MANAGING MULTIPLE SCLEROSIS IN PREGNANCY

Managing Multiple Sclerosis (MS) in Pregnancy

How common is this situation- pregnancy in women with MS?

MS is most often diagnosed between the ages of 20 to 40 years. This is the age when most women plan their pregnancies. Therefore, it is very common to find women with MS, who are pregnant or those who are planning pregnancy.

Which is a better option- starting MS treatment and then planning pregnancy or delaying MS treatments until after completing family?

MS is characterized by multiple relapses (when new symptoms occur). With each relapse, the disability increases. These relapses are often more frequent in the initial years after diagnosis of MS. Disease modifying drugs (DMD) can reduce relapses and disability. Therefore, it is always better to start DMD and then plan pregnancy. One should not postpone starting DMD after pregnancy/delivery.

How does pregnancy affect MS?

Pregnancy does not affect MS in the first trimester.

The MS relapses are lesser in 2^nd and 3^rd trimesters, which is good news.

However, the relapses become more frequent in the post partum period (after delivery) and this higher risk persists until 6 months after delivery.

How does MS affect pregnancy?

By and large, there are no adverse effects of MS on pregnancy. Women with MS have no extra risk of miscarriage or birth defects in their babies; as compared to women without MS. The mode of delivery too need not be altered just because the patient has MS.      

MS has no direct effect on fertility. Women with MS may have sexual dysfunction resulting in lesser libido. Male partners who have MS may suffer from erectile dysfunction.  

What MS medications are safe in pregnancy?

No DMD has yet been tested in pregnancy and hence none can be declared safe. However, recent evidence suggests that some DMDs are less risky than others. Less risky DMDs in pregnant women with MS include beta interferons (Avonex, Rebif, Betaseron) and Glatiramer acetate.

For prospective fathers, beta interferon and Glatiramer acetate as DMD showed no risk to baby’s health. Teriflunomide is detected in semen and it should be discontinued before trying to conceive.

Steroids can be safely used to treat MS relapses during pregnancy.

Will babies born to women with MS have a higher risk of getting MS themselves?

Most cases of MS are sporadic and most women with MS do not have a history of MS in their family members. However, having a relative with MS does slightly increase the risk of being diagnosed with MS.

In UK, the lifetime risk of being diagnosed with MS in general population in 1 in 330. The risk increases to 1 in 48, if one of the first degree relatives has MS. If one of the second-degree relatives has MS, the risk of being diagnosed with MS is 1 in 100.

an women with MS breastfeed?

Breastfeeding is safe and can be continued as usual.

What impact does pregnancy have on the course of MS?

There is limited data on this topic. However, in one study, pregnancy and childbirth were associated with lesser chances of developing severe disability. Women who gave birth at any time (either before or after the onset of MS) were 34% less likely to develop severe disability (as defined by need to use walking aid).

(For more reading, Multiple sclerosis Trust, UK)

Dr Sudhir Kumar MD DM
Consultant Neurologist
Apollo Hospitals, Hyderabad
04023607777
drsudhirkumar@yahoo.com

Frequent Coffee Breaks Keep You Healthy Too!

Coffee Breaks Make You Healthier

Coffee drinking is quite popular all across the world. There are many, who have coffee first thing in morning, referred to as bed coffee. Bed coffee is supposed to energize people and get them out of sleepiness. Many others take “coffee breaks” while at work, which relaxes them. Who would have forgotten the student days, when numerous coffee cups kept them awake until late nights just before examinations? Coffee drinking is supposed to increase alertness and concentration. The effects are mainly related to caffeine contained in the coffee.

Health-Related Benefits of Drinking Coffee

1. Lower risk of diabetes: In a Dutch study done on 40,000 people, it was found that drinking at least 3 cups of coffee or tea per day reduced the risk of developing diabetes by 42%. (Diabetologia 2009). The anti-diabetic effects are related to polyphenols found in coffee.

