Medicine, King Saud Bin Abdul Aziz University for Health Sciences, Riyadh, Saudi Arabia
| | | | | | | | - Edward J Cupler
- King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
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16
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Chitnis T, Banwell B, Kappos L, Arnold DL, Gücüyener K, Deiva K, Skripchenko N, Cui LY, Saubadu S, Hu W, Benamor M, Le-Halpere A, Truffinet P, Tardieu M. Safety and efficacy of teriflunomide in paediatric multiple sclerosis (TERIKIDS): a multicentre, double-blind, phase 3, randomised, placebo-controlled trial. Lancet Neurol 2021; 20:1001-1011. [PMID: 34800398 DOI: 10.1016/s1474-4422(21)00364-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 09/17/2021] [Accepted: 10/12/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Therapeutic options for children with multiple sclerosis are scarce. Teriflunomide is approved in more than 80 countries for the treatment of adults with relapsing multiple sclerosis. The TERIKIDS study examined the safety and efficacy of teriflunomide in children with relapsing multiple sclerosis. METHODS The TERIKIDS trial was a multicentre, phase 3, double-blind, parallel-group, randomised, placebo-controlled study conducted at 57 clinical centres in 22 countries in Asia, Europe, the Middle East, North Africa, and North America. The trial enrolled patients aged 10-17 years, diagnosed with relapsing multiple sclerosis and with at least one relapse in the year preceding screening or at least two relapses in the 2 years preceding screening. Patients were randomly assigned (2:1) to oral teriflunomide (dosage equivalent to 14 mg in adults) or matching placebo, using an interactive web and voice response system, for up to 96 weeks. Personnel in all sites and all patients were masked to study treatment in the double-blind period. Early entry into a subsequent 96-week open-label extension phase was possible before the end of the double-blind period for patients with confirmed clinical relapse or high MRI activity (at least five new or enlarged T2 lesions at week 24, followed by at least nine new or enlarged T2 lesions at week 36, or at least five new or enlarged T2 lesions at weeks 36 and 48, or at weeks 48 and 72). The primary endpoint was time to first confirmed clinical relapse by the end of the double-blind period. Key secondary imaging endpoints were number of new or enlarged T2 lesions and number of gadolinium-enhancing lesions per MRI scan. Efficacy endpoints were analysed in the intention-to-treat population, and safety was assessed in all patients randomly assigned to treatment and exposed to the double-blind study medication. This study is registered with ClinicalTrials.gov (trial number NCT02201108) and is closed to recruitment, but an additional optional open-label extension is ongoing. FINDINGS Between July 24, 2014, and the date of last patient visit on Oct 25, 2019, 185 patients were screened for eligibility, 166 (90%) were enrolled, and 109 were randomly assigned teriflunomide and 57 were randomly assigned placebo. 102 (94%) of 109 and 53 (93%) of 57 completed the double-blind period. Switch to the ongoing open-label extension because of high MRI activity was more frequent than anticipated in the placebo group (14 [13%] of 109 patients in the teriflunomide group vs 15 [26%] of 57 in the placebo group), decreasing the power of the study. After 96 weeks, there was no difference in time to first confirmed clinical relapse with teriflunomide compared with placebo (hazard ratio 0·66, 95% CI 0·39-1·11; p=0·29). Teriflunomide reduced the number of new or enlarged T2 lesions versus placebo by 55% (relative risk 0·45, 95% CI 0·29-0·71; p=0·00061), and the number of gadolinium-enhancing lesions by 75% (relative risk 0·25, 0·13-0·51; p<0·0001). Adverse events occurred in 96 (88%) patients in the teriflunomide group and 47 (82%) patients in the placebo group; serious adverse events occurred in 12 (11%) patients in the teriflunomide group and 6 (11%) patients in the placebo group. Nasopharyngitis, upper-respiratory-tract infection, alopecia, paraesthesia, abdominal pain, and increased blood creatine phosphokinase were more frequent with teriflunomide than with placebo. During the double-blind phase, four patients in the teriflunomide group had pancreatic adverse events (two with acute pancreatitis and two with pancreatic enzyme elevation), of which three events led to treatment discontinuation. INTERPRETATION No significant difference in time to first confirmed clinical relapse was found, possibly because more patients than expected switched from the double-blind to the open-label treatment period because of high MRI activity. Key secondary imaging analyses and a prespecified sensitivity analysis of probability of relapse or high MRI activity suggest that teriflunomide might have beneficial effects in children with relapsing multiple sclerosis by reducing the risk of focal inflammatory activity. FUNDING Sanofi.
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Affiliation(s)
- Tanuja Chitnis
- Massachusetts General Hospital for Children, Boston, MA, USA.
| | - Brenda Banwell
- Children's Hospital of Philadelphia, Philadelphia, PA, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ludwig Kappos
- Research Centre for Clinical Neuroimmunology and Neuroscience Basel, Departments of Medicine, Clinical Research and Biomedical Engineering, University Hospital and University of Basel, Basel, Switzerland
| | - Douglas L Arnold
- NeuroRx Research, Montréal, QC, Canada; Montréal Neurological Institute, McGill University, Montréal, QC, Canada
| | - Kivilcim Gücüyener
- Gazi Universitesi Tip Fakültesi Pediatrik Nöroloji Bilim Dali, Ankara, Turkey
| | | | - Natalia Skripchenko
- FSBI Research Institute for Paediatric Infectious Diseases FMBA Russia, St Petersburg, Russia
| | - Li-Ying Cui
- Peking Union Medical College Hospital, Beijing, China
| | | | | | | | | | | | - Marc Tardieu
- Hôpitaux Universitaires Paris-Sud, Paris, France
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17
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Massarotti C, Sbragia E, Gazzo I, Stigliani S, Inglese M, Anserini P. Effect of Multiple Sclerosis and Its Treatments on Male Fertility: Cues for Future Research. J Clin Med 2021; 10:jcm10225401. [PMID: 34830684 PMCID: PMC8623707 DOI: 10.3390/jcm10225401] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 11/12/2021] [Accepted: 11/17/2021] [Indexed: 11/28/2022] Open
Abstract
Multiple sclerosis is a chronic disease that may lead to different types of symptoms and disabilities. with the better quality of life and decreased disability due to early diagnosis and the availability of disease-modifying therapies (DMTs), the treating physician is increasingly asked to counsel patients on its effects on fertility and reproduction. In particular, reproductive issues are still scarcely studied and discussed in men. Among the still open questions are the following: (a) Does multiple sclerosis cause infertility per sè? (b) Is multiple sclerosis correlated with conditions that increase the risk of infertility? (c) Do DMTs or other therapies for multiple sclerosis impact gonadal function in men? The aim of this review is to provide an overview on the available literature data about the reproductive issues unique to men with multiple sclerosis, underlining the numerous areas where evidence is lacking and, therefore, the priorities for future research.
