Use of belimumab throughout pregnancy to treat active systemic lupus erythematosus—A case report

https://doi.org/10.1016/j.semarthrit.2014.05.006Get rights and content

Abstract

Background

Pregnancy can lead to flares in systemic lupus erythematosus (SLE), and the presence of SLE in pregnancy could lead to a poor outcome for the mother and the fetus.

Objective

To describe a patient whose active SLE (including lupus nephritis) was managed with the use of belimumab throughout pregnancy.

Methods

A case report and review of relevant literature is presented.

Results

A 38-year-old Caucasian woman with SLE was seen for advice regarding planning a pregnancy and management of her active lupus (cutaneous lupus, angioedema, lupus nephritis, leukopenia, and anti-phospholipid antibody syndrome) that could only be controlled by mycophenolate, a drug contraindicated in pregnancy. Azathioprine, hydroxychloroquine, rituximab, and moderate doses of prednisone were either unable to control her disease or led to unacceptable toxicity. After detailed discussions, she was treated with belimumab, which controlled her SLE and allowed withdrawal of mycophenolate. Belimumab was continued throughout the pregnancy, leading to well-controlled SLE and uneventful course, albeit with the presence of mild Ebstein׳s anomaly in the baby.

Conclusion

To our knowledge, this is the first case report of belimumab use throughout pregnancy for controlling active SLE. Data from the belimumab pregnancy registry would be useful to confirm our findings and to further assess safety of this agent for use in pregnancy.

Introduction

Systemic lupus erythematosus (SLE) is an autoantibody-mediated systemic autoimmune disease that occurs more frequently in women of childbearing age compared to men (F:M ratio of 7:1) [1]. Pregnancy can be challenging to manage in patients with SLE for various reasons, including impact of pregnancy on the disease activity, effect of SLE on maternal and fetal health, the varied presentation of SLE during pregnancy, and the limited treatment options. Here we describe a patient with lupus nephritis who was successfully managed with belimumab throughout pregnancy. As far as we know, this is the first report of an uneventful pregnancy in a patient with lupus nephritis treated with belimumab throughout pregnancy.

Section snippets

Objective

To describe a patient with active SLE (including lupus nephritis) who was successfully managed with the use of belimumab throughout pregnancy.

Methods

A case report and review of relevant literature is presented.

Case report

A 38-year-old Caucasian woman with SLE was seen with her husband for advice regarding planning a pregnancy and management of lupus during pregnancy. She was diagnosed to have SLE at the age of 27 years based on biopsy-proven discoid lupus erythematosus, polyarticular arthralgia, angioedema, leukopenia (lymphopenia as well as neutropenia), thrombocytopenia, positive ANA (1:2560) in homogenous pattern, positive dsDNA (>200 IU/ml), SSA antibody, antigranulocyte antibodies, and low complements. The

Lupus management during pregnancy

After a year on belimumab, she became pregnant. Being a high-risk pregnancy, she was closely followed up by specialists in maternal–fetal medicine, rheumatology, and hematology. Warfarin was switched to a low-molecular-weight heparin, enoxaparin. SLE was treated with low-dose prednisone (2.5 mg daily), hydroxychloroquine 400 mg daily, and belimumab 10 mg/kg monthly infusions. Since patients with lupus nephritis are at high risk of preeclampsia, preterm delivery, and worsening nephritis, it was

Delivery and postpartum course

The patient delivered by cesarean section at term, after the failure of external cephalic version that attempted for breech presentation. The female baby was 19-in long and weighed 5 lb 15 oz and was found to have normal APGAR scores at birth. However, the baby had mild Ebstein׳s anomaly (mild displacement of tricuspid valve with mild to moderate regurgitation) on ECHO preformed at day 1 of her life. EKG did not show any heart blocks or signs of pre-excitation.

At the serial follow-up

Discussion

We describe the first case of belimumab use throughout pregnancy in a patient with difficult-to-control SLE. Our patient had very limited treatment choices left to control her persistently active SLE, and none of the choices were suitable for use in pregnancy. After a careful assessment and counseling, we embarked on belimumab therapy, as the benefits of the treating her SLE outweighed the risks to the fetus.

There are no human clinical studies available evaluating the use of belimumab in

References (14)

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