2. Lower risk of coronary heart disease: Moderate habitual coffee consumption (3-4 cups per day) lowers the risk of coronary heart disease, especially in women. (International Journal of Cardiology)

3. Coffee improves headaches and migraine, if taken alone or along with other painkillers.

4. Lower risk of brain stroke: Middle aged people in Japan, who drank 3 or more cups of coffee per day had lower rates of silent brain infarctions (strokes without symptoms, picked up on MRI scan of brain). Lesser brain infarctions would also lead to lesser incidence of dementia. (Journal of Stroke and Cerebrovascular Diseases, 2016)

3 or more cups of coffee intake per day reduced the risk of brain stroke (despite smoking tendency in coffee drinkers). A lower incidence of heart failure, diabetes and hypertension was also observed. (Nutritional Neuroscience, 2015)

5. Reduced risk of Alzheimer’s disease: Alzheimer’s disease is the commonest cause of dementia (memory loss and loss of other higher mental functions) in the world. Based on the meta-analysis of 11 research studies, it was found that higher coffee consumption reduced the risk of Alzheimer’s disease. (Nutrition, 2015)

6. Reduced risk of Parkinson’s disease: Parkinson’s disease is the commonest cause of movement disorder, characterized by tremors, rigidity and slowness of movements. Based on meta-analysis of 26 studies, increased caffeine/coffee consumption was associated with reduced risk of Parkinson’s disease. (Journal of Alzheimer’s Disease, 2010)

7. Reduced risk of multiple sclerosis: Researchers in USA and Sweden have found that drinking at least 900 ml (six cups) of coffee per day has protective effects against multiple sclerosis. Caffeine has neuroprotective properties and suppresses inflammation. (JNNP, 2016)

8. Reduced risk of depression and suicide: A meta-analysis of 11 studies showed a protective effect of coffee against depression. The relationship between coffee intake and depression was linear; for each cup/day increase in coffee intake, the risk of depression reduced by 8%. (Australia NZ Journal of Psychiatry 2016)

In addition, increased coffee consumption was also associated with reduction in incidence of completed suicides. (World Journal of Biol Psychiatry, 2014)

9. Reduced risk of cancer: Various studies have shown that regular coffee consumption is associated with lower risk of cancers. 5 or more cups per day reduced the risk of colorectal cancer (Oncotarget, 2016). Other studies have shown reduced risk of cancers of oral cavity, pancreas, urinary bladder, breast, uterus, and liver among regular coffee drinkers.

10. Lesser incidence of erectile dysfunction: Coffee can provide a boost to sexual health too. Men with coffee intakes of 2-3 cups of coffee/ day reported significantly lesser incidence of erectile dysfunction, as compared to those with no coffee intake or only 1 cup/day. (PLos One, 2015)

11. Lower death rates: Regular intake of coffee can increase longevity and prevent deaths too. Recent research has shown that people drinking 2-5 cups of coffee/day had significantly lower deaths from heart disease, chronic lung diseases, diabetes, pneumonia and influenza, and intentional self-harm. Coffee may reduce mortality risk by favorably affecting inflammation, lung function, insulin sensitivity, and depression. (American Journal of Epidemiology,

Possible Health Hazards of Coffee Drinking

1. Poor control of BP in patients with hypertension:  A recent study showed that older people with hypertension, who consumed 3 or more cups of coffee per day, had higher BP (systolic and diastolic). Coffee drinking, however, does not lead to an increased risk of developing hypertension (in people with normal BP).

2. Increased cholesterol levels: Drinking unfiltered or boiled coffee may cause an increase in the levels of LDL cholesterol and triglycerides.

3. Increased risk of coronary heart disease: Drinking 3 or more cups of Italian-style coffee (espresso or mocha) is associated with increased risk of coronary heart disease. (PLoS One, 2015). This effect was independent of cholesterol levels, as the cholesterol levels did not increase in this study.

