Management of Multiple Sclerosis During Pregnancy and the Reproductive Years

Bove, Riley; Alwan, Sura; Friedman, Jan M.; Hellwig, Kerstin; Houtchens, Maria K.; Koren, Gideon; Lu, Ellen; McElrath, Thomas F.; Smyth, Penelope; Tremlett, Helen; Sadovnick, A. Dessa

doi:10.1097/aog.0000000000000541

Cited by 114 publications

(65 citation statements)

References 147 publications

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“…In the best-worst scaling, one patient reported an additional attribute to be important: the effect of the DMD during pregnancy on the unborn child. Although it is generally recommended to discontinue DMD treatment before trying to conceive, treatment with certain DMDs can be continued in case of highly active MS [32–36]. Moreover, during DMD treatment patients may become pregnant inadvertently.…”

Section: Discussionmentioning

confidence: 99%

Identification and Prioritization of Important Attributes of Disease-Modifying Drugs in Decision Making among Patients with Multiple Sclerosis: A Nominal Group Technique and Best-Worst Scaling

et al. 2016

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ObjectivesUnderstanding the preferences of patients with multiple sclerosis (MS) for disease-modifying drugs and involving these patients in clinical decision making can improve the concordance between medical decisions and patient values and may, subsequently, improve adherence to disease-modifying drugs. This study aims first to identify which characteristics–or attributes–of disease-modifying drugs influence patients´ decisions about these treatments and second to quantify the attributes’ relative importance among patients.MethodsFirst, three focus groups of relapsing-remitting MS patients were formed to compile a preliminary list of attributes using a nominal group technique. Based on this qualitative research, a survey with several choice tasks (best-worst scaling) was developed to prioritize attributes, asking a larger patient group to choose the most and least important attributes. The attributes’ mean relative importance scores (RIS) were calculated.ResultsNineteen patients reported 34 attributes during the focus groups and 185 patients evaluated the importance of the attributes in the survey. The effect on disease progression received the highest RIS (RIS = 9.64, 95% confidence interval: [9.48–9.81]), followed by quality of life (RIS = 9.21 [9.00–9.42]), relapse rate (RIS = 7.76 [7.39–8.13]), severity of side effects (RIS = 7.63 [7.33–7.94]) and relapse severity (RIS = 7.39 [7.06–7.73]). Subgroup analyses showed heterogeneity in preference of patients. For example, side effect-related attributes were statistically more important for patients who had no experience in using disease-modifying drugs compared to experienced patients (p < .001).ConclusionsThis study shows that, on average, patients valued effectiveness and unwanted effects as most important. Clinicians should be aware of the average preferences but also that attributes of disease-modifying drugs are valued differently by different patients. Person-centred clinical decision making would be needed and requires eliciting individual preferences.

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Section: Discussionmentioning

confidence: 99%

Identification and Prioritization of Important Attributes of Disease-Modifying Drugs in Decision Making among Patients with Multiple Sclerosis: A Nominal Group Technique and Best-Worst Scaling

et al. 2016

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“…MS is more prevalent among females, and the peak age of onset for women is during the childbearing years. 1,2 MS does not seem to significantly impair fertility although there is emerging data on decreased ovarian reserve and higher prevalence of thyroid autoimmunity in MS patients, possibly affecting fertility. 2–5 A chronic neurologic illness may also influence pregnancy intentions.…”

Section: Introductionmentioning

confidence: 98%

“…1,2 MS does not seem to significantly impair fertility although there is emerging data on decreased ovarian reserve and higher prevalence of thyroid autoimmunity in MS patients, possibly affecting fertility. 2–5 A chronic neurologic illness may also influence pregnancy intentions. Although some patients report having completed their families prior to MS diagnosis, one study found that among women with MS who did not become pregnant after diagnosis, nearly one-third cited MS-related concerns such as symptoms interfering with parenting, burdening their partner, and children inheriting MS. 6 Many women with MS use disease modifying therapies (DMTs).…”

Section: Introductionmentioning

confidence: 98%

“…7 If a woman is on certain DMTs, a washout period before conception is recommended. 2 Table 1 summarizes the DMTs in wide use today with known or suspected pregnancy risks. Providers are always encouraged to review up-to-date product-specific information for their practice location and scope, prior to giving advice to their patients.…”

Section: Introductionmentioning

confidence: 99%

“…Although several clinical reviews are available on the management of and therapeutic considerations for women with MS during the reproductive years, 2,7,17,18 the focus of these reviews has largely been on issues around the time pregnancy. Topics have included the effect of pregnancy on the MS disease course; the management of MS during pregnancy, labor, and postpartum; and safety of breastfeeding while on DMTs.…”

Section: Introductionmentioning

confidence: 99%

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Contraception for women with multiple sclerosis: Guidance for healthcare providers

et al. 2017

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Family planning is essential for any comprehensive treatment plan for women of reproductive age with multiple sclerosis (MS), including counseling on using effective contraception to optimally time desired and prevent unintended pregnancies. This topical review summarizes the first evidence-based recommendations on contraception safety for women with MS. In 2016, evidence-based recommendations for contraceptive use by women with MS were included in US Medical Eligibility Criteria for Contraceptive Use. They were developed after review of published scientific evidence on contraception safety and consultation with experts. We summarize and expand on the main conclusions of the Centers for Disease Control and Prevention guidance. Most contraceptive methods appear based on current evidence to be safe for women with MS. The only restriction is use of combined hormonal contraceptives among women with MS with prolonged immobility because of concerns about possible venous thromboembolism. Disease-modifying therapies (DMTs) do not appear to decrease the effectiveness of hormonal contraception although formal drug–drug interaction studies are limited. Neurologists can help women with MS make contraceptive choices that factor their level of disability, immobility, and medication use. For women with MS taking potentially teratogenic medications, highly effective methods that are long-acting (e.g. intrauterine devices, implants) might be the best option.

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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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Management of Multiple Sclerosis During Pregnancy and the Reproductive Years

Cited by 114 publications

References 147 publications

Identification and Prioritization of Important Attributes of Disease-Modifying Drugs in Decision Making among Patients with Multiple Sclerosis: A Nominal Group Technique and Best-Worst Scaling

Identification and Prioritization of Important Attributes of Disease-Modifying Drugs in Decision Making among Patients with Multiple Sclerosis: A Nominal Group Technique and Best-Worst Scaling

Contraception for women with multiple sclerosis: Guidance for healthcare providers

Association Between Breastfeeding and Postpartum Multiple Sclerosis Relapses

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