No additive relapse risk with second pregnancy


REPORT FROM THE EUROPEAN CHARCOT FOUNDATION ANNUAL MEETING – BAVENO, ITALY, NOVEMBER 28-30, 2013 – It is well established that relapse frequency declines during pregnancy, followed by an increased relapse risk during the first three months postpartum (Vukusic et al. Brain 2004;127(Pt 6):1353-1360). A similar pattern appears to occur during a second pregnancy, so relapse risk is not additive, according to Dr. Sandra Vukusic, Lyons, France (Vukusic S. ECF 2013).

When faced with a patient who wants to become pregnant again, clinicians can offer the same advice as they gave for the first pregnancy. It should be noted that patients receiving in vitro fertilization have a higher risk of relapse following the procedure because of exposure to gonadotrophin releasing hormone (GnRH) agonists; the relapse risk is higher in women who do not become pregnant with IVF (Michel et al. J Neurol Neurosurg Psychiatry 2012;83:796-802).

The transient increase in relapse frequency does not appear to influence the risk of long-term disability in RRMS (Ramagopalan et al. J Neurol Neurosurg Psychiatry 2012;83:793-795; Hanulíková et al. Ceska Gynekol 2013;78:142-148). However, pregnancy has been reported to shorten the time to a first neurological event in patients with radiologically isolated syndrome (RIS) (Lebrun et al. Mult Scler 2012;18:1297-1302).

A low relapse rate and use of a disease-modifying therapy (DMT) prior to conception are independently protective against postpartum relapses (Hughes et al. Mult Scler 2013; epublished October 9, 2013).

It is generally recommended that all DMTs should be interrupted during pregnancy (Ghezzi et al. Expert Rev Clin Immunol 2013;9:683-691). Treatment with some agents (e.g. glatiramer acetate, azathioprine) may be continued in selected patients at high risk of relapse in accordance with good clinical judgment and with the consent of the patient. A recent systematic review found no evidence of lower birth weights with glatiramer acetate exposure during pregnancy, although data were limited (Charles et al. Neurology 2013;80:1068-1069). A recent retrospective review reported no long-term deleterious effects in offspring following short-term DMT exposure in utero (Fragoso et al. CNS Drugs 2013;27:955-961).

The effect of newer DMTs (natalizumab, fingolimod, dimethyl fumarate) on pregnancy outcomes has not been sufficiently examined so treatment interruption is advised. Teriflunomide has teratogenic effects in animals and an active elimination protocol (cholestyramine or activated charcoal) is immediately required in patients reporting pregnancy. Males with MS must also use contraception since teriflunomide is detectable in semen.

Reviewer: Dr. Daniel Selchen. Head of Neurology, St. Michael’s Hospital, Toronto, Canada.

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