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Affiliation(s)
- Claudia Massarotti
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, 16128 Genova, Italy; (C.M.); (I.G.)
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy
| | - Elvira Sbragia
- Center of Excellence for Biomedical Research and Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, 16128 Genova, Italy; (E.S.); (M.I.)
| | - Irene Gazzo
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, 16128 Genova, Italy; (C.M.); (I.G.)
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy
| | - Sara Stigliani
- Physiopathology of Human Reproduction Unit, IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy;
| | - Matilde Inglese
- Center of Excellence for Biomedical Research and Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, 16128 Genova, Italy; (E.S.); (M.I.)
- IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy
| | - Paola Anserini
- Physiopathology of Human Reproduction Unit, IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy;
- Correspondence:
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18
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Abstract
PURPOSE OF REVIEW To provide the latest evidence and treatment advances of multiple sclerosis in women of childbearing age prior to conception, during pregnancy and postpartum. RECENT FINDINGS Recent changes permitting interferon beta (IFN-β) use in pregnancy and breastfeeding has broadened the choices of disease modifying treatments (DMTs) for patients with high relapse rates. Natalizumab may also be continued until 34 weeks of pregnancy for patients requiring persisting treatment. Drugs with a known potential of teratogenicity such as fingolimod or teriflunomide should be avoided and recommended wash-out times for medications such as cladribine, alemtuzumab or ocrelizumab should be considered. Teriflunomide and fingolimod are not recommended during breastfeeding, however, glatiramer acetate and IFN-β are considered to be safe. SUMMARY The evidence of potential fetotoxicities and adverse pregnancy outcomes associated with DMTs is increasing, although more research is needed to evaluate the safety of drugs and to track long-term health outcomes for the mother and the child.
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Affiliation(s)
- Guoda Varytė
- Clinic of Obstetrics and Gynaecology, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
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19
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Miller AE. An updated review of teriflunomide's use in multiple sclerosis. Neurodegener Dis Manag 2021; 11:387-409. [PMID: 34486382 DOI: 10.2217/nmt-2021-0014] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Teriflunomide, a once daily, oral disease-modifying therapy, has demonstrated consistent efficacy, safety and tolerability in patients with relapsing forms of multiple sclerosis (MS) and with a first clinical episode suggestive of MS treated up to 12 years. This review is an update to a previous version that examined data from the teriflunomide core clinical development program and extension studies. Data have since become available from active comparator trials with other disease-modifying therapies, treatment-related changes in brain volume (analyzed using structural image evaluation using normalization of atrophy) and real-world evidence including patient-reported outcomes. Initial data on the potential antiviral effects of teriflunomide in patients with MS, including case reports of patients infected with the 2019 novel coronavirus (SARS-CoV-2), are also presented.
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Affiliation(s)
- Aaron E Miller
- Icahn School of Medicine at Mount Sinai, New York City, NY 10029, USA
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20
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Sadovnick D, Criscuoli M, Yee I, Carruthers R, Schabas A, Smyth P. The road to conception for women with multiple sclerosis. Mult Scler J Exp Transl Clin 2021; 7:20552173211032313. [PMID: 34350028 PMCID: PMC8287372 DOI: 10.1177/20552173211032313] [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: 02/25/2021] [Accepted: 06/25/2021] [Indexed: 11/30/2022] Open
Abstract
Objective The objective of this prospective “real world” study is to gain insight into
the different “roads to conception” that women with MS take as part of the
prospective Canadian Multiple Sclerosis Pregnancy Study (CANPREG-MS). Methods Participants are women with MS who are planning a pregnancy. Data cut-off for
analyses was April 30, 2020. Results We believe this is the first prospective National study of women with MS
planning pregnancies. The data are for the first 44 women enrolled of whom 26 achieved pregnancy by
cut-off date. Seven women used assisted reproductive technologies (ARTs); 6
stopped disease modifying therapy (DMT) against their neurologists’
recommendations; 6 had an interruption(s) in trying to conceive due to MS
relapses, MRI-detected inflammation, or limited “windows of opportunity”
between DMT courses. Conclusion The study illustrates the roads that women take to conception, even if they
are on the same therapy and have similar clinical expression of MS. Advice
given by treating neurologists on washout periods show discrepancies. This
paper highlights the real problem that there is no definitive, international
consensus on managing these women due to the lack of “real world” data and
thus the goal of CANPREG-MS is to provide such real world data.
