Antirheumatic Drugs in Pregnancy and Lactation

The clinical content of preconception care: women with chronic medical conditions

This article reviews the medical conditions that are associated with adverse pregnancy outcomes for women and their offspring. We also present the degree to which specific preconception interventions and treatments can impact the effects of the condition on birth outcomes. Because avoiding, delaying, or achieving optimal timing of a pregnancy is often an important component of the preconception care of women with medical conditions, contraceptive considerations particular to the medical conditions are also presented.

Rituximab administration in third trimester of pregnancy suppresses neonatal B-cell development

We describe the effect on the neonate of administration of rituximab to a woman with idiopathic thrombocytopenic purpura (ITP). Rituximab, an anti-CD20 antibody, was given weekly for 4 weeks to a woman with ITP in her third trimester of pregnancy. One month after the last rituximab administration a healthy girl was born. She had normal growth and development during the first six months. At birth, B-lymphocytes were not detectable. Rituximab levels in mother and neonate were 24000 and 6700 ng/mL, respectively. Only 7 cases of rituximab administration during pregnancy were described. No adverse events are described for fetus and neonate. We demonstrate that rituximab passes the placenta and inhibits neonatal B-lymphocyte development. However, after 6 months B-lymphocyte levels normalized and vaccination titres after 10 months were adequate. No infection-related complications occurred. Rituximab administration during pregnancy appears to be safe for the child but further studies are warranted.

Pregnancy and rheumatic disease: "by the book" or "by the doc"

Pregnancy is an important condition that can affect and be affected by rheumatic disease. Overall, pregnancy is viewed as a Th2-predominant state, but several Th1-related cytokines are vital to early pregnancy. In rheumatoid arthritis for example, the majority of women improve by the beginning of the second trimester, but the majority (90%) will flare in the first 3 to 4 months postpartum. In contrast, systemic lupus erythematosus has an unpredictable course in pregnancy, leaving most rheumatologists to recommend a disease-quiescent state prior to conception. Other diseases such as scleroderma are less clear because the disease less commonly presents in the childbearing period. Many immunosuppressive medications for the rheumatic diseases are contraindicated in pregnancy because of their mechanisms of action leaving only a select few "safe" medications. Significant heterogeneity between the Food and Drug Administration (FDA) category for a medication and what a rheumatologist does in clinic leads to confusion on how a patient should be treated for active rheumatic disease both peripartum and postpartum, particularly if the patient is breastfeeding. We review the general state of pregnancy and how it is affected by prototypical rheumatic diseases including rheumatoid arthritis and systemic lupus erythematosus. In addition, we present the most commonly used disease-modifying antirheumatic drugs and immunosuppressants and explain the difference between the FDA category and clinical practice among rheumatologists. Finally, we provide some general recommendations on how to manage a rheumatic disease during pregnancy including: (a) preconception planning to ensure no teratogenic medications on board, (b) early disclosure of pregnancy to all caregivers including the rheumatologist, family physician, obstetrician, and maternal-fetal medicine specialist, and (c) planning of safe medication use for acute flare-ups and disease suppression peripartum and postpartum.

Management of immune thrombocytopenic purpura in pregnancy

Chronic immune thrombocytopenic purpura (ITP) is an autoimmune disease characterized by a low platelet count and mucocutaneous bleeding. Pregnancy does not increase the incidence of ITP nor does it exacerbate a preexisting disease. Although pregnant women with ITP may experience several maternal and fetal complications, in most cases even with a very low platelet count, there is neither maternal nor fetal morbidity or mortality. Corticosteroids are the first line of therapy in pregnant women; intravenous immune globulin is commonly used in steroid resistant patients. Other treatments such as intravenously administered anti-D (Rhogam) and splenectomy during pregnancy have been reported. Antiplatelet IgG antibodies can cross the placenta and can induce fetal thrombocytopenia. In most women there is no indication to assess fetal platelet counts during the pregnancy. The mode of delivery is determined by obstetrical considerations.

