Pregnancy and Reproductive Issues in MS. Annette Wundes, MD Co-Director University of Washington MS Center November 12,2014

Transcription

1 Pregnancy and Reproductive Issues in MS Annette Wundes, MD Co-Director University of Washington MS Center November 12,2014

2 Conflicts of Interest Reports no conflicts pertaining to this presentation. Research funding: Biogen Idec

3 Instructional Objectives Participants will be able to: Discuss the impact of MS on pregnancy Describe the risk of post-partum relapses List at least three ways that MS can affect sexual function Describe at least two interventions to address sexual dysfunction

4 Pregnancy Outcomes Overall no adverse pregnancy outcomes No increase in pregnancy complications Risk of MS in children: 3-5% No impact on long-term disability outcomes

5 Glatiramer acetate Copaxone Interferon-beta 1 a/b Avonex, Rebif, Betaseron, Extavia Pregnancy category B C Most anecdotal reports of use during pregnancy and BF Slightly increase risk of spontaneous abortions during early pregnancy Natalizumab Tysabri Fingolimod Gilenya Terflunimide Aubagio Dimethyl fumerate Tecfidera Mitoxantrone Novantrone C C X C D Per FDA discontinuation 2 months prior attempting conception Chelation therapy for both women and men prior to conception Excellent review: Bruce Cree, MS Journal 2013

6 Post-Pregnancy Relapses 72% of women without relapse Risk factors: - Increased pre-pregnancy RR - Relapse during pregnancy - Higher EDSS univariant analysis only Poor predictive value: - Only 13% by # % by best predictive model Confavreux NJEM 1998, Vukusic Brain 2004

7 Pregnancy-related Relapse Risk MS should not dictate mode of delivery Most women are RRMS, severely disabled pt are rare No convincing data to argue against an epidural PRIMS study and large prospective Italian study no impact on relapse rate or disability 1,2 NMSS expert panel: all forms anesthesia considered safe Few anecdotal cases of complication in literature Remember steroid stress dose if indicated 1 Vukusic, Brain Pasto BMC Neurology 2012

8 Breast-feeding PRIMS study: no impact Exclusively It Rocks!

9 MS management in post-partum setting MS drugs No DMT approved during lactation Most anecdotal reports for glatiramer acetate (Copaxone ) Greater concern for small molecules Breast-feeding Conflicting data on benefit of exclusive BF x 2 months Monthly IV steroids with pump & dump IVIG, no excretion into breast-milk

10 Sexual Dysfunction Meghan Beier, PhD Acting Instructor UW Medicine Multiple Sclerosis Center Department of Rehabilitation Medicine University of Washington School of Medicine Slides and Information provided with permission by: Frederick W. Foley, Ph.D. Professor of Psychology, Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, NY Director of Neuropsychology and Psychosocial Research, Multiple Sclerosis Comprehensive Care Center, Holy Name Medical Center, Teaneck, NJ

11 Conflict of Interest No conflicts of interest to disclose

12 Epidemiology of Sexual Dysfunction Adult US Population US MS Population 52% of men 1 43% of women; 31% of men 2 67% of MS patients report significant sexual dysfunction in over the past 6 months 3 1. Massachusetts Male Aging Study 2. National Health & Social Life Survey 3. Foley et al. Consortium of MS Centers, NARCOMS registry 4. Zorzon et al (1999) 5. Valleroy & Kraft (1984) 6. Minderhound (1984) 73% of MS 4 75% of men; 56% of women 5 74% of women 6