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Affiliation(s)
- Dessa Sadovnick
- Department of Medical Genetics, University of British Columbia, Vancouver, BC, Canada
| | - Maria Criscuoli
- Department of Medicine (Neurology), University of Alberta, Edmonton, Alberta, Canada
| | - Irene Yee
- Department of Medical Genetics, University of British Columbia, Vancouver, BC, Canada
| | - Robert Carruthers
- Department of Medicine (Neurology), University of Alberta, Edmonton, Alberta, Canada
| | - Alice Schabas
- Faculty of Medicine, Division of Neurology, University of British Columbia, Vancouver, BC, Canada
| | - Penelope Smyth
- Department of Medicine (Neurology), University of Alberta, Edmonton, Alberta, Canada
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21
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Simone IL, Tortorella C, Ghirelli A. Influence of Pregnancy in Multiple Sclerosis and Impact of Disease-Modifying Therapies. Front Neurol 2021; 12:697974. [PMID: 34276545 PMCID: PMC8280312 DOI: 10.3389/fneur.2021.697974] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 05/26/2021] [Indexed: 01/25/2023] Open
Abstract
Purpose of this Review: This article is a systematic review on the influence pregnancy has on multiple sclerosis and the resulting impact of disease-modifying therapies. Findings: Multiple sclerosis predominantly affects young women with a clinical onset most often during the child-bearing age. The impact of multiple sclerosis and disease-modifying therapies on fertility, pregnancy, fetal outcome, and breastfeeding is a pivotal topic when it comes to clinical practice. The introduction of disease-modifying therapies has changed not only the natural history of the disease but also the perspective of pregnancy in women with multiple sclerosis. Family planning requires careful consideration, especially because many disease-modifying drugs are contraindicated during pregnancy. In this article, we review current evidence collected from published literature and drug-specific pregnancy registers on the use of disease-modifying therapies. Additionally, we discuss safety profiles for each drug and correlate them to both risk for the exposed fetus and risk for the mothers interrupting treatments when seeking pregnancy.
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Affiliation(s)
- Isabella Laura Simone
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari, Bari, Italy
| | - Carla Tortorella
- Department of Neurosciences, San Camillo-Forlanini Hospital, Rome, Italy
| | - Alma Ghirelli
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari, Bari, Italy
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22
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Papp V, Buron MD, Siersma V, Rasmussen PV, Illes Z, Kant M, Hilt C, Mezei Z, Roshanisefat H, Sejbæk T, Weglewski A, van Wingerden J, Geertsen SS, Bramow S, Sellebjerg F, Magyari M. Real-world outcomes for a complete nationwide cohort of more than 3200 teriflunomide-treated multiple sclerosis patients in The Danish Multiple Sclerosis Registry. PLoS One 2021; 16:e0250820. [PMID: 34003862 PMCID: PMC8130956 DOI: 10.1371/journal.pone.0250820] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 04/15/2021] [Indexed: 11/18/2022] Open
Abstract
Objective Teriflunomide is a once-daily, oral disease-modifying therapy (DMT) for relapsing forms of multiple sclerosis (MS). We studied clinical outcomes in a real-world setting involving a population-based large cohort of unselected patients enrolled in The Danish Multiple Sclerosis Registry (DMSR) who started teriflunomide treatment between 2013–2019. Methods This was a complete nationwide population-based cohort study with prospectively enrolled unselected cases. Demographic and disease-specific patient parameters related to treatment history, efficacy outcomes, and discontinuation and switching rates among other clinical variables were assessed at baseline and during follow-up visits. Results A total of 3239 patients (65.4% female) started treatment with teriflunomide during the study period, 56% of whom were treatment-naïve. Compared to previously treated patients, treatment-naïve patients were older on average at disease onset, had a shorter disease duration, a lower Expanded Disability Status Scale score at teriflunomide treatment start and more frequently experienced a relapse in the 12 months prior to teriflunomide initiation. In the 3001 patients initiating teriflunomide treatment at least 12 months before the cut-off date, 72.7% were still on treatment one year after treatment start. Discontinuations in the first year were due mainly to adverse events (15.6%). Over the full follow-up period, 47.5% of patients discontinued teriflunomide treatment. Sixty-three percent of the patients treated with teriflunomide for 5 years were relapse-free, while significantly more treatment-naïve versus previously treated patients experienced a relapse during the follow-up (p<0.0001). Furthermore, 85% of the patients with available data were free of disability worsening at the end of follow-up. Conclusions Solid efficacy and treatment persistence data consistent with other real-world studies were obtained over the treatment period. Treatment outcomes in this real-world scenario of the population-based cohort support previous findings that teriflunomide is an effective and generally well-tolerated DMT for relapsing MS patients with mild to moderate disease activity.
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Affiliation(s)
- Viktoria Papp
- Odense University Hospital, Odense, Denmark
- * E-mail:
| | - Mathias Due Buron
- The Danish Multiple Sclerosis Registry, University Hospital Copenhagen, Rigshospitalet, Copenhagen, Denmark
- Danish Multiple Sclerosis Center, University Hospital Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Volkert Siersma
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | | | | | | | | | - Zsolt Mezei
- Aalborg University Hospital, Aalborg, Denmark
| | | | - Tobias Sejbæk
- Department of Neurology, Hospital of South West Jutland, Esbjerg, Denmark
| | | | | | | | - Stephan Bramow
- Danish Multiple Sclerosis Center, University Hospital Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Finn Sellebjerg
- Danish Multiple Sclerosis Center, University Hospital Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Melinda Magyari
- The Danish Multiple Sclerosis Registry, University Hospital Copenhagen, Rigshospitalet, Copenhagen, Denmark
- Danish Multiple Sclerosis Center, University Hospital Copenhagen, Rigshospitalet, Copenhagen, Denmark
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Alhomoud MA, Khan AS, Alhomoud I. The Potential Preventive Effect of Pregnancy and Breastfeeding on Multiple Sclerosis. Eur Neurol 2021; 84:71-84. [PMID: 33744881 DOI: 10.1159/000514432] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 01/09/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Multiple sclerosis (MS) is an inflammatory demyelinating chronic neurological disease that affects the central nervous system of young adults and their quality of life. Several studies have investigated the effects of pregnancy and breastfeeding on MS. However, the evidence regarding the influence of pregnancy and breastfeeding on MS is still accumulating. This review aimed to summarize the current evidence regarding the effects of pregnancy and breastfeeding on MS. SUMMARY A systematic electronic literature search of the PubMed and Embase databases was conducted to determine relevant published articles. The eligible studies were summarized and evaluated in tables. Key Messages: The majority of the studies indicated that pregnancy appears to lower the rate of MS relapses, particularly in the third trimester. The evidence regarding the effect of breastfeeding on MS remains inconsistent. Despite reports of negative obstetric outcomes in some pregnant women with MS, pregnancies in women with MS should not be categorized as high-risk pregnancies.