4. Sleep problems: Caffeine is a brain stimulant and after consuming it, people feel alert. People sensitive to the stimulant effects of caffeine may not get proper sleep, if they drink coffee close to bedtime. Since, the effect of coffee may last for 5-6 hours, people sensitive to it should avoid coffee after 6 PM.

5. Not recommended for children: Coffee suppresses appetite, and may cause children to eat less. Also, after having coffee, children feel full, and avoid nutritious foods such as milk.

6. Pregnant and nursing women should have coffee in moderation: There is no restriction of coffee in pregnant or nursing mothers. However, they should restrict the coffee intake to 2-3 cups per day.

So, what is the final take home message?

1. Coffee is good for health, and can be safely consumed by adults.

2. For optimum benefits, it should be restricted to 2-5 cups per day.

3. The maximum safe limits for caffeine/coffee intake is 200 mg in one sitting (around 2½ cups of coffee) or 400 mg daily (around 5 cups of coffee). 

4. Coffee (without sugar and milk) has zero calories; and hence, people on strict diet too can freely have coffee.

DR SUDHIR KUMAR MD (Internal Medicine) DM (Neurology)

Senior Consultant Neurologist

Apollo Health City, Jubilee Hills, Hyderabad

Phone: 040-23607777/60601066

Email: drsudhirkumar@yahoo.com

Online Consultation: http://bit.ly/Dr-Sudhir-kumar

MULTIPLE SCLEROSIS

DIAGNOSIS AND TREATMENT OF MULTIPLE SCLEROSIS

1. What is multiple sclerosis?

Multiple sclerosis is a demyelinating disease of central nervous system-CNS (brain and spinal cord), which is characterized by involvement of “multiple” parts of CNS.

The disease is also characterized by remissions (improvement of symptoms) and relapses (occurrence of new symptoms) over a period of time, causing “multiple” episodes of symptoms.  

Multiple sclerosis is an autoimmune disease, which means the antibodies produced in the body attacks own healthy tissues.

2. What is the meaning of demyelination or demyelinating illness?

Nerves in central nervous system are like “electric wires”, that is, they have a central core surrounded by an insulation or covering. This covering of the nerves is called “myelin sheath”.

A disease, where the myelin sheath is affected or damaged is called a demyelinating disease or illness, and the process is called as demyelination. Multiple sclerosis is one of the most common demyelinating diseases of the CNS.

3. Who are the common people affected by multiple sclerosis?

·        Multiple sclerosis is commonly seen between the ages of 10 and 60 years, which means, it is uncommon in children below 10 years and those adults who are above 60 years of age.

·        Multiple sclerosis is typically more common in young women (between the ages of 18-36 years),

·        Multiple sclerosis is seen all over the world, probably more common in the West, as compared to Asian countries.

·        Also, the severity of multiple sclerosis seems to be lesser in Asians, leading to lesser degrees of disability, which has led some people to label Asian multiple sclerosis as relatively “benign form” of multiple sclerosis.

4. What are the common symptoms of multiple sclerosis?

Common symptoms of multiple sclerosis include:

• Sudden onset diminished vision in one or both eyes, which may get worse over a few days,
• Numbness of arm or leg on one or both sides of body,
• Weakness of arm or leg on one or both sides of body,
• Imbalance while walking,
• Bladder symptoms,

Less common symptoms of multiple sclerosis include

·        Memory disturbances,

·        Seizures or fits,

·        Depression

It is important to note that a patient with multiple sclerosis may have only one or more than one symptom described above at one point of time, or different symptoms may occur during multiple episodes of the disease.

5. How is the diagnosis of multiple sclerosis confirmed?

A person who has one or more symptoms suspicious of multiple sclerosis should consult a neurologist. A neurologist would take history and do a clinical examination to ascertain the number of episodes of illness, and also to identify the affected the parts of central nervous system.

After that he would order for investigations to confirm the diagnosis of multiple sclerosis.

