Proof of the Pudding. Treatment free pregnancies may be possible

P
Your Pregnancy Symptoms Week by Week | Parents

Yesterday there was a debate on whether we should use anti-CD20 antibodies as immune reconsititution therapies. Of course the answer needs a trial, but what do peole think was the outcome. Sadly, it seems that a substantial number of the clinical fraternity don’t get or buy it. My head is so bruised and the wall has a dint it in. The only way to covince them is data, but in the absence of a trial how much more evidence do you need. We looked at trial data from the phase II study and suggested that you may be able to get a drug free pregnacy.

The ocrelizumab phase II extension trial suggests the potential to improve the risk: Benefit balance in multiple sclerosis.Baker D, Pryce G, James LK, Marta M, Schmierer K.Mult Scler Relat Disord. 2020;44:102279.

Well it seems the data was already there.

Disease activity in pregnancy and postpartum in women with MS who suspended rituximab and natalizumab Neda Razaz, Fredrik Piehl, Thomas Frisell, et al. October 21, 2020 Neurology N2. 2020DOI: https://doi.org/10.1212/NXI.0000000000000903

Objective To evaluate risks of disease reactivity during pregnancy and postpartum following rituximab (RTX) and natalizumab (NTZ) suspension in women with MS.

Methods An observational cohort study of all women with MS disease onset before childbirth between 2006 and 2017. Women were identified through the Swedish MS Registry, a nationwide clinical register, with substratification into 3 groups: women who suspended RTX and NTZ within 6 months before conception and women who were not treated with any disease-modifying treatment (DMT) within 1 year of conception. The primary outcome was the annualized relapse rate (ARR) during pregnancy and 1 year postpartum.

Results We identified 2,386 women with MS onset before a live birth; of these, 76 women suspended RTX and 53 suspended NTZ, and 457 were untreated within 1 year before conception. In all women, regardless of the treatment type, the ARR declined from 0.05–0.04 prepregnancy to 0.03–0.02 during pregnancy, returning to prepregnancy rates at 3–6 months (0.05) postpartum. In the suspended cohort, 76% (98/129) of women resumed a DMT after delivery. The relapse rate 1 year postpartum was significantly higher in the suspended NTZ women compared with the suspended RTX women (adjusted rate ratio [aRR] 7.65, 95% CI 2.47–23.6) and was lower in the suspended RTX women compared with the untreated women (aRR 0.21, 95% CI 0.08–0.61).

Conclusion Disease reactivity during the post-partum period was lower among women with MS who suspended RTX before pregnancy, relative to those who suspended NTZ and untreated women. These findings suggest that RTX may exert long-acting effects on MS disease activity that encompass pregnancy and post-partum periods.

This has to be discussed with your neurologists. A trial needs to be done

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