Here is My Question:

I was on Aubiago for ten months and was taken off it, due to severe side effects. I was wondering if it is safe to get pregnant? And I was taking Copaxone which was a month of pain. Is it safe to continue my family?

Answer:

Aubagio (or teriflunomide) is a pregnancy category X medication which means that fetal abnormalities are a real risk (this is based on information from a similar medication called leflunomide).  Data presented at the American Academy of Neurology this year indicated 83 reported pregnancies among women exposed to Aubagio.  Among these 83 exposures, 70 were exposed up to week 11 of pregnancy with 26 live births demonstrating no structural or functional abnormality.  Among the rest, 29 patients elected for an induced abortion and 13 had a spontaneous miscarriage (and 2 were unaccounted for).

Family planning is an issue for patients who decide to start Aubagio.  If you are contemplating pregnancy, I would make sure to check a teriflunomide level (blood lab) to ensure that it is adequately out of your system.  Usually, coming off Aubagio means undergoing an “elimination protocol” using a medication called cholestyramine for 11 days.  We do this because Aubagio tends to remain in the body for quite a long time (up to 2 years after the last dose if you don’t do the elimination protocol).  The elimination protocol usually accelerates the removal of Aubagio, but occasionally a second round of cholestyramine is needed.  Before attempting pregnancy, I’d recommend ensuring it is completely out of your system.

Copaxone is a pregnancy category B medication, and should not be a contraindication to pursue pregnancy (as you have been off of it for a while).

I would encourage you to discuss this with your MS provider as there can be other considerations to take into account when planning for pregnancy with MS.  For the average patient, pregnancy has a good effect on MS, and may be on par with many of our disease modifying therapies (especially during the third trimester).  Good luck!

-ASN

Question:  This is a difficult one, but let's give it a try. I am trying to decide whether or not I should have my own child, since I am terribly afraid of passing the disease to my child. Sometimes I try to encourage myself by thinking that medical research have done a great work lately for MS, and that very soon we might find a cure. In your opinion, how far are we from that moment, where having MS will be not more cumbersome than perhaps a need for taking a lifelong medication?

Answer:  As recently as 10 years ago, I would shy away from directly answering questions like yours, since we did not have the technology or platforms to make rapid advances in MS or other diseases; all of this has changed, largely as a result of networks of physicians and patients beginning to work together to find more rapid solutions to health care problems. This is the crowd sharing revolution that has finally come to medical research. We (meaning the accelerated cure project) just received a large grant from the Patient Centered Outcomes Research Institute (PCORI) to set up a network of 20,000 MS patients for the purpose of large scale research studies. We are also forming a network of sites around the United States for a study called Opt-Up, for optimizing treatment and understanding progressive MS. This will provide many of the tools requires for large scale clinical studies. So I think we already have good solutions for MS patients and will have far better solutions in the next 15 to 20 years.

That being said, it is often difficult to decide on having children even if you do not have MS. So much depends on your prior attitudes towards becoming a parent (is it having children that is important or having your own children?), your age (increased risk of Down’s Syndrome and other chromosomal abnormalities with age), your goals in life, your supports, your finances and your own health. Plus having children is usually a decision between two people, which adds an extra layer of complexity. The risk of MS in your children is almost a minor consideration compared to these issues. The facts are well known; any of your children will have approximately a 9% risk of MS.  So I recommend, all other things being equal, make your decision about having children independent of your concerns that some day they may too develop MS. Hope this helps.

 -- Dr. Kinkel

PLEASE NOTE:  The medical information on this site is provided as an information resource only, and is not to be used or relied on for any diagnostic or treatment purposes. This information does not create any patient-physician relationship, and should not be used as a substitute for professional diagnosis and treatment.  Please consult your health care provider before making any healthcare decisions or for guidance about a specific medical condition.

Q:  Have there been any studies on the impact of oral contraceptives on the course of MS? I was just wondering, since pregnancy is protective, whether taking hormones that prevent ovulation and to some extent mimic pregnancy can help too?

The verdict on oral contraceptives and their effect on MS is still out. Several case control studies, including a recent analysis of the Swedish Multiple Sclerosis registry, suggest that combined oral contraceptives (progestin and estrogen) use is associated with a later age of onset of MS. One study even suggested less severe disease in patients with longer combined oral contraceptive use. Unfortunately, case control studies are not able to prove causation and there are other possible explanations for these results. There is a randomized control study underway to determine if a pregnancy related estrogen (estriol) is effective at decreasing MS disease activity. Although this will help answer many questions, it will not tell us if oral contraceptives are helpful as these contain different hormones. Stay tuned for more information in the future.

--Dr. Kinkel

Discontinuation of Tysabri therapy after more than a year of treatment is associated with an increased risk of relapse, typically 4 to 8 months after the last infusion. In some cases these relapses are quite widespread and severe. Patients with active disease before starting treatment with Tysabri, usually defined as recent relapses and multiple enhancing lesions on MRI prior to starting Tysabri , have the highest risk of relapse after stopping Tysabri therapy, even if Tysabri was completely effective at shutting down all evidence of active disease.

The most common reason for stopping Tysabri in these circumstances is the desire to get pregnant or concern about developing PML (Progressive Multifocal Leukoencephalopathy)  with continued treatment. Normally, pregnancy is partially protective in MS patents during the 2nd and 3rd trimester but there are increasing reports of patients stopping tysarbi and experiencing severe relapses even during the 2nd and 3rd trimester.  These relapses coincide with the period of greatest risk for relapses after stopping Tysabri, in other words 4-8 months after the last infusion. One approach is to stop Tysabri and not attempt pregnancy until you are beyond the risk period for these more severe relapses but undergo frequent MRI and clinical monitoring by your MS specialist during this period to ensure your MS is not becoming too active to attempt pregnancy.  Often we will place individuals on copaxone immediately after the last infusion of Tysabri or even before stopping Tysabri in an attempt to prevent Tysabri withdrawal relapses. The best approach and advice will depend on your individual circumstances. I would suggest discussing this with an MS specialist who has significant experience with the use of Tysabri and managing pregnancy in MS.

PLEASE NOTE:  The medical information on this site is provided as an information resource only, and is not to be used or relied on for any diagnostic or treatment purposes. This information does not create any patient-physician relationship, and should not be used as a substitute for professional diagnosis and treatment.  Please consult your health care provider before making any healthcare decisions or for guidance about a specific medical condition.