A successful pregnancy in women suffering from multiple sclerosis (MS), a disease more prevalent in women of childbearing age (around age 30), needs to be managed in a way that allows both the mother and the baby a safe journey to delivery.
Although MS itself does not affect pregnancy, the disease-associated symptoms need to be treated for a normal pregnancy to continue. Guidelines recommend early use of disease-modifying therapies (DMTs).
However, the currently available DMTs — Rebif (interferon beta-1a); Betaferon (interferon beta-1b); Copaxone (glatiramer); Aubagio (teriflunomide); Tecfidera (dimethyl fumarate or DMF); Tysabri (natalizumab); Lemtrada (alemtuzumab); Gilenya (fingolimod); and Novantrone (mitoxantrone) — are not approved for use during pregnancy due to limited information about their safety. Most physicians are reluctant to prescribe them to women who are planning to get pregnant.
The currently available limited data indicates a low risk of fetal harm for DMTs such as Copaxone, Tecfidera, Tysabri, and Lemtrada. More studies are needed to determine their potential risks before, during, and after pregnancy in female MS patients.
DMTs before pregnancy
Doctors generally recommend women with MS discontinue use of DMTs before conception except in highly active disease cases. Women who plan to become pregnant should discuss the potential risks (miscarriage, fetal abnormalities) and benefits of DMTs to decide on a treatment plan. Depending on the patient’s circumstances and preferences, a DMT with limited safety information (such as Aubagio or Tecfidera) could be replaced with a DMT with more safety information (such as interferon beta or Copaxone).
Interferon beta could be used during pregnancy since it lacks adverse effects in pregnancy.
For interferon, Copaxone, or Tysabri, women may continue the DMTs until the pregnancy is confirmed.
However, other DMTs such as Aubagio, Tecfidera, Gilenya, and Lemtrada need a gap period from two to four months so that the drug is eliminated from the body. For Tecfidera and Gilenya, a two-month washout period is recommended, and for Lemtrada, a four-month washout time is recommended prior to conception.
There is an increase in relapse rates following withdrawal of DMTs during pregnancy, but this needs more research.
DMTs after pregnancy
There is an increased risk of disease reactivation after delivery. DMTs could be resumed immediately after delivery for those women who do not breastfeed. However, DMTs are not recommended for breastfeeding mothers due to limited information about their presence in breast milk. While interferon, Aubagio, Tysabri, Lemtrada, Gilenya, and Novantrone are all discouraged during breastfeeding, there is insufficient data regarding the safety of Copaxone and Tecfidera during breastfeeding.
Some studies indicate that breastfeeding may provide protection from relapses and is recommended for MS mothers, if possible.
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