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Affiliation(s)
- Mohsen Ali Alhomoud
- Department of Public Health, Ministry of Health, Eastern Province, Al Qatif, Saudi Arabia,
| | - Abdul Sattar Khan
- Family and Community Medicine Department, King Faisal University, Eastern Province, Al Ahsa, Saudi Arabia
| | - Iftetah Alhomoud
- Neurosciences Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
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Abstract
PURPOSE OF REVIEW The fact that multiple sclerosis (MS) predominantly affects women has been recognized for many years. As the age at diagnosis is decreasing, and treatment options are becoming more complex, increasing numbers of women are facing decisions about the use of disease modifying therapy (DMT) in and around pregnancy. RECENT FINDINGS New data are rapidly becoming available, particularly regarding the safety of therapies in both pregnancy and breastfeeding. Effective treatment and suppression of relapses is key to ensuring good outcomes in the longer term for the woman, however this must be balanced against individual risk of relapse and risks to the fetus. Women should be advised that it is possible to breastfeed while taking selected DMT. SUMMARY In this review, we discuss evidence surrounding the safety of DMTs in both pregnancy and breastfeeding, and use this knowledge to suggest approaches to pregnancy and family planning in women with MS.
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Family Planning for People with Multiple Sclerosis in Saudi Arabia: an Expert Consensus. Mult Scler Int 2021; 2021:6667006. [PMID: 33628508 PMCID: PMC7899766 DOI: 10.1155/2021/6667006] [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: 10/09/2020] [Accepted: 02/01/2021] [Indexed: 11/18/2022] Open
Abstract
More than half of all patients with multiple sclerosis (MS) in the Kingdom of Saudi Arabia (KSA) are women of childbearing age. Raising a family is an important life goal for women in our region of the world. However, fears and misconceptions about the clinical course of relapsing-remitting MS (RRMS) and the effects of disease-modifying drugs (DMDs) on the foetus have led many women to reduce their expectations of raising a family, sometimes even to the point of avoiding pregnancy altogether. The increase in the number of DMDs available to manage RRMS and recent studies on their effects in pregnancy have broadened management options for these women. Interferon beta now has an indication in Europe for use during pregnancy (according to clinical need) and can be used during breastfeeding. Glatiramer acetate is a further possible option for women with lower levels of RRMS disease activity who are, or about to become, pregnant; natalizumab may be used up to 30 weeks in patients with higher levels of disease activity. Where possible, physicians need to support and encourage women to pursue their dream of a fulfilling family life, supported where necessary by active interventions for RRMS that are increasingly evidence based.
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Real world experience with teriflunomide in multiple sclerosis: the TER-Italy study. J Neurol 2021; 268:2922-2932. [PMID: 33616742 DOI: 10.1007/s00415-021-10455-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 02/08/2021] [Accepted: 02/09/2021] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To identify baseline factors associated with disease activity in patients with relapsing-remitting multiple sclerosis (RRMS) under teriflunomide treatment. METHODS This was an independent, multi-centre, retrospective post-marketing study. We analysed data of 1,507 patients who started teriflunomide since October 2014 and were regularly followed in 28 Centres in Italy. We reported the proportions of patients who discontinued treatment (after excluding 32 lost to follow-up) and who experienced clinical disease activity, i.e., relapse(s) and/or confirmed disability worsening, as assessed by the Expanded Disability Status Scale (EDSS). Decision tree-based analysis was performed to identify baseline factors associated with clinical disease activity during teriflunomide treatment. RESULTS At database lock (September 2020), approximately 29% of patients (430 out of 1,475) discontinued teriflunomide because of disease activity (~ 46%), adverse events (~ 37%), poor tolerability (~ 15%), pregnancy planning (~ 2%). Approximately 28% of patients experienced disease activity over a median follow-up of 2.75 years: ~ 9% had relapses but not disability worsening; ~ 13% had isolated disability worsening; ~ 6% had both relapses and disability worsening. The most important baseline factor associated with disease activity (especially disability worsening) was an EDSS > 4.0 (p < 0.001). In patients with moderate disability level (EDSS 2.0-4.0), disease activity occurred more frequently in case of ≥ 1 pre-treatment relapses (p = 0.025). In patients with milder disability level (EDSS < 2.0), disease activity occurred more frequently after previous exposure to ≥ 2 disease-modifying treatments (p = 0.007). CONCLUSIONS Our study suggests a place-in-therapy for teriflunomide in naïve patients with mild disability level or in those who switched their initial treatment for poor tolerability. Adverse events related with teriflunomide were consistent with literature data, without any new safety concern.
