Postpartum issues with multiple sclerosis

Abstract

A patient with relapsing-remitting multiple sclerosis (RRMS) elected to pursue pregnancy (see Case 16 and 17). As she was currently prescribed teriflunomide, her medication needed to be halted and eliminated from the bloodstream, as it is contraindicated in pregnancy. As teriflunomide is eliminated slowly from the plasma, an accelerated elimination procedure is required [1]. Without accelerated elimination, an average of 8 months is required to reach the recommended preconceptual plasma level of less than 0.02 mg/L; in some patients, this may take up to 2 years. There are two recommended procedures for accelerated elimination of teriflunomide [2]. Under the first, cholestyramine is administered in a dose of 8 g every 8 hours for 11 days; if this is not well tolerated, a dose of 4 g three times a day may be used. An alternate regimen consists of 50 g of oral activated charcoal powder given every 12 hours for 11 days. After completing accelerated elimination with cholestyramine, the patient’s serum teriflunomide levels were confirmed to be <0.02 mg/L. Contraception was discontinued and she conceived 4 months later.