Polly: What can MSers do for pain management that is a hundred per cent safe during pregnancy?
Professor Gavin Giovannoni, Neurologist: Pain management that is safe during pregnancy? Very difficult. It all depends, I mean MS pain, there’s different types of pain, so it’ll have to say what type of pain it is. I suspect people are talking about the neuralgia type pain and for that the medications that we tend to use are the anticonvulsants and very few of them are a hundred per cent safe in pregnancy. But as long as you take them after the first few months where the foetus is developing the organs, then it should be relatively safe. So depending on what stage of pregnancy, they can be safe later on. What we call the central pain, which is that gnawing, toothachey type pain that people usually get in their backs and spinal cord, that is much more difficult to treat and we tend to use antidepressant type drugs and they are, in inverted commas, ‘safe’ during pregnancy. So it all depends on how severe the pain is, but I don’t think there are any drugs that can be safe, categorically safe in pregnancy, it’s always a risk-benefit and it’s up to the individual person to make the decision, are they prepared to take those risks or not.
Polly: And another pregnancy related thing, why is it that people are often well through pregnancy, off medication but somehow well for those nine months, what’s working behind that?
Professor Gavin Giovannoni: Well, I think it’s got to do with the immune system. So we know that pregnancy is a state of relative immune suppression, in other words, the immune system of the mother or the expectant mother, has to be suppressed because the baby is actually foreign, it’s like a transplant. So to prevent your body from rejecting that baby, your immune system goes into immune suppressed mode and that in itself is a treatment for MS, because we do know that the attack rate, particularly in the second and third trimesters, which is the last six months of pregnancy, drops substantially compared to periods outside of that. And then at post-partum after delivery of the baby there’s a rebound in the relapse rate, so there’s something very interesting about the immune function in pregnancy and there are a large number of people and companies trying to work out what factor in pregnancy is associated with that, because we can’t really treat MS with pregnancy here, can we?
Polly: No, I don’t think that’s probably wise, but maybe replicating it without.
Professor Gavin Giovannoni: But let’s say we can induce a state of pseudo-pregnancy where you’re not really pregnant but the immune system thinks you’re pregnant, then we could probably treat MS and we could do it quite safely. So I mean that’s a kind of a strategy that’s being explored by a large number of scientists across the world.
Polly: Okay, that’s really interesting. Is it possible to stay on medication while you are trying to get pregnant?
Professor Gavin Giovannoni: Yes, so this is the question, are the disease modifying – I assume you’re referring to the disease modifying therapies – are they safe in pregnancy and then wait to fall pregnant before stopping them. By the time you know you’re pregnant a large amount of development has occurred already, so some of the drugs that are shown to be what we call teratogenic – that’s a big term – that actually shows that these drugs cause mutations or abnormalities in animals, cannot be used in pregnancy and there’s a list of those drugs. Most of the drugs though are not, in inverted commas, teratogenic, so we are beginning to allow people with MS to stay on them and fall pregnant, and then we stop the drugs after pregnancy and these are the ones that really have got a lot of safety data supported by big registries. So these are registries that have been collected by the pharmaceutical companies that make the drugs and neurologists all over the world showing that these drugs are safe in pregnancy. And the one that we’ve got the most data for is a drug called glatiramer acetate or Copaxone, and a large number of neurologists now are allowing women to fall pregnant and stay on the drug.
Polly: Okay, but with sort of Tysabri you’d probably suggest if it was a planned pregnancy to come off it?
Professor Gavin Giovannoni: No. To be honest with you, the Tysabri database is also looking quite interesting and obviously the kind of people that are on Tysabri happen to have the most active MS. And you know that if you stop Tysabri there’s this risk of rebound, so there’s now a tendency, if somebody has had a highly active disease, is to fall pregnant and then stop the drug during pregnancy and then restart it towards the end of pregnancy before delivery. And it’s looking like that’s a safe option.
Polly: And then what about breastfeeding? Could someone breastfeed while taking it?
Professor Gavin Giovannoni: Tysabri? Yes, you probably could breastfeed, but what you’ve got to realise is, the antibody will go across into the breast milk and hopefully it will not affect the immune function of the baby. And so I know a large number of women, across the planet actually, who’ve decided to take the risk and continue breastfeeding and go back on to Tysabri. And one of the reasons is that antibody tends to get broken down in the stomach because it’s a protein, so the risks to the baby are very low. You can’t read about, though, in the packaging, if you look at what the drug company says, it says you can’t fall pregnant – or, not the case you can’t, it’s a risk-benefit decision – and you shouldn’t really breastfeed on the drug. That’s because they don’t have any information or data, they haven’t done the studies for that. But I think from a holistic management point of MS, you know, I think it’s important for mothers to breastfeed, it’s also important for us to get their disease under control, so we tend to discuss this with people and a large number of my patients have opted to breastfeed and go back on to Tysabri.
Polly: Oh right.
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Professor Gavin Giovannoni has an MBBCh, PhD, FCP (Neurol., SA), FRCP, FRCPath amongst his qualifications. He is the Chair of Neurology at Barts and The London School of Medicine. His research interests have focused around multiple sclerosis and inflammatory disorders of the central nervous system. His teaching focuses on clinical neurology and neuroimmunology.