Treatment of Women with Multiple Sclerosis
Planning Pregnancy
Krysko, K. M., Bove, R., Dobson, R., Jokubaitis, V. Hellwig, K.
Curr Treat Options Neurol (2021) 23:11
Bottom Line:
Up to three-quarters of persons with MS are young women, many planning future pregnancies. We also know that women with relapsing forms of multiple sclerosis have a sharp decline in relapses during pregnancy, with sharp increases in relapse rates shortly after giving birth. While pregnancy, per se, does not change the long term prognosis of MS, relapses can lead to permanent disability. The challenge for health care providers and women with MS is how to manage the relapsing forms of multiple sclerosis before, during and after pregnancy in the context of the new disease-modifying therapies.
The above cited paper discusses protocols for providing disease-modifying therapies to women wishing to become pregnant. The goals are to control relapses during pregnancy and thereafter, with no rebound of disease if disease-modifying therapies are stopped, and with no or minimal harm to the fetus. Important issues to consider are the degree of disease activity before pregnancy, the need to monitor for disease activity during and after pregnancy using both clinical and MRI criteria and encouraging non-medication related behavior such exclusive breast feeding.
For women with mild MS, stopping a disease-modifying therapy during pregnancy can be considered, but only if there is no disease-rebound associated with their medication. In women with more active and severe disease, continuing a disease-modifying therapy during pregnancy can be considered, but only if their medication does not cause fetal harm. Following delivery, when the risk of relapses increases, careful clinical and brain imaging evaluations should be done to determine when disease-modifying therapy is restarted. Exclusive (no supplementary baby food) breast feeding may reduce or lessen the risk of post-partum relapses.
Key Points Related to Above Article:
1. The risks of relapses during pregnancy greatly decreases, most notably during the third trimester. The risks then increase sharply in the three months after delivery, exceeding pre-pregnancy levels in about one-third of women. Relapse activity then gradually returns to baseline.
2. Ideally, disease-modifying therapy should be stopped prior to becoming pregnant to minimize fetal risk, but this may not be possible in women with very active disease, especially those requiring treatment with high-efficacy drugs. In addition, data on the safety of disease-modifying therapies during pregnancy are relatively limited. Thus, the decision whether to continue or stop a disease-modifying therapy prior to becoming pregnant, or during pregnancy, should be based on a woman’s clinical and brain imaging status, as well as her disease-modifying therapy.
3. Some disease-modifying therapies carry a high risk of disease rebound when stopped. Some of these drugs also may harm the fetus, though data on this are limited, especially for the newer disease-modifying therapies.
4. Most data are available for glatiramer acetate and interferon-beta, and these two agents are approved for use during pregnancy. If a woman with MS has very mild disease, with few previous relapses and no acute central nervous system inflammation on brain MRIs, stopping treatment can be considered if stopping their disease-modifying therapy is not associated with a risk of disease rebound.
5. Exclusive breast-feeding, i.e. without supplementary baby food after delivery may reduce the risk of post-pregnancy relapses . Ideally, disease-modifying therapies should be withheld until breast-feeding is stopped to avoid the transfer of any medication to the newborn. However, careful clinical and brain imaging evaluations should be done in the months after delivery to be sure there is no reappearance of disease activity. If new disease activity is noted, restarting a disease-modifying therapy should be considered with additional discussion, if relevant, as to whether breast-feeding should be continued.
Discussion:
The possibility of pregnancy adds to the complexity of choosing, starting and stopping a disease-modifying therapy. Women with very active disease may require high-efficacy therapies but such drugs could harm the fetus. Stopping such medications or having the person undergo a “washout” period to eliminate the drug could result in a burst of new disease activity. Switching to a safer but possibly less potent disease-modifying therapy is an option, but that too carries a risk of disease recurrence.
There is no standard algorithm for addressing these issues. Each woman with MS must assess her previous course of illness in the context of her response to her current disease-modifying therapy and its potential for fetal harm. This is especially important since relapses occurring in the year prior to becoming pregnant increase the risk of long-term disability.
After consultation with her health care provider the options of stopping therapy, changing therapy, or continuing treatment during pregnancy can be decided. If therapy is stopped or changed, neurologic evaluations during pregnancy should be continued. After delivery, clinical as well as brain imaging studies should be performed to assess for recurrence of disease. Should that be the case, restarting treatment, and possibly stopping breast-feeding, may be necessary.