- •3 (42%) patients suffered rebound after fingolimod cessation for pregnancy planning.
- •Pregnancy failed to halt such exaggerated inflammatory activity.
- •New-borns were delivered healthy despite using steroids throughout pregnancy.
- •Lymphocyte count <300/ul was related to reappearance of activity disease.
Rebound of multiple sclerosis (MS) activity has been described after the withdrawal of high-efficacy drugs, but its impact during pregnancy is less known. We describe a series of cases of rebound syndrome after the cessation of fingolimod due to pregnancy planning.
The clinical and radiological data of 7 MS patients who discontinued fingolimod therapy between May 2012 and March 2018 to plan a pregnancy was analysed.
Three (42.8%) of the 7 patients experienced a rebound effect, all of whom became pregnant. During pregnancy, the 3 patients had a mean (SD) of 5.3 (1.3) relapses, and 13 of the 15 relapses were treated with intravenous steroids and/or immunoglobulin. These patients experienced a median increase of 3 points in the Expanded Disability Status Scale (range, 2–4), as well as a median increase of 27 new gadolinium-enhancing lesions (range, 9–40) and 38 new T2 lesions in a post-partum MRI (range, 21–70). The 3 pregnancies resulted in the delivery of healthy babies. A strong correlation was found between the lymphocyte count at fingolimod onset and the annual relapse rate in the period without therapy (r= -0.84, p = 0.005). The time to first relapse was shorter in patients who had <300/μl lymphocytes at fingolimod onset (median time 46 vs 426 days, p = 0.010).
Rebound activity after fingolimod suspension represents a severe long-lasting inflammatory syndrome that may affect up to 40% of female MS patient who discontinue therapy due to pregnancy planning. Lymphopenia (<300/μl) in the first 3 months of fingolimod onset may predispose patients to suffer earlier and higher disease activity upon cessation.
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Published online: October 29, 2019
Accepted: October 27, 2019
Received in revised form: October 3, 2019
Received: July 15, 2019
© 2019 Elsevier B.V. All rights reserved.