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      Family Planning for People with Multiple Sclerosis in Saudi Arabia: an Expert Consensus


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          More than half of all patients with multiple sclerosis (MS) in the Kingdom of Saudi Arabia (KSA) are women of childbearing age. Raising a family is an important life goal for women in our region of the world. However, fears and misconceptions about the clinical course of relapsing-remitting MS (RRMS) and the effects of disease-modifying drugs (DMDs) on the foetus have led many women to reduce their expectations of raising a family, sometimes even to the point of avoiding pregnancy altogether. The increase in the number of DMDs available to manage RRMS and recent studies on their effects in pregnancy have broadened management options for these women. Interferon beta now has an indication in Europe for use during pregnancy (according to clinical need) and can be used during breastfeeding. Glatiramer acetate is a further possible option for women with lower levels of RRMS disease activity who are, or about to become, pregnant; natalizumab may be used up to 30 weeks in patients with higher levels of disease activity. Where possible, physicians need to support and encourage women to pursue their dream of a fulfilling family life, supported where necessary by active interventions for RRMS that are increasingly evidence based.

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          Most cited references42

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          Rate of pregnancy-related relapse in multiple sclerosis. Pregnancy in Multiple Sclerosis Group.

          Multiple sclerosis often occurs in young women, and the effect of pregnancy on the disease is poorly understood. We studied 254 women with multiple sclerosis during 269 pregnancies in 12 European countries. The women were followed during their pregnancies and for up to 12 months after delivery to determine the rate of relapse per trimester and the score on the Kurtzke Expanded Disability Status Scale (range, 0 to 10, with higher scores indicating more severe disability). The relapse rate in each trimester was compared with the rate during the year before the pregnancy. The effects of epidural analgesia and breast-feeding on the frequency of relapse during the first three months post partum and the disability score at 12 months post partum were also determined. The mean (+/-SD) rate of relapse was 0.7+/-0.9 per woman per year in the year before pregnancy; it was 0.5+/-1.3 during the first trimester (P=0.03 for the comparison with the rate before pregnancy), 0.6+/-1.6 during the second trimester (P=0.17), and 0.2+/-1.0 during the third (P<0.001). The rate increased to 1.2+/-2.0 during the first three months post partum (P<0.001) and then returned to the prepregnancy rate. The mean Kurtzke disability score worsened by 0.7 point during 33 months of follow-up, with no apparent acceleration during the post-partum period. Neither breast-feeding nor epidural analgesia had an adverse effect on the rate of relapse or on the progression of disability in multiple sclerosis. In women with multiple sclerosis, the rate of relapse declines during pregnancy, especially in the third trimester, and increases during the first three months post partum before returning to the prepregnancy rate.
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            Natalizumab use during the third trimester of pregnancy.

            Natalizumab reduces multiple sclerosis relapses very effectively; however, severe disease activity may return once natalizumab treatment is withdrawn, as recommended during pregnancy. Sometimes restarting natalizumab treatment may be the best option for the mother, but the consequences for the infant are unknown. Except for a few single case reports, to our knowledge, comprehensive data about third-trimester natalizumab exposure are scant.
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              Fingolimod Rebound: A Review of the Clinical Experience and Management Considerations

              Because the treatment of multiple sclerosis (MS) may span decades, the need often arises to make changes to the treatment plan in order to accommodate changing circumstances. Switching drugs, or the discontinuation of immunomodulatory agents altogether, may leave patients vulnerable to relapse or disease progression. In some cases, severe MS disease activity is noted clinically and on MRI after treatment withdrawal. When this disease activity is disproportionate to the pattern observed prior to treatment initiation, patients are said to have experienced rebound. Of the US Food and Drug Administration (FDA)-approved agents to treat MS, the drugs most commonly implicated in rebound are natalizumab and fingolimod. In this review based on the reported cases and data from clinical trials, we characterize disease rebound after fingolimod cessation. We also outline fingolimod rebound management considerations, summarizing what evidence is available to help clinicians mitigate the risk of rebound, switch therapies, and treat rebound events when they occur. The commonly encountered situation of fingolimod discontinuation prior to pregnancy is also discussed.

                Author and article information

                Mult Scler Int
                Mult Scler Int
                Multiple Sclerosis International
                15 February 2021
                : 2021
                : 6667006
                1Neurology Department, King Fahad Medical City, Riyadh, Saudi Arabia
                2College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
                3Division of Neurology, King Abdulaziz Medical City (National Guard Health Affairs), Riyadh, Saudi Arabia
                4College of Medicine, King Saud University, Riyadh, Saudi Arabia
                5Division of Neurology, King Saud University Medical City, Riyadh, Saudi Arabia
                6Neurology Department, King Abdullah Bin Abdulaziz University Hospital, Riyadh, Saudi Arabia
                7Neurology Department, King Fahad Military Medical Complex Dhahran, Dammam Eastern Region, Saudi Arabia
                8Department of Neurosciences, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
                9Neurology Department, King Fahad Specialist Hospital Dammam, Dammam Eastern Region, Saudi Arabia
                10Department of Neurosciences, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
                11Merck KGaA, Riyadh, Saudi Arabia
                12Clinical and Biological Sciences Department, University of Torino, Orbassano, Italy
                Author notes

                Academic Editor: Pasquale Calabrese

                Copyright © 2021 Mohammed Al Jumah et al.

                This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                : 9 October 2020
                : 1 February 2021
                Funded by: Novartis
                Funded by: Sanofi
                Funded by: Roche
                Funded by: Biogen
                Funded by: King Abdulaziz city for Science and technology
                Funded by: Genzyme
                Funded by: Merck KGaA
                Funded by: Merck
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