Practical Considerations for Managing Pregnancy in Patients With Multiple Sclerosis: Dispelling the Myths.

Purpose of Review: Lack of consistent data and guidance have led to variations between clinicians in the management of pregnancy in women with multiple sclerosis (MS). Pregnant and/or lactating women are often excluded from clinical trials conducted in MS, and thus, the labeling for most disease-modifying therapies (DMTs) excludes use during pregnancy. This has led to heterogeneity in interpretation and labeling regarding the safety of DMTs during pregnancy and lactation and the required preconception washout periods. This review identifies key themes where there is conflicting information surrounding family planning and pregnancy in MS, focusing on the most common discussion points between physicians and patients during preconception planning, pregnancy, postpartum, and lactation. The goal was to inform the patient-physician conversation and provide best practice recommendations based on expert clinical expertise and experience. Recent Findings: We outline the latest evidence-based data for DMT use during pregnancy and lactation, the effect of MS on fertility and fertility treatments, the risk of adverse pregnancy and delivery outcomes, the risk of postpartum relapse, and immunization and clinical imaging safety during pregnancy and breastfeeding. Summary: Management of family planning and pregnancy in patients with MS requires the most current information. Health care providers should discuss family planning early and frequently with patients with MS, and partners where practicable. Because management of pregnant people with MS will often require a risk/benefit analysis of their needs, shared decision-making in family planning discussions is emphasized. Additional data are needed for specific and underrepresented populations with MS (e.g., single parents or those from the LGBTQ+ community) and those at risk of racial and socioeconomic disparities in care. Pregnancy registries and the design and conduct of clinical trials focused on pregnant and lactating patients should provide additional data to guide the ongoing management of patients with MS.

Seroconversion after COVID-19 vaccination for multiple sclerosis patients on high efficacy disease modifying medications.

The impaired ability to mount an effective immune response to vaccination leaves immunosuppressed patients at higher risk of severe COVID-19 infection. This retrospective study aimed to evaluate COVID-19 seroconversion and antibody titers for patients on immune modulating therapies compared to those not on disease modifying therapy (DMT). As expected, individuals on B-cell depletion therapies (BCDT) and those on sphingosine 1-phosphate (S1P) modulators had an impaired humoral response to mRNA vaccination. We observed variable seroconversion depending on the type of B-cell depleting medication, with a smaller percentage of seroconversion in patients on infused BCDT (iBCDT, ocrelizumab and rituximab) compared to ofatumumab. The humoral response to vaccination was not impaired for individuals on natalizumab or for untreated MS patients. These observations may influence DMT selection during the COVID-19 era.

Severe acute inflammatory demyelinating polyradiculoneuropathy with persistent weakness associated with tumor-like nerve root enlargement.

We report a 23-year-old woman with rapid onset of proximal and distal limb weakness and areflexia, associated with tumor-like spinal nerve root enlargement and markedly elevated cerebrospinal fluid protein. Our patient developed the inability to walk within days, without preceding illness. Within two weeks, she had near-complete bilateral wrist and foot drop. Her cranial nerves and respiratory function remained intact. She received intravenous immunoglobulin early on for suspected Guillain-barre syndrome but remained wheelchair-bound until 6 Plasma exchange sessions were completed. After that, she continued to improve with intravenous immunoglobulin dosed every 3-4 weeks. Prominent demyelinating features were found on NCS, with cerebrospinal fluid protein of 415 mg/dL. Comprehensive infectious work-up was negative. Magnetic resonance imaging of lumbosacral and cervical spine showed tumor-like masses mistaken for neurofibromatosis (axial diameter, 7.5-10 mm). Repeated magnetic resonance imaging 6 months later showed persistent nerve root enlargement, despite the patient's improved functional status.

Use of therapies other than disease-modifying agents, including complementary and alternative medicine, by patients with multiple sclerosis: a survey study.

CONTEXT: Many patients with multiple sclerosis use complementary and alternative medicine (CAM) to supplement their traditional treatment. OBJECTIVE: To identify both the prevalence and frequency of use of therapies other than disease-modifying agents (DMAs), including CAM, among patients with multiple sclerosis. DESIGN: The authors administered a 13-question survey regarding patients' current use of non-DMA therapies-including dietary supplements, exercise, and "true" CAM (eg, acupuncture, chiropractic, massage)-and mainstream treatments, including physical therapy and osteopathic manipulative treatment. Patients rated their level of disability on a scale of 1 to 10 (with 10 being most severe). SETTING: A hospital outpatient clinic in Philadelphia, Pennsylvania. PATIENTS: Inclusion criteria were physician-confirmed multiple sclerosis (either relapsing-remitting or progressive), regardless of sex, duration of disease, age at onset, disability level, or type of disease. Patients were excluded if they were younger than 18 years. MAIN OUTCOME MEASURE: Patient-reported use of non-DMA therapies and perception of disability. RESULTS: A total of 111 patients with multiple sclerosis completed the survey properly. All respondents used non-DMA therapies. Twenty-three patients (20.7%) used these therapies without concomitantly taking a DMA. A plurality (34.8%) of those patients reported a disability score of 7 or 8. Sixty-two of the 88 participants (70.5 %) who used DMAs reported disability scores of 5 or less. Sixty-five patients (58.6.%) reported exercising on a weekly basis. Among those patients, 47 (72.3%) reported a disability score of 5 or less. Sixty-four patients (57.7%) used such CAM therapies as acupuncture and massage, or such other non-DMA treatments as osteopathic manipulative treatment and psychotherapy. Among those patients, 37 (64.9%) reported a disability score of 5 or less. CONCLUSION: Many patients with multiple sclerosis are seeking more than traditional medical treatment. Physicians and other health care professionals must be aware of the extensive use of alternative modalities among these patients, and these professionals must provide guidance and monitoring in use of these therapies to improve outcomes.