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Pavelek Z, Sobíšek L, Šarláková J, Potužník P, Peterka M, Štětkárová I, Štourač P, Mareš J, Hradílek P, Ampapa R, Grünermelová M, Vachová M, Recmanová E, Angelucci F, Halúsková S, Vališ M. Comparison of Therapies in MS Patients After the First Demyelinating Event in Real Clinical Practice in the Czech Republic: Data From the National Registry ReMuS. Front Neurol 2021; 11:593527. [PMID: 33510704 PMCID: PMC7835499 DOI: 10.3389/fneur.2020.593527] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 12/08/2020] [Indexed: 01/25/2023] Open
Abstract
Background: Multiple sclerosis (MS) is a chronic inflammatory and neurodegenerative disease of the central nervous system. Well-established drugs used for MS patients after the first demyelinating event in the Czech Republic include glatiramer acetate (GA), interferon beta-1a (IFNβ-1a), IFN beta-1b (IFNβ-1b), peginterferon beta-1a (peg-IFNβ-1a), and teriflunomide. Objective: The objective of this observational study was to compare the effectiveness of the abovementioned drugs in patients with MS who initiated their therapy after the first demyelinating event. Patients were followed for up to 2 years in real clinical practice in the Czech Republic. Methods: A total of 1,654 MS patients treated after the first demyelinating event and followed up for 2 years were enrolled. Evaluation parameters (endpoints) included the annualized relapse rate (ARR), time to next relapse, change in the Expanded Disability Status Scale (EDSS) score, and time of confirmed disease progression (CDP). When patients ended the therapy before the observational period, the reason for ending the therapy among different treatments was compared. Results: No significant difference was found among the groups of patients treated with IFNβ-1a/1b, GA, or teriflunomide for the following parameters: time to the first relapse, change in the EDSS score, and the proportion of patients with CDP. Compared to IFNβ-1a (44 mcg), a significant increase in the percentage of relapse-free patients was found for GA, but this treatment effect was not confirmed by the validation analysis. Compared to the other drugs, there was a significant difference in the reasons for terminating GA therapy. Conclusion: Small differences were found among GA, IFNβ and teriflunomide therapies, with no significant impact on the final outcome after 2 years. Therefore, in clinical practice, we recommend choosing the drug based on individual potential risk from long-term therapy and on patient preferences and clinical characteristics.
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Affiliation(s)
- Zbyšek Pavelek
- Department of Neurology, Faculty of Medicine and University Hospital Hradec Králové, Charles University in Prague, Hradec Králové, Czechia
| | - Lukáš Sobíšek
- Department of Neurology, Faculty of Medicine and University Hospital Hradec Králové, Charles University in Prague, Hradec Králové, Czechia
| | - Jana Šarláková
- Department of Neurology, Faculty of Medicine and University Hospital Hradec Králové, Charles University in Prague, Hradec Králové, Czechia
| | - Pavel Potužník
- Department of Neurology, Faculty of Medicine and University Hospital Plzen, Charles University in Prague, Plzeň, Czechia
| | - Marek Peterka
- Department of Neurology, Faculty of Medicine and University Hospital Plzen, Charles University in Prague, Plzeň, Czechia
| | - Ivana Štětkárová
- Third Faculty of Medicine, Charles University and Hospital Kralovské Vinohrady, Charles University in Prague, Prague, Czechia
| | - Pavel Štourač
- Department of Neurology, University Hospital and Masaryk University, Brno, Czechia
| | - Jan Mareš
- Department of Neurology, Faculty of Medicine, Palacky University and University Hospital Olomouc, Olomouc, Czechia
| | - Pavel Hradílek
- Clinic of Neurology, University Hospital Ostrava, Ostrava, Czechia
| | - Radek Ampapa
- Department of Neurology, Hospital of Jihlava, Jihlava, Czechia
| | | | - Marta Vachová
- Department of Neurology, KZ a.s., Hospital Teplice, Teplice, Czechia
| | - Eva Recmanová
- Department of Neurology, Tomas Bata Regional Hospital, Zlín, Czechia
| | - Francesco Angelucci
- Department of Neurology, Faculty of Medicine and University Hospital Hradec Králové, Charles University in Prague, Hradec Králové, Czechia.,Memory Clinic, Department of Neurology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czechia
| | - Simona Halúsková
- Department of Neurology, Faculty of Medicine and University Hospital Hradec Králové, Charles University in Prague, Hradec Králové, Czechia
| | - Martin Vališ
- Department of Neurology, Faculty of Medicine and University Hospital Hradec Králové, Charles University in Prague, Hradec Králové, Czechia
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Krysko KM, Bove R, Dobson R, Jokubaitis V, Hellwig K. Treatment of Women with Multiple Sclerosis Planning Pregnancy. Curr Treat Options Neurol 2021; 23:11. [PMID: 33814892 PMCID: PMC8008016 DOI: 10.1007/s11940-021-00666-4] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2021] [Indexed: 02/01/2023]
Abstract
PURPOSE OF REVIEW We review data available for treatment of multiple sclerosis (MS) before, during, and after pregnancy. We present recent data on disease-modifying therapies (DMT) before/during pregnancy and while breastfeeding, with treatment recommendations. RECENT FINDINGS Observational data support the safety of injectable DMTs (glatiramer acetate, interferon-beta) for use in pregnancy, while some oral DMTs might be associated with fetal risk. Monoclonal antibodies (mAbs) before pregnancy such as rituximab or natalizumab likely do not pose significant fetal risks, but can cross the placenta with neonatal hematological abnormalities if given in the second trimester or later. Breastfeeding is associated with decreased risk of postpartum relapses. Finally, injectables and mAbs likely have low transfer into breastmilk. SUMMARY Many women with MS do not require DMTs during pregnancy, although injectables could be continued. For women with highly active MS, cell-depleting therapies could be given before conception, or natalizumab could be continued through pregnancy, with monitoring of the fetus. Women should be encouraged to breastfeed, and those with higher relapse risk could consider injectables or mAbs while breastfeeding. Further data on safety of DMTs around pregnancy are needed. Maximizing function through non-pharmacologic approaches is complementary to DMTs. Special considerations for pregnancy and DMTs during the COVID-19 pandemic are needed.
