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Natalizumab in Pregnancy Planning – Rebound Risk — SCE Neurology MCQ

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HardMultiple Sclerosis & CNS InflammationNatalizumab in Pregnancy Planning – Rebound RiskSCE Neurology

A 35-year-old woman with MS is planning pregnancy. She is on natalizumab and is JCV antibody negative. Her MS has been very active before natalizumab (5 relapses in 2 years). She is concerned about stopping natalizumab for pregnancy due to rebound risk. What is the emerging approach?

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Correct answer: C — Extend natalizumab dosing interval to every 6–8 weeks during pregnancy planning and into early pregnancy, with close MRI monitoring — some centres continue natalizumab through the first trimester to reduce rebound risk, then stop with washout

For highly active MS patients on natalizumab with high rebound risk, stopping abruptly before conception risks severe rebound relapses. Emerging practice (supported by observational data and expert consensus) includes: extending the natalizumab dosing interval during pregnancy planning (reducing fetal exposure while maintaining some disease control), continuing through the first trimester in high-risk cases, then stopping. Some centres use IVIg as bridge therapy. The decision requires careful risk-benefit discussion. A: Abrupt cessation risks rebound. C: Full-dose throughout pregnancy has fetal exposure concerns. D: Interferon is less effective in highly active disease. E: Some DMTs can be used with appropriate risk-benefit assessment.

Reference: ABN MS and Pregnancy Guidelines; Portaccio et al. Natalizumab in Pregnancy