Pregnancy and the Use of Disease-Modifying Therapies in Patients with Multiple Sclerosis: Benefits versus Risks

Abstract

The burden of multiple sclerosis (MS) in women of childbearing potential is increasing, with peak incidence around the age of 30 years, increasing incidence and prevalence, and growing female : male ratio. Guidelines recommend early use of disease-modifying therapies (DMTs), which are contraindicated or recommended with considerable caution, during pregnancy/breastfeeding. Many physicians are reluctant to prescribe them for a woman who is/is planning to be pregnant. Interferons are not absolutely contraindicated during pregnancy, since interferon-β appears to lack serious adverse effects in pregnancy, despite a warning in its labelling concerning risk of spontaneous abortion. Glatiramer acetate, natalizumab, and alemtuzumab also may not induce adverse pregnancy outcomes, although natalizumab may induce haematologic abnormalities in newborns. An accelerated elimination procedure is needed for teriflunomide if pregnancy occurs on treatment or if pregnancy is planned. Current evidence supports the contraindication for fingolimod during pregnancy; data on other DMTs remains limited. Increased relapse rates following withdrawal of some DMTs in pregnancy are concerning and require further research. The postpartum period brings increased risk of disease reactivation that needs to be carefully addressed through effective communication between treating physicians and mothers intending to breastfeed. We address the potential for use of the first- and second-line DMTs in pregnancy and lactation.

Pregnancy and Multiple Sclerosis: An Update on the Disease Modifying Treatment Strategy and a Review of Pregnancy’s Impact on Disease Activity

“…As well, natalizumab was detected in all newborns' umbilical cord blood samples (n = 5) [26]. When natalizumab is taken at the time of pregnancy, it is mandatory to test fetuses for thrombocytopenia and anemia after the birth [27]. Natalizumab treatment could be maintained during pregnancy as it is a promising strategy.…”

Recommendations for neurological, obstetrical and gynaecological care in women with multiple sclerosis: a statement by a working group convened by the Section of Multiple Sclerosis and Neuroimmunology of the Polish Neurological Society

“…Such management, based on previous open studies which postulated a reduction in the increased number of relapses in the postpartum period by intravenous administration of IgG [57,58], was not confirmed in randomised studies [59,60]. A prompt return to immunomodulatory treatment is recommended [61][62][63].…”

Multiple sclerosis and pregnancy

“…The rate of miscarriage, stillbirth and congenital abnormality are not increased in women with MS . Several studies have shown no increased risk of miscarriage in women with MS who are exposed to disease‐modifying therapies (DMTs) . The risk of congenital malformations of children born to women with MS is comparable to that in the general population .…”