6. What are the important investigations for confirming a diagnosis of multiple sclerosis?

• MRI (Magnetic resonance imaging) of brain and spinal cord- this is the most important investigation. MRI shows the involvement of different parts of brain and spinal cord. The white matter of brain and spinal cord are typically affected in multiple sclerosis. The diseased part of brain and spinal cord are also referred to as “lesions” or “plaques”. A new or active lesion shows enhancement on MRI with contrast dye injection. In addition, there may be swelling around the active lesions. MRI is also able to distinguish new versus old lesions, and is useful to monitor the disease progression or improvement and also the effectiveness of treatment.

• CSF (cerebrospinal fluid) analysis- CSF is removed by lumbar puncture (LP) by inserting a needle in lower back. In multiple sclerosis, the CSF protein is elevated; however, the number of white blood cells (WBCs) is either normal or only slightly elevated. CSF sugar is often normal. CSF is also tested for the presence of oligoclonal bands (OCBs), the presence of which indicates an active disease.
• Evoked potential studies may be ordered to look for involvement of optic nerve (visual evoked potential or VEP) or spinal cord (somatosensory evoked potential).
• Blood tests (such as ANA, Anti-dsDNA, ANCA, etc) may be ordered to exclude other diseases that can mimic multiple sclerosis.

7. What are the current treatment options for multiple sclerosis?

Treatment of multiple sclerosis can be divided into two categories- treatment of acute episodes and treatment to prevent future relapses of disease.

Treatment for acute episodes:

Steroid injections are the preferred treatment options. The drug of choice is methylprednisolone given as injections in the veins over 3-5 days. Then, steroid tablets are given for 15-20 days.

Treatment to prevent relapses of disease:

The most preferred treatment is interferon injections (such as avonex, relibeta and rebif in India). Avonex and relibeta are given as injections in the muscles, once a week, whereas rebif is given as injections underneath the skin three times a week.

Other FDA-approved treatment options to prevent relapses of disease in multiple sclerosis are:

1. Glatiramer acetate (copaxone)- given as injection underneath the skin, once a day.

2. Fingolimod- oral capsule (0.5 mg) once daily

3. Mitoxantrone- given as infusion in the vein, every three months (maximum 8-12 doses over two-three years),

4. Natalizumab (tysabri)- given as infusion in the vein, once every four weeks.

5. Dimethyl fumerate (tecfidera)- twice a day oral capsules.

6. Teriflunomide (Aubagio)- once daily tablets. 

 8. Is Multiple sclerosis curable?

As of today, there is no cure for multiple sclerosis. However, with current treatments, the disease can be kept under control and new relapses can be prevented.

9. Is multiple sclerosis always disabling?

Multiple sclerosis does cause disability in a significant number of people. However, more than two-thirds of patients suffering from multiple sclerosis are independent for their activities of daily living and are gainfully employed in a job. The good outcome depends on proper treatment as well as physical & occupational therapies.

10. Is multile sclerosis contagious or genetic?

Multiple sclerosis is not contagious and does not get transmitted from one affected person to another.

There may be genetic predisposition to get multiple sclerosis but it is not a genetic disease in a strict sense, as most patients with multiple sclerosis do not give a positive family history.

11. Is multiple sclerosis fatal or lethal?

In more than 95% of patients with multiple sclerosis, it does not lead to death. However, in a minority (less than 3%) it may lead to death either due to the direct effect of the severe disease or another complication such as pneumonia or deep vein thrombosis.

I hope this article is useful for hundreds of patients with multiple sclerosis as well as their caregivers. In addition, if someone is looking for information on multiple sclerosis (MS), it should be useful.

For any additional information, please email me at drsudhirkumar@yahoo.com

DR SUDHIR KUMAR MD (Internal Medicine), DM (Neurology)

Senior Consultant Neurologist

Apollo Hospitals, Hyderabad, India

Phone: 0091-40-23607777/60601066

drsudhirkumar@yahoo.com