13 Primary Occurs as a result of MSrelated changes in the CNS that directly impair sexual feelings and/or response Secondary Occurs as MS-related physical changes or medical/pharmacological treatments that indirectly affect sexual feelings and/or response Tertiary Refers to the psychological, social, and cultural issues that interfere with sexual feelings and/or response Examples: Decreased/absent libido Altered genital sensation Erectile dysfunction Decreased vaginal lubrication Examples: Bladder/bowel dysfunction Fatigue Spasticity Pain Cognitive impairment Examples: Depression Changes in self-image/body image Performance anxiety Family/social role changes Sexuality expectations Foley, Zemon, Campagnolo, Marrie, Cutter, Tyry, Millier, Sipski, & Vollmer. The Epidemiology of Sexual Dysfunction in Multiple Sclerosis in the United States; supported by CMSC

14 IF asked, what symptoms do individuals with MS report? Men % P/S/T MSISQ Item 52 P difficulty getting/keeping an erection 38 T feeling less confident about my sexuality due to MS 37 P less intense or pleasurable orgasms 37 P takes too long to orgasm/climax 31 P less feeling or numbness in genitals Women % P/S/T MSISQ Item 40 P takes too long to orgasm/climax 36 P less intense or pleasurable orgasms 36 P lack of sexual desire 34 P Inadequate vaginal wetness/lubrication 28 P less feeling or numbness in genitals Foley, Zemon, Campagnolo, Marrie, Cutter, Tyry, Millier, Sipski, & Vollmer. The Epidemiology of Sexual Dysfunction in Multiple Sclerosis in the United States; supported by CMSC

15 Physician Questioning Increases Patient Reporting of Sexual Dysfunction

16 100 Percentage of Patients* % 55% 0 Spontaneous Reporting *Patients receiving SSRI treatment (N=308) Reporting After Direct Questioning Montejo AI, et al. Actas Luso Esp Neurol Psiquiatr Cienc Afines. 1996;24:

17 How to Ask Your Patient Use a structured questionnaire: The Multiple Sclerosis Intimacy and Sexuality Questionnaire (available on NMSS website) Inquire about sexual functioning when asking about bowel and bladder function If a person acknowledges sexual dysfunction, ask if they would like help with these symptoms

18 Detailed resources for both patient and clinician are available on the NMSS website: Care/Managing-MS/Symptom-Management/Sexual-Dysfunction-Problems#section-4 Treatment will depend on etiology Primary Men: Oral medications (sildenafil, vardenafil, tadalafil); injectable/suppository medication (alprostadil); prosthetic devices Women: lubrication, enhanced stimulation Secondary Determine if medications might be contributing Effectively manage MS symptoms (e.g., fatigue, bladder/bowel changes) Tertiary Individual or couple s counseling Provide education Professionals/Clinical-Care/Managing-MS/Symptom- Management/Sexual-Dysfunction-Problems#section-5

19 Reproductive Issues Additional Resources Talking with Your MS Patient about Reproductive Issues Assessment & Treatment of Sexual Dysfunction Talking with Your MS Patient about Sexual Dysfunction UW MEDCON (WWAMI): For your Patients: MS Navigator Program (1-800 FIGHT MS)

20 Supplemental slides on treatments/reproductive safety information

21 Cree B, Mult Scler 2013 epub

22 C* *updated for DMF approval, adopted Cree B, Mult Scler 2013 epub

23 Post-partum MS management

24 IVIG - Not secreted in breast milk Dose comparison 1 150mg/kg d mg/kg qm x 5 (n=75) 450, 300, 150mg/kg d mg/kg qm x 5 (n=76) Relapse-free 1 st 3 months: 75.6% vs 81.5% (ns) No increase in postpartum ARR Single center 2 Single dose 60g within 3 d relapse-free 1 st 3 months: 75% IVMP - pump & dump x 4-6h 60g w/in 3d + 10g qm x5 94% Single center 3 Naïve (n=22) relapse rate 1 st 3months: mean 2, SD 0.66 Sex hormones Monthly IVMP x 6 (n=20) mean 0.8, SD 0.41 POPART MUS trial 4 progesterone po qd x 12 wk + estradiol transdermal qw x 12 placebo pending 1 Haas, MS Journal Haas, MS de Seze, MS Journal Vukusic J Neurol Sci