“We are increasingly more comfortable with the use of disease modifying therapies (DMTs) in and around pregnancy. We still need to vote on our final recommendations regarding pregnancy management. However, overall, there is strong consensus that DMTs should not be discontinued before pregnancy. Instead, we should use those that have been shown to be safe.” Professor Vilija Jokubaitis of Monash University, in Melbourne, distils the key takeaway from the ECTRIMS Focused Workshop 2026.
Family planning is a central aspect of multiple sclerosis (MS) clinical care. Therapeutic inertia should not be an option for women who wish to have children [1.] In fact, DMTs play a crucial role, particularly in women with active disease, by reducing the risk of relapses before, during, and after pregnancy [1.]
“Women should just receive the same treatment approach as men.” Professor Sandra Vukusic, from Claude Bernard University Lyon 1, puts it bluntly: “Nonetheless, what we observe in France – and not only in France – is that often the treatment is initiated later in women than in men, and that treatment switching also occurs later in women than in men. Overall, women are less treated than men and are more likely to receive less effective therapies. We need to change this situation. Change is already happening, but it really needs to take hold. One way to achieve this is to strengthen our knowledge of therapy use in the peri-pregnancy period. This is why ECTRIMS has been actively working on international consensus recommendations.”
Indeed, the goal of the ECTRIMS Focused Workshop 2026, held in Edinburgh last March, was to review the latest evidence and approaches to the clinical management of pregnancy and the peri-pregnancy period in women with MS, neuromyelitis optica spectrum disorder (NMOSD), and MOG antibody-associated disease (MOGAD). The meeting marks an important step in building the foundation for future clinical recommendations.
“The labels of certain DMTs recommend a conservative approach, but observational studies have provided reassuring evidence that will allow us to advise slightly differently regarding their use,” says Professor Jokubaitis.
DMT mismanagement can increase the annualised relapse rate during gestation and postpartum [2.] The highest relapse rate was observed in women who interrupted natalizumab before the second trimester or resumed it more than 3 months after delivery, as well as in those receiving fingolimod [2.] The most effective strategy for mitigating the risk of increased relapses was the use of anti-CD20 therapies prior to pregnancy [2.] In a study of 3,244 pregnancies in women treated with ocrelizumab, no increased risk of adverse pregnancy or infant outcomes was observed following in utero exposure [3.] Another study using data from the MSBase Registry found that among 1,744 women with relapsing-remitting MS or clinically isolated syndrome, treatment with ocrelizumab, rituximab or natalizumab (continued through at least 28 weeks of gestation and resumed within 1 month after delivery) was associated with a lower risk of relapses compared with other treatment approaches [4.]
Prioritising Disease Control
“We need to treat women with the therapy they need for their MS,” Professor Vukusic continues, “The question of pregnancy should only come second. First, I choose the treatment that the patient needs for her disease, and then I adapt it to her pregnancy plans. Delaying treatment after diagnosis or undertreating a woman because of a pregnancy plan can have catastrophic consequences. The problem is that we don’t know how long it will take for them to become pregnant. Sometimes it happens immediately, but most often it takes a year, two years, three years – and during that time the disease progresses. There are more lesions, relapses occur, disability sets in, and suddenly it’s too late. That’s why we must fight against this approach. We now have enough evidence to support the use of a range of treatments during pregnancy, including high-efficacy options.”
Switching Treatment Safely
Professor Vukusic tells us, “Another issue concerns switching treatments. When a patient is not responding well – for example, experiencing relapses or new MRI lesions – the treatment should normally be changed. However, in women with a pregnancy plan, this decision is sometimes delayed. In other cases, women are treated with therapies that are contraindicated for pregnancy, such as sphingosine-1-phosphate (S1P) receptor modulators. When a woman receiving an S1P modulator expresses a desire to become pregnant, neurologists sometimes stop the treatment without initiating an alternative therapy. This is especially problematic with S1P receptor modulators, given the risk of rebound disease activity at around 30% within 3-5 months after discontinuation. Therefore, our recommendations will move towards stopping S1P modulators but switching to another highly effective treatment that is compatible with pregnancy – such as certain monoclonal antibodies or anti-CD20 therapies. In this way, disease control can be maintained, and the pregnancy can proceed with the mother remaining protected, without risk to the foetus.”
Protecting Women with Mild and Severe MS
Relapse rates typically decrease during pregnancy and then increase again during the first 3 months postpartum [5.] This is observed not only in women with low disability scores (EDSS 0-2), but also in those with higher disability levels (EDSS ≥3) [5.] A multicenter retrospective study analysed data from the MSBase Registry involving more than 500 pregnant women with an EDSS score of 3 or higher. The study found that the relapse rate decreased by 75% during the first trimester and subsequently increased by 36% in the first 3 months postpartum [5.] Continuation of DMTs during pregnancy was associated with a reduced risk of relapse [5.]
Professor Jokubaitis comments on these results with us, “Reassuringly, we found that using natalizumab into the third trimester in women with moderate to severe disease effectively prevented relapses during pregnancy. This benefit was comparable to that previously observed in women with milder disease. These findings are particularly encouraging. Using DMTs, women with more severe disease can achieve the same protective effect during pregnancy as those with milder disease.”
Over the past decades, the treatment landscape for MS has evolved rapidly. Given the growing body of evidence confirming safety of several DMTs use before, during, and after pregnancy, regular updated recommendations are crucial. This will help reduce variability among clinicians and ensure optimal treatment during the peri-pregnancy period [6.]
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Written by Stefania de Vito
Special thanks to Prof. Sandra Vukusic (Université Claude Bernard Lyon 1; Hospices Civils de Lyon OFSEP) and to Prof. Vilija Jokubaitis (Monash University, Melbourne) for their insights.
References
[1] Krysko KM et al The Lancet Neurology 2023; 22(4): 350-366.
[2] Gavoille A et al JAMA Neurology 2025; 82(10): 994-1003.
[3] Vukusic S et al Neurology: Neuroimmunology & Neuroinflammation 2024; 12(1): e200349.
[4] Yeh WZ et al Neurology: Neuroimmunology & Neuroinflammation 2024; 11(6): e200328.
[5] Shipley J et al JAMA Network Open 2025; 8(9): e2531581.
[6] Graham EL et al Neurology: Clinical Practice 2024; 14(2): e200253.