Intravenous immunoglobulins for the prevention of postpartum relapses in multiple sclerosis

Ledinek, Alenka Horvat; Jakob, Gregor Brecl; Jerše, Jana; Ruška, Berislav; Pavičić, Tin; Gabelić, Tereza; Barun, Barbara; Adamec, Ivan; Rot, Uroš; Jazbec, Saša Šega; Skorić, Magdalena Krbot; Habek, Mario

doi:10.1016/j.msard.2019.101519

Cited by 7 publications

(13 citation statements)

References 14 publications

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“…Of these, 63 studies were excluded (31 duplicate data, 27 not studying breastfeeding, 2 review articles, 2 lacking a comparison group, and 1 not studying relapses) and 24 studies (2974 women) were included in the review. 8,[10][11][12][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37] Some well-known studies of breastfeeding were excluded 6,38,39 owing to duplicate data on the same patients as included studies. 8,21,35 Of the 24 studies, 16 were included in the quantitative meta-analysis 8,[10][11][12]20,21,[23][24][25][26][27][30][31][32]35,37 these included the required data or the data were provided by authors.…”

Section: Resultsmentioning

confidence: 99%

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Association Between Breastfeeding and Postpartum Multiple Sclerosis Relapses

et al. 2020

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IMPORTANCE Multiple sclerosis (MS) relapses may be increased in the postpartum period, and whether breastfeeding is associated with reduction in the risk of postpartum relapses remains controversial.OBJECTIVE To perform a systematic review and meta-analysis to evaluate whether breastfeeding is associated with reduction in postpartum MS relapses compared with not breastfeeding.DATA SOURCES PubMed and Embase were searched for studies assessing the association between breastfeeding and MS disease activity published between January 1, 1980, and July 11, 2018, as well as reference lists of selected articles.STUDY SELECTION All study designs assessing the association between breastfeeding and postpartum relapses in MS relative to a comparator group were included. DATA EXTRACTION AND SYNTHESISStudy eligibility assessment and extraction of study characteristics, methods, and outcomes, were performed independently by 2 reviewers following PRISMA guidelines. Risk of bias was evaluated by 2 independent reviewers with the ROBINS-I tool for nonrandomized, interventional studies. Findings from studies with data available for the number of women with postpartum relapses in the breastfeeding and nonbreastfeeding groups were combined with a random-effects model. MAIN OUTCOMES AND MEASURES Postpartum MS relapse. RESULTSThe search identified 462 unique citations, and 24 (2974 women) satisfied eligibility criteria and were included, of which 16 were included in the quantitative meta-analysis. The pooled summary odds ratio for the association of breastfeeding with postpartum relapses was 0.63 (95% CI, 0.45-0.88; P = .006) compared with a reference of nonbreastfeeding. Pooled adjusted hazard ratio across 4 studies that reported this finding was 0.57 (95% CI, 0.38-0.85; P = .006). There was moderate heterogeneity (I 2 = 48%), which was explained by variable prepregnancy relapse rate, postpartum follow-up duration, and the publication year. A stronger association was seen in studies of exclusive rather than nonexclusive breastfeeding, although both demonstrated an association. Studies were rated at moderate and serious risk of bias, with concern for residual confounding, although sensitivity analysis including only moderate quality studies was consistent with a protective outcome of breastfeeding.CONCLUSIONS AND RELEVANCE These findings suggest that breastfeeding is protective against postpartum relapses in MS, although high-quality prospective studies to date are limited and well-designed observational studies that aim to emulate a randomized trial would be of benefit.

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Section: Resultsmentioning

confidence: 99%

“…Eight studies were excluded from the metaanalysis owing to lack of data. 18,19,22,28,29,33,34,36 Agreement between reviewers for eligibility was noted at both abstract (Cohen κ = 0.90) and full-text (Cohen κ = 0.89) review. Characteristics of the 24 studies are presented in the eTable in the Supplement.…”

Section: Resultsmentioning

confidence: 99%

Association Between Breastfeeding and Postpartum Multiple Sclerosis Relapses

et al. 2020

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“…Four retrospective studies, including non-treated controls, found contradictory results. [143][144][145][146] One phase 3 randomised clinical trial compared doses of IVIgs (high vs. low dose), but no untreated control group found no difference. 147 A meta-analysis of 6 studies found no benefit in using IVIgs.…”

Section: Intravenous Immunoglobulins (Ivigs)mentioning

confidence: 99%

Pregnancy and multiple sclerosis: 2022 recommendations from the French multiple sclerosis society

Vukusic

Ciron²,

Maillart

et al. 2022

Mult Scler

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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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“…Some studies have shown that intravenous immunoglobulins, at different doses and with different administration schedules, both during pregnancy and immediately after delivery, can reduce the risk of postpartum relapse. [236][237][238][239][240] However, other reports 241,242 and a recent meta-analysis 243 have failed to confirm these benefits, and so there is no clear evidence to support the routine use of intravenous immunoglobulins. 214 Methylprednisolone, 1000 milligrams monthly for 6 months, has been found to be effective in preventing postpartum relapses in a small casecontrol study.…”

Section: Management Of Ms After Delivery (Box 1)mentioning

confidence: 99%

Updated Perspectives on the Challenges of Managing Multiple Sclerosis During Pregnancy

Villaverde-González¹

2022

DNND

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Multiple sclerosis (MS) is a chronic immune-mediated, inflammatory, and degenerative disease that is up to three times more frequent in young women. MS does not alter fertility and has no impact on fetal development, the course of pregnancy, or childbirth. The Pregnancy in Multiple Sclerosis Study in 1998 showed that pregnancy, mostly in untreated women, did not adversely affect MS, as disease activity decreased during pregnancy (although it significantly increased in the first trimester postpartum). These findings, together with the limited information available on the potential risks of fetal exposure to disease modifying treatments (DMTs), meant that women were advised to delay the onset of DMTs, stop them prior to conception, or, in case of unplanned pregnancy, discontinue them when pregnancy was confirmed. Now, many women with MS receive DMTs before pregnancy and, despite being considered a period of MS stability, up to 30% of patients could relapse in the first trimester postpartum. Factors associated with an increased risk of relapse and disability during pregnancy and postpartum include relapses before and during pregnancy, a greater disability at the time of conception, the occurrence of relapses after DMT cessation before conception, and the use of high-efficacy DMTs before conception, especially natalizumab or fingolimod. Strategies to prevent postpartum activity are needed in some patients, but consensus is lacking regarding the therapeutic strategies for women with MS of a fertile age. This, along with the increasing number of DMTs, means that the decision-making processes in aspects related to family planning and therapeutic strategies before, during, and after pregnancy are increasingly more complex. The purpose of this review is to provide an update on pregnancy-related issues in women with MS, including recommendations for counseling, general management, use of DMTs in pre-pregnancy, pregnancy, and postpartum periods, and breastfeeding-related aspects of DMTs.

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Intravenous immunoglobulins for the prevention of postpartum relapses in multiple sclerosis

Cited by 7 publications

References 14 publications

Association Between Breastfeeding and Postpartum Multiple Sclerosis Relapses

Association Between Breastfeeding and Postpartum Multiple Sclerosis Relapses

Pregnancy and multiple sclerosis: 2022 recommendations from the French multiple sclerosis society

Updated Perspectives on the Challenges of Managing Multiple Sclerosis During Pregnancy

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