Background TNF-inhibitors are not teratogenic and can be given during pregnancy if warranted by active maternal disease (1). In our outpatient clinic arthritis patients who are planning their pregnancy are advised to continue ongoing TNF-inhibitors until a positive pregnancy test. Pregnancy compatible disease modifying drugs (DMARDs) and corticosteroids (CS) are usually continued throughout gestation.
Objectives To analyse the treatment strategy regarding disease activity during pregnancy and pregnancy outcome in our arthritis patients between 2000 and 2014.
Methods 128 pregnant patients of whom 71 had rheumatoid arthritis (RA) and 57 had spondyloarthritis (SpA) were prospectively followed once during the pre-conception phase, once at each trimester and at 6-8 weeks postpartum. Disease activity assessments, CRP and pregnancy outcome data were analyzed regarding the exposure to medication.
Results Out of 128 patients, 32 remained on TNF-inhibitors from 20 weeks pre-conception until the positive pregnancy test (TNFpos) with 21.9% receiving additional DMARDs and 9.4% with additional CS. 96 patients had no TNF-inhibitor during the pre-pregnancy period (TNFneg) while 32.2% of them were treated with DMARDs and 25% with CS.
In RA patients, TNFneg patients showed mild disease activity (median DAS28-CRP ≤3.2) during the pre-pregnancy period until gestation. Among the 12 TNFpos RA patients disease activity was similarly low during the pre-conception period but CRP levels spiked at the 1st trimester resulting in restart of TNF-inhibitors in one or CS in 5 patients. During the 2nd and 3rd trimester disease activity returned to low levels comparable to the levels of the TNFneg RA group. In SpA patients, the 37 TNFneg SpA patients showed an active disease (median ASDAS >2.1) during the pre-conception period whereas disease activity in the 20 TNFpos SpA patients was mild to moderate (median ASDAS <2.1). During the 2nd trimester TNFpos SpA patients experienced a flare of their disease activity leading to similar CRP levels as TNFneg SpA patients and a restart of TNF-inhibitors in 6 or CS in 10 patients. However, increased CRP levels persisted until delivery.
In a separate analysis of patients with new onset of medication during pregnancy, elevated CRP levels of SpA patients did not respond to CS (n=14) whereas the new onset of TNF-inhibitors (n=7) resulted in an improvement of the CRP levels. Elevated CRP levels in RA patients did respond to CS (n=15), while TNF-inhibitors (n=5) disclosed no evident improvement.
Pregnancy outcome data of the 128 pregnancies resulted in 128 live born infants with three sets of twins, one stillbirth and two early abortions. In all patients elevated CRP levels at the 2nd trimester resulted in higher incidence of premature deliveries independent of TNF-inhibitor or CS medication during pregnancy.
Conclusions Attention should be given to the risk of prematurity in case of active disease during pregnancy. Since a rebound in disease activity after the discontinuation of TNF-inhibitors may occur, tailored medication to maintain remission during pregnancy should be considered.
Østensen M, Förger F. How safe are anti-rheumatic drugs during pregnancy? Current opinion in pharmacology. 2013;13(3):470-5. Epub 2013/03/26.
Disclosure of Interest None declared