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Affiliation(s)
- Kristen M. Krysko
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California San Francisco, 675 Nelson Rising Lane, San Francisco, CA 94158 USA
- Division of Neurology, Department of Medicine, St. Michael’s Hospital, University of Toronto, 9 Donnelly Wing South, 30 Bond Street, Toronto, Ontario M5B 1W8 Canada
| | - Riley Bove
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California San Francisco, 675 Nelson Rising Lane, San Francisco, CA 94158 USA
| | - Ruth Dobson
- Preventive Neurology Unit, Wolfson Institute of Preventive Neurology, Queen Mary University of London, Charterhouse Square, London, UK
- Department of Neurology, Royal London Hospital, Whitechapel, London, UK
| | - Vilija Jokubaitis
- Department of Neuroscience, Monash University, Melbourne, VIC Australia
- Department of Neurology, Alfred Health, Melbourne, VIC Australia
| | - Kerstin Hellwig
- Department of Neurology, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
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Alroughani R, Inshasi J, Al-Asmi A, Alkhabouri J, Alsaadi T, Alsalti A, Boshra A, Canibano B, Ahmed SF, Shatila A. Disease-Modifying Drugs and Family Planning in People with Multiple Sclerosis: A Consensus Narrative Review from the Gulf Region. Neurol Ther 2020; 9:265-280. [PMID: 32564333 PMCID: PMC7606397 DOI: 10.1007/s40120-020-00201-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Indexed: 12/15/2022] Open
Abstract
Most disease-modifying drugs (DMDs) are contraindicated in pregnancy. Management of MS is especially challenging for pregnant patients, as withdrawal of DMDs leave the patient at risk of increased disease activity. We, a group of experts in MS care from countries in the Arab Gulf, present our consensus recommendations on the management of MS in these patients. Where possible, a patient planning pregnancy can be switched to a DMD considered safe in this setting. Interferon β now can be used during pregnancy, where there is a clinical need to maintain treatment, in addition to glatiramer acetate. Natalizumab (usually to 30 weeks' gestation for patients with high disease activity at high risk of relapse and disability progression) may also be continued into pregnancy. Cladribine tablets and alemtuzumab have been hypothesised to act as immune reconstitution therapies (IRTs). These drugs provide a period of prolonged freedom from relapses for many patients, but the patient must be prepared to wait for up to 20 months from initiation of therapy before becoming pregnant. If a patient becomes pregnant while taking fingolimod, and requires continued DMD treatment, a switch to interferon β or natalizumab after a variable washout period may be prescribed, depending on the level of disease activity. Women who wish to breastfeed should be encouraged to do so, and interferon β may also be used during breastfeeding. There is a lack of data regarding the safety of using other DMDs during breastfeeding.
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Affiliation(s)
| | - Jihad Inshasi
- Department of Neurology, Rashid Hospital, Dubai, United Arab Emirates
- Dubai Medical College, Dubai Health Authority (DHA), Dubai, United Arab Emirates
| | - Abdullah Al-Asmi
- Neurology Unit, Department of Medicine, College of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Oman
| | | | - Taoufik Alsaadi
- Department of Neurology, American Center of Psychiatry and Neurology, Abu Dhabi, United Arab Emirates
| | | | - Amir Boshra
- Neurology and Immunology Medical Affairs Gulf Region, Merck Serono Middle East FZ LTD, Dubai, United Arab Emirates
| | - Beatriz Canibano
- Department of Neurology (Neuroscience Institute), Hamad Medical Corporation, Doha, Qatar
| | | | - Ahmed Shatila
- Neurology Department, Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates
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Vukusic S, Michel L, Leguy S, Lebrun-Frenay C. Pregnancy with multiple sclerosis. Rev Neurol (Paris) 2020; 177:180-194. [PMID: 32736812 DOI: 10.1016/j.neurol.2020.05.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 05/05/2020] [Accepted: 05/05/2020] [Indexed: 10/23/2022]
Abstract
Multiple sclerosis (MS) is usually diagnosed between twenty and forty years of age, when people often plan to have children. A lot has been said about the effect of pregnancy on the course of MS. The individual factors responsible for the disease modifying effect of pregnancy are not well determined. Having MS neither affects the fertility or the course of pregnancy itself. During pregnancy, many women find that their symptoms stay the same or even improve. Epidural and spinal analgesia appear to be safe and in general are not contraindicated for patients with MS. The management of disease-modifying treatments (DMTs) in pregnancy is a new issue for consideration in the clinical practice. There is limited information available into the safety of DMT use during pregnancy, especially for the most recent ones. In general, discontinuation of DMTs is recommended before conception to minimize risk of fetal harm. Women with very active MS before pregnancy who stop second-line treatments may show an increase in disease activity during pregnancy. Therefore, it might be discussed to maintain patients on DMTs until pregnancy is confirmed, and sometimes throughout pregnancy, to avoid a rebound of disease activity and severe relapses during pregnancy in very active patients.
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Affiliation(s)
- S 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
| | - L Michel
- Inserm, CIC 1414 [(centre d'investigation clinique de Rennes)], neurology, université Rennes, CHU Rennes, 35000 Rennes, France; Inserm, établissement français du sang, unité mixte de recherche (UMR) S1236, university of Rennes, Rennes, France
| | - S Leguy
- Inserm, CIC 1414 [(centre d'investigation clinique de Rennes)], neurology, université Rennes, CHU Rennes, 35000 Rennes, France
| | - C Lebrun-Frenay
- CRCSEP, CHU de Nice Pasteur 2, Université Nice Côte d'Azur UR2CA URRIS, Nice, France.