Prescribing of sulfasalazine, azathioprine and methotrexate round pregnancy--a descriptive study

PURPOSE

Continuation or discontinuation of drugs during pregnancy in chronic diseases is an issue of concern. Information on prescribing of disease modifying anti-rheumatic drugs (DMARDs) during pregnancy is scarce. In this study, we report prescribing patterns round pregnancy of sulfasalazine (SSZ), azathioprine (AZA), methotrexate (MTX) and co-medications among women to whom one of these DMARDs were prescribed before pregnancy.

METHODS

The pregnancy-interaction database (IADB.nl, 1994-2004), containing pharmacy dispensing data from Northern- Netherlands, was used. Women to whom SSZ (N = 13), AZA (N = 10) or MTX (N = 6) was prescribed before their first pregnancy were identified and described in detail.

RESULTS

AZA and SSZ are continued during pregnancy by 60% and 38% of the women, respectively, MTX was stopped before pregnancy. Among women receiving SSZ (N = 13) as their initial DMARD, anti-inflammatory and anti-rheumatic drugs (69%) and analgesics (45%) were the most commonly prescribed co-medications. Among women receiving AZA (N = 8) as their initial DMARD, corticosteroids for systemic use (100%) and intestinal anti-inflammatory agents (88%) were the most commonly prescribed co-medications. All women receiving intestinal anti-inflammatory drugs before pregnancy continued this during pregnancy, in contrast to other co-medications which were mainly discontinued.

CONCLUSIONS

Our study showed that DMARDs and co-medication are received before, during and after pregnancy, although no specific prescription patterns were found. Administrative databases, such as the pregnancy-IADB.nl, are useful in describing drug-prescribing patterns for better understanding of drug prescribing around pregnancy in daily practice. Based on these data, we conclude that prescribing of DMARDs and related co-medication is based on the individual patient.

Prevalence of undiagnosed autoimmune rheumatic diseases in the first trimester of pregnancy. Results of a two-steps strategy using a self-administered questionnaire and autoantibody testing

OBJECTIVE

To evaluate the prevalence of undiagnosed rheumatic diseases in the first trimester of pregnancy.

DESIGN

We screened for rheumatic diseases in 1210 consecutive pregnant women during the first trimester of pregnancy using a 10-item questionnaire.

SETTING

A university hospital in northern Italy.

POPULATION

One hundred and thirty-seven (11.3%) women who answered positively to at least one question constituted the cases and were compared with 107 negative controls.

METHODS

Cases and controls were tested for rheumatic autoantibodies (antinuclear antibody, anti-double-stranded DNA, anti-extractable nuclear antigen, anticardiolipin antibody, anti-beta2-glycoprotein I antibodies and lupus anticoagulant) and were evaluated by a rheumatologist for a definite diagnosis of rheumatic disease.

MAIN OUTCOME MEASURES

Prevalence of undiagnosed rheumatic disease in the first trimester of pregnancy.

RESULTS

The overall rate of positivity to the antibodies tested was 43.1% (59/137) among cases and 9.3% (10/107) in the controls (P < 0.001). A definitive diagnosis of rheumatic disease was made in 35 cases (25.5%) and in none of the controls (P <0.001). In stepwise logistic regression analysis, photosensitivity (adjusted OR 5.72; 95% CI 2.38-13.8), erythema or malar rash (adjusted OR 3.91; 95% CI 1.53-10) and history of two or more miscarriages (adjusted OR 5.6; 95% CI 1.55-20.6) were independent predictors of a definitive diagnosis of rheumatic disease (area under receiving operator curve = 0.814; 95% CI 0.76-0.86). Birthweight was lower (3180 g +/- 475 compared with 3340 g +/- 452, P= 0.008), and overall serious pregnancy complications (miscarriage, fetal growth restriction, delivery before 34 weeks of pregnancy and severe pre-eclampsia) were higher among cases (12/137) than controls (2/107) (adjusted OR 5.60; 95% CI 1.29-24.3; P= 0.021).

CONCLUSIONS

A two-step screening process with a self-administered questionnaire proved to be a useful method to screen for undiagnosed rheumatic diseases during the first trimester of pregnancy.

