There are many approved medications for MS with varying levels of safety during pregnancy.
Infusion therapies
These are monoclonal antibodies that are highly effective as treatments for MS. Many of them have biologic effects even after they have been cleared from the body which makes them an appropriate treatment to plan to stop before pregnancy.
Alemtuzumab
Prepartum: Contraception is recommended for at least 4 months after stopping the drug and increased monitoring if you do become pregnant within one month of stopping. Does not interact with hormonal contraception.
Pregnancy: Not safe. For four years after stopping the drug, women are at increased risk for certain autoimmune diseases, so your obstetrics team should increase monitoring of you and your baby. Irradiated blood products should be used during pregnancy.
If you conceive while taking this medication: Stop intake immediately.
Breastfeeding: Not safe while taking the drug.
B-Cell Depleting Agents*
Ocrelizumab, Rituximab, Ublituximab
Prepartum: Does not interact hormonal contraception. Recommend 2 months from last infusion until attempting conception.
Pregnancy: Not safe due to evidence that Ocrelizumab can cross the placenta and cause depletion of the infant’s B cells, but recent safety data with pregnancy exposures is reassuring.
If you conceive while taking this medication: Notify your neurologist and do not take your next infusion before discussion. Your healthcare team may monitor your baby’s blood counts before giving live or live-attenuated vaccines.
Breastfeeding: Likely safe while taking these medications. These are large antibody molecules that are detected in low amounts in breastmilk, and if present, transferred in small amounts from the infant’s gut into circulation.
*Ofatumumab is also a B-Cell Depleting Agent but is categorized under Injectables
Natalizumab
Prepartum: Consider stopping intake 2 months before trying to conceive. There is a risk of rebound disease activity after stopping this medication. May need to continue into pregnancy if MS is considered highly active- with a risk – benefit discussion with neurologist.
Pregnancy: Not safe, but recent safety data with pregnancy exposures is reassuring.
If you conceive while taking this medication: Notify your neurologist and consider a plan for the next infusion under extended interval dosing.
Breastfeeding: Likely safe. This is a large molecule antibody, which is found in low amounts in breastmilk, and if present, passes in low quantities from the infant’s gut into circulation.
Infusion Premedications
These are medications, such as diphenhydramine (Benadryl) or acetaminophen (Tylenol) that can be taken before infusions to prevent infusion reactions. If resuming a disease modifying therapy within the first two weeks postpartum, you may choose to forgo premedications for the first infusion so that milk supply is not affected
Injectables
These therapies are lower efficacy but have the most published safety data.
These medications are generally safe to take up until a positive pregnancy test. For patients with a high level of disease activity, this medication can be considered for continuation during pregnancy.
Ofatumumab*
Prepartum: Does not interact hormonal contraception. Recommend 2 months from last infusion until attempting conception.
Pregnancy: Not safe due to evidence that Ocrelizumab can cross the placenta and cause depletion of the infant’s B cells, but recent safety data with pregnancy exposures is reassuring.
If you conceive while taking this medication: Notify your neurologist and do not take your next injection before discussion. Your healthcare team may monitor your baby’s blood counts before giving live or live-attenuated vaccines.
Breastfeeding: Likely safe while taking these medications. These are large antibody molecules that are detected in low amounts in breastmilk, and if present, transferred in small amounts from the infant’s gut into circulation.
*Although Ofatumumab is an injectable medication, it is considered a B-Cell Depleting Agent
Glatiramer Acetate
Prepartum: Stop intake until a positive pregnancy test. You can consider continuing for high disease activity.
During pregnancy: Safe.
Breastfeeding: Safe. Glatiramer acetate is a large molecule amino acid (Copaxone) that is detected in low amounts in breastmilk, and if present, transferred in small amounts from the infant’s gut into circulation.
Interferons
Prepartum: Stop intake until a positive pregnancy test. You can consider continuing for high disease activity.
During pregnancy: Safe.
Breastfeeding: Safe. IFN-beta is a large molecule protein (IFNb) that is detected in low amounts in breastmilk and if present, transferred in small amounts from the infant’s gut into circulation.
Orals
These therapies are moderate efficacy but should generally be avoided if patients are planning pregnancy.
Cladribine
Prepartum: Does not affect hormonal contraception but use extra barrier method of contraception during treatment and for at least 4 weeks after the last dose in each treatment year. Pregnancy is not recommended for at least 6 months after last treatment course (interferes with DNA synthesis).
Pregnancy: Not safe.
If you conceive while taking this medication: Stop intake until after pregnancy and irradiated blood products should be used during pregnancy.
Breastfeeding: Not safe while taking this drug and for one week after last dose.
Fumarates
Prepartum: May cause GI upset that can affect the absorption of oral contraceptive forms, but by itself does not interact with contraception. Due to limited safety data, switch to alternative treatment if pregnancy is desired.
Pregnancy: Insufficient data, but not recommended.
Breastfeeding: Not safe.
S1P Receptor Modulators
fingolimod, ozanimod, ponesimod, siponimod
Prepartum: Discontinue 2 months before trying to conceive. Rebound disease activity can occur after discontinuing this therapy.
Pregnancy: Not safe.
Breastfeeding: Not safe.
Teriflunomide
Prepartum: If you wish to conceive, stop the drug and undergo an accelerated elimination which will bring drug levels in the body down to a safe level. Otherwise, contraception would be recommended two years after stopping the drug.
Pregnancy: Not safe.
If you conceive while taking this medication: Follow accelerated elimination protocol.
Breastfeeding: Not safe. Some adverse reactions have been reported for infants exposed to teriflunomide through breastmilk, including infections, low blood cell counts, toxicity to the liver.
Symptomatic Treatments
These are medications commonly prescribed to manage symptoms, such as mobility issues, spasticity, and fatigue for which is there is limited safety data in pregnancy and postpartum
Gabapentin
Baclofen
Oxcarbazepine
Modafinil
Prepartum: Discontinue if planning pregnancy.