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Krysko KM, Graves JS, Dobson R, Altintas A, Amato MP, Bernard J, Bonavita S, Bove R, Cavalla P, Clerico M, Corona T, Doshi A, Fragoso Y, Jacobs D, Jokubaitis V, Landi D, Llamosa G, Longbrake EE, Maillart E, Marta M, Midaglia L, Shah S, Tintore M, van der Walt A, Voskuhl R, Wang Y, Zabad RK, Zeydan B, Houtchens M, Hellwig K. Sex effects across the lifespan in women with multiple sclerosis. Ther Adv Neurol Disord 2020; 13:1756286420936166. [PMID: 32655689 PMCID: PMC7331774 DOI: 10.1177/1756286420936166] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 05/28/2020] [Indexed: 02/06/2023] Open
Abstract
Multiple sclerosis (MS) is an autoimmune inflammatory demyelinating central nervous system disorder that is more common in women, with onset often during reproductive years. The female:male sex ratio of MS rose in several regions over the last century, suggesting a possible sex by environmental interaction increasing MS risk in women. Since many with MS are in their childbearing years, family planning, including contraceptive and disease-modifying therapy (DMT) counselling, are important aspects of MS care in women. While some DMTs are likely harmful to the developing fetus, others can be used shortly before or until pregnancy is confirmed. Overall, pregnancy decreases risk of MS relapses, whereas relapse risk may increase postpartum, although pregnancy does not appear to be harmful for long-term prognosis of MS. However, ovarian aging may contribute to disability progression in women with MS. Here, we review sex effects across the lifespan in women with MS, including the effect of sex on MS susceptibility, effects of pregnancy on MS disease activity, and management strategies around pregnancy, including risks associated with DMT use before and during pregnancy, and while breastfeeding. We also review reproductive aging and sexual dysfunction in women with MS.
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Affiliation(s)
- Kristen M Krysko
- Department of Neurology, UCSF Weill Institute for Neurosciences, University of California San Francisco, 675 Nelson Rising Lane, Suite 221, San Francisco, CA 94158, USA
| | - Jennifer S Graves
- Department of Neurosciences, University of California San Diego, UCSD ACTRI, La Jolla, CA, USA
| | - Ruth Dobson
- Preventive Neurology Unit, Wolfson Institute of Preventive Neurology, Queen Mary University of London, London, UK
| | - Ayse Altintas
- Department of Neurology, School of Medicine, Koc University, Istanbul, Turkey
| | - Maria Pia Amato
- Department NEUROFARBA, Section of Neurosciences, University of Florence, Florence, Italy
| | - Jacqueline Bernard
- Department of Neurology, Oregon Health Science University, Portland, OR, USA
| | - Simona Bonavita
- Department of Advanced Medical and Surgical Sciences, University of Campania, "Luigi Vanvitelli", Naples, Italy
| | - Riley Bove
- Department of Neurology, UCSF Weill Institute for Neurosciences, University of California San Francisco, San Francisco CA, USA
| | - Paola Cavalla
- Department of Neuroscience and Mental Health, City of Health and Science University Hospital of Torino, Turin, Italy
| | - Marinella Clerico
- Department of Clinical and Biological Sciences, University of Torino, San Luigi Gonzaga Hospital, Orbassano, Turin, Italy
| | - Teresa Corona
- Clinical Laboratory of Neurodegenerative Disease, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico
| | - Anisha Doshi
- Department of Neuroinflammation, Queen Square Multiple Sclerosis Centre, University College London (UCL) Institute of Neurology, London, UK
| | - Yara Fragoso
- Multiple Sclerosis & Headache Research Institute, Santos, SP, Brazil
| | - Dina Jacobs
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Vilija Jokubaitis
- Department of Neuroscience, Monash University, Melbourne, VIC, Australia
| | - Doriana Landi
- Department of Systems Medicine, Multiple Sclerosis Center and Research Unit, Tor Vergata University and Hospital, Rome, Italy
| | | | | | | | - Monica Marta
- Neurosciences and Trauma Centre, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Luciana Midaglia
- Department of Neurology-Neuroimmunology, Multiple Sclerosis Centre of Catalonia, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Suma Shah
- Department of Neurology, Duke University, Durham, NC, USA
| | - Mar Tintore
- Department of Neurology-Neuroimmunology, Multiple Sclerosis Centre of Catalonia, Vall d'Hebron University Hospital, Barcelona, Spain
| | | | - Rhonda Voskuhl
- Department of Neurology, University of California Los Angeles, Los Angeles, CA, USA
| | - Yujie Wang
- Department of Neurology, Johns Hopkins University, Baltimore, MD, USA
| | - Rana K Zabad
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, USA
| | - Burcu Zeydan
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Maria Houtchens
- Department of Neurology, Partners MS Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kerstin Hellwig
- Department of Neurology, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
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Canibaño B, Deleu D, Mesraoua B, Melikyan G, Ibrahim F, Hanssens Y. Pregnancy-related issues in women with multiple sclerosis: an evidence-based review with practical recommendations. J Drug Assess 2020; 9:20-36. [PMID: 32128285 PMCID: PMC7034025 DOI: 10.1080/21556660.2020.1721507] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Accepted: 01/21/2020] [Indexed: 12/18/2022] Open
Abstract
Objective: To review the current evidence regarding pregnancy-related issues in multiple sclerosis (MS) and to provide recommendations specific for each of them. Research design and methods: A systematic review was performed based on a comprehensive literature search. Results: MS has no effect on fertility, pregnancy or fetal outcomes, and pregnancies do not affect the long-term disease course and accumulation of disability. There is a potential risk for relapse after use of gonadotropin-releasing hormone agonists during assisted reproduction techniques. At short-term, pregnancy leads to a reduction of relapses during the third trimester, followed by an increased risk of relapses during the first three months postpartum. Pregnancies in MS are not per se high risk pregnancies, and MS does not influence the mode of delivery or anesthesia unless in the presence of significant disability. MRI is not contraindicated during pregnancy; however, gadolinium contrast media should be avoided whenever possible. It is safe to use pulse dose methylprednisolone infusions to manage acute disabling relapses during pregnancy and breastfeeding. However, its use during the first trimester of pregnancy is still controversial. Women with MS should be encouraged to breastfeed with a possible favorable effect of exclusive breastfeeding. Disease-modifying drugs can be classified according to their potential for pregnancy-associated risk and impact on fetal outcome. Interferon beta (IFNβ) and glatiramer acetate (GA) may be continued until pregnancy is confirmed and, after consideration of the individual risk-benefit if continued, during pregnancy. The benefit of continuing natalizumab during the entire pregnancy may outweigh the risk of recurring disease activity, particularly in women with highly active MS. GA and IFNβ are considered safe during breastfeeding. The use of natalizumab during pregnancy or lactation requires monitoring of the newborn. Conclusions: This review provides current evidence and recommendations for counseling and management of women with MS preconception, during pregnancy and postpartum.