[Chronic inflammatory disorders and reproduction]

The desire of reproduction is a true challenge for the physicians in charge of patients with chronic inflammatory disorders such as rheumatoid arthritis or other connective tissue diseases. It requires: 1) the strict evaluation of the potential risks of flare of the rheumatic disease because of the pregnancy; 2) the assessment of risks on pregnancy outcome and fetus development; 3) the management of the different anti-rheumatic agents in order to maintain optimal control of disease activity and avoid any teratogenic problem. Besides this, it clearly appears that inflammatory rheumatic diseases may have an impact on patients' fertility, which may be explained by different mechanisms, physical, psychological, hormonal or immunological. Moreover, some treatments may directly affect fertility, which may justify specific managements in order to preserve gonadic functions.

Consensus statement on the use of rituximab in patients with rheumatoid arthritis

A large number of experts experienced in the treatment of rheumatoid arthritis were involved in formulating a consensus statement on the use of B cell-targeted treatment with rituximab in patients with rheumatoid arthritis. The statement was supported by data from randomised controlled clinical trials and the substantial literature on oncology. The statement underwent three rounds of discussions until its ultimate formulation. It should guide clinicians in the use of this newly approved biological agent in treating patients with rheumatoid arthritis.

Birth outcome in women treated with azathioprine or mercaptopurine during pregnancy: A Danish nationwide cohort study

BACKGROUND

Data on birth outcome after exposure to azathioprine or mercaptopurine during pregnancy is sparse.

AIM

To examine the risk of adverse birth outcome among newborns of women exposed to azathioprine or mercaptopurine during pregnancy.

METHODS

Data on drug use and births were obtained from Danish population registries. We included 76 exposed pregnancies in 69 women. Of these, we used 64 pregnancies exposed 30 days before conception or during the first trimester to examine the risk of congenital abnormalities, and 65 pregnancies exposed during the entire pregnancy to examine preterm birth and low birth weight at term. Their birth outcomes were compared with outcomes among women who did not fill prescriptions for azathioprine or mercaptopurine during pregnancy.

RESULTS

Azathioprine- or mercaptopurine-exposed women had a higher risk of adverse birth outcomes than unexposed controls. However, when the comparison was limited to newborns of women with the same types of underlying disease, relative risks for spontaneous and induced preterm birth, low birth weight at term, and congenital abnormalities were 1.1 (95% CI: 0.5-2.4), 4.0 (95% CI: 1.5-10.8), 1.7 (95% CI: 0.3-8.7) and 1.1 (95% CI: 0.5-2.9), respectively.

CONCLUSION

Our results suggest that adverse birth outcomes were caused by the underlying disease rather than by use of azathioprine or mercaptopurine.

Systemic lupus erythematosus and pregnancy

Women with systemic lupus erythematosus (SLE) face significant risks when embarking on a pregnancy, but attending a multidisciplinary clinic staffed by an experienced team can improve pregnancy outcome for women and their babies. Pregnancy in SLE should be planned and a management strategy should be agreed in full consultation with the patient, prior to conception. Pregnancy increases the likelihood of a lupus flare. It is not possible to predict when, or if, an individual patient will flare, although flare is more likely if disease has been active within 6 months of conception. Worsening of proteinuria in pregnancy could herald a lupus flare, but the differential diagnosis also includes the physiological response to pregnancy and pre-eclampsia. Corticosteroids, hydroxychloroquine and azathioprine are safe to use in pregnancy, with no adverse fetal effects reported despite many years of experience with their use. Correct identification of patients with antiphospholipid syndrome is important because treatment of affected women during pregnancy can improve fetal and maternal outcome. Neonatal SLE, although rare, carries a significant mortality and morbidity when the fetal heart is the targeted organ. Prophylaxis therapies, including treatment with intravenous immunoglobulin, await larger trials.

Update on the treatment of systemic lupus erythematosus

The improving prognosis in patients with systemic lupus erythematosus is due in no small part to refinements in treatment. One idea is to tailor the treatment to the specific clinical features. For example, the treatment of cutaneous lupus may require antimalarial and topical agents initially, with more severe cases requiring dapsone or even thalidomide. Conversely, renal involvement in systemic lupus erythematosus is better treated with corticosteroids and immunosuppressive agents such as intravenous cyclophosphamide, mycophenolate mofetil or azathioprine. It is very clear that comorbidities such as steroid-induced diabetes mellitus, hