The use of immunomodulatory therapy in pregnant patients with multiple sclerosis
Julia Rudnicka-Czerwiec1, Małgorzata Popiel1, Halina Bartosik-Psujek1,2
Multiple sclerosis is a chronic autoimmune disease which mainly affects young adults – women are 2–3 times more likely to be affected than men. The highest incidence in the procreative age entails the issue of the coexistence of the disease with pregnancy. The treatment of multiple sclerosis in pregnant women is an important problem, as, so far, none of the drugs modifying the course of the disease has been considered completely safe for the foetus. In this article, on the basis of the analysis of relevant literature, information was collected on the mechanisms of action of drugs modifying the course of multiple sclerosis: beta interferon, glatiramer acetate, natalizumab, fingolimod, dimethyl fumarate, teriflunomide, alemtuzumab, mitoxantrone, cladribine, and ocrelizumab, as well as medicines used in relapse: methylprednisolone, immunoglobulins. The safety profile of drugs used in pregnancy is discussed, as well as the indications for interruption or continuation of a therapy in pregnant patients. Data on bridging therapy before planning the offspring were also summed up. Glatiramer acetate is the only drug modifying the course of the disease which is not contraindicated for use during pregnancy as part of the National Health Fund’s drug program. The continuation of interferon beta, natalizumab, dimethyl fumarate, alemtuzumab and ocrelizumab therapy can be considered when the risk of high disease activity outweighs the risk to the foetus. In the case of drugs with the highest toxicity and long half-life in the body (teriflunomide, mitoxantrone, cladribine), an interval between drug withdrawal and pregnancy planning adequate for each of the substances should be maintained. The treatment of multiple sclerosis relapse in pregnant women is no different from the one used in non-pregnant patients – methylprednisolone crosses the placental barrier but is metabolised to inactive forms. Used in the first trimester, it increases the risk of cleft lip and low birth weight, while remaining relatively safe in the second and third trimester. As part of bridging therapy, it is recommended during pregnancy planning to consider the use of glatiramer acetate and interferon beta.