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Affiliation(s)
- Beatriz Canibaño
- Department of Neurology, Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Dirk Deleu
- Department of Neurology, Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Boulenouar Mesraoua
- Department of Neurology, Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Gayane Melikyan
- Department of Neurology, Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Faiza Ibrahim
- Department of Neurology, Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Yolande Hanssens
- Clinical Services Unit, Pharmacy, Hamad Medical Corporation, Doha, Qatar
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Yamout B, Sahraian M, Bohlega S, Al-Jumah M, Goueider R, Dahdaleh M, Inshasi J, Hashem S, Alsharoqi I, Khoury S, Alkhawajah M, Koussa S, Al Khaburi J, Almahdawi A, Alsaadi T, Slassi E, Daodi S, Zakaria M, Alroughani R. Consensus recommendations for the diagnosis and treatment of multiple sclerosis: 2019 revisions to the MENACTRIMS guidelines. Mult Scler Relat Disord 2019; 37:101459. [PMID: 31670208 DOI: 10.1016/j.msard.2019.101459] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 10/11/2019] [Accepted: 10/18/2019] [Indexed: 12/19/2022]
Abstract
With evolving diagnostic criteria and the advent of new oral and parenteral therapies for MS, most current diagnostic and treatment algorithms need revision and updating. The diagnosis of MS relies on incorporating clinical and paraclinical findings to prove dissemination in space and in time, and exclude alternative diseases that can explain the findings at hand. The differential diagnostic workup should be guided by clinical and laboratory red flags to avoid unnecessary tests. Appropriate selection of multiple sclerosis (MS) therapies is critical to maximize patient benefit. The current guidelines review the scientific evidence supporting treatment of acute relapses, radiologically isolated syndrome, clinically isolated syndrome, relapsing remitting MS, and progressive MS. The purpose of these guidelines is to provide practical recommendations and algorithms for the diagnosis and treatment of MS based on current scientific evidence and clinical experience.
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Affiliation(s)
- B Yamout
- Nehme and Therese Tohme MS Center, American University of Beirut Medical Center, Beirut, Lebanon.
| | - M Sahraian
- MS Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - S Bohlega
- King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - M Al-Jumah
- King Fahad Medical Cit, MOH, Riyadh, Saudi Arabia
| | - R Goueider
- Service de Neurologie, Hôpital Razi, Manouba, Tunis
| | | | - J Inshasi
- Department of Neurology, Rashid Hospital and Dubai Medical College, Dubai Health Authority, Dubai, United Arab Emirates
| | - S Hashem
- Faculty of Medicine, Cairo University, Cairo, Egypt
| | - I Alsharoqi
- Dept of Clinical Neurosciences, Salmaniya Medical Complex, Manama, Bahrain
| | - S Khoury
- Nehme and Therese Tohme MS Center, American University of Beirut Medical Center, Beirut, Lebanon
| | - M Alkhawajah
- Department of Neurology, The Royal Hospital, Sultanate of Oman
| | - S Koussa
- MS Center- Geitaoui Lebanese University Hospital, Beirut, Lebanon
| | - J Al Khaburi
- Department of Neurology, The Royal Hospital, Sultanate of Oman
| | - A Almahdawi
- Consultant neurologist, neurology unit, Baghdad Teaching Hospital, Medical City Complex, Iraq
| | - T Alsaadi
- American Center for Psychiatry & Neurology- UAE
| | - E Slassi
- Hôpital Cheikh Khalifa Ibn Zaid, Casablanca- Morocco
| | - S Daodi
- Hospital Center Nedir Mohamed, Faculty of Medicine University Mouloud Mammeri Tizi-ouzou Algeria
| | | | - R Alroughani
- Amiri Hospital, Arabian Gulf Street, Sharq, Kuwait
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Chisari CG, Toscano S, D’Amico E, Lo Fermo S, Zanghì A, Arena S, Zappia M, Patti F. An update on the safety of treating relapsing-remitting multiple sclerosis. Expert Opin Drug Saf 2019; 18:925-948. [DOI: 10.1080/14740338.2019.1658741] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Clara G. Chisari
- Department “GF Ingrassia”, Section of Neurosciences, Multiple Sclerosis Center, University of Catania, Catania, Italy
| | - Simona Toscano
- Department “GF Ingrassia”, Section of Neurosciences, Multiple Sclerosis Center, University of Catania, Catania, Italy
| | - Emanuele D’Amico
- Department “GF Ingrassia”, Section of Neurosciences, Multiple Sclerosis Center, University of Catania, Catania, Italy
| | - Salvatore Lo Fermo
- Department “GF Ingrassia”, Section of Neurosciences, Multiple Sclerosis Center, University of Catania, Catania, Italy
| | - Aurora Zanghì
- Department “GF Ingrassia”, Section of Neurosciences, Multiple Sclerosis Center, University of Catania, Catania, Italy
| | - Sebastiano Arena
- Department “GF Ingrassia”, Section of Neurosciences, Multiple Sclerosis Center, University of Catania, Catania, Italy
| | - Mario Zappia
- Department “GF Ingrassia”, Section of Neurosciences, Multiple Sclerosis Center, University of Catania, Catania, Italy
| | - Francesco Patti
- Department “GF Ingrassia”, Section of Neurosciences, Multiple Sclerosis Center, University of Catania, Catania, Italy
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