The mean age of women in the European Union on giving birth to their first child has gradually increased from 28.8 years in 2013 to 29.3 years in 2018. Importantly, it has increased in all EU countries over this period. As the majority of female pwMS develop the disease in their early thirties, it’s therefore not acceptable to take decisions on DMTs without discussing the implications for family planning. Especially, as pwMS in their thirties will not be keen on postponing pregnancy for one or two years to organise a DMT switch towards a more MS and/or pregnancy safe option.
Family planning implies a triad: conception, pregnancy and breastfeeding. In practice, DMTs need to be safe on all three domains to earn their spot on a future mother’s lap. However, there are four important issues when reconciling the triad with DMT strategies:
- Only two of the DMTs in the extensive MS armamentarium, Copaxone and interferons, are entirely safe during the full triad.
- Copaxone and interferons have a low efficacy when it comes to preventing MS-related brain inflammation
- When DMTs are stopped, they often require three to four months to reach their full anti-inflammatory potency after being restarted, or they are associated with rebound MS disease activity
- Relapses during pregnancy or in the postpartum period are associated with an increased risk of sustained and long-term disability
Although there is considerable evidence that DMTs such as Tecfidera are likely to be safe during the triad, many female pwMS will prefer stopping the DMT when there is remaining doubt about safety or teratogenicity. Pausing treatment will leave these pwMS unprotected for about two years on average – assuming ‘Mao-istically’ the family planning only entails one child.
Therefore, I would argue it is paramount that with every female pwMS who is prior to completing her family and prior to starting a DMT, a ‘DMT-free’ option is discussed. As words are always – and especially in MS – arbitrary labels, this should be done irrespective of whether the disease course is considered ‘mild’ or ‘aggressive’. ‘DMT-free’ options are only possible when treatment results in prolonged disease control (i.e. several years) after a short treatment interval. This is the concept of induction therapies such as cladribine, alemtuzumab (and potentially also anti-CD20) which have a biological effect that outlasts exposure to the drug many times. After completing the two treatment cycles in year one and two, disease activity is monitored clinically and radiologically conveying into the perfect window for family planning and – more satisfactory – action.
Disclaimer: Please note that the opinions expressed here are those of dr. Ide Smets and do not necessarily reflect the position of the Barts and The London School of Medicine and Dentistry nor Barts Health NHS Trust.
Ruth Dobson, Kerstin Hellwig
- PMID: 33709977
- DOI: 10.1097/WCO.0000000000000922
Purpose of review: The fact that multiple sclerosis (MS) predominantly affects women has been recognized for many years. As the age at diagnosis is decreasing, and treatment options are becoming more complex, increasing numbers of women are facing decisions about the use of disease modifying therapy (DMT) in and around pregnancy. Recent findings: New data are rapidly becoming available, particularly regarding the safety of therapies in both pregnancy and breastfeeding. Effective treatment and suppression of relapses is key to ensuring good outcomes in the longer term for the woman, however this must be balanced against individual risk of relapse and risks to the fetus. Women should be advised that it is possible to breastfeed while taking selected DMT. Summary: In this review, we discuss evidence surrounding the safety of DMTs in both pregnancy and breastfeeding, and use this knowledge to suggest approaches to pregnancy and family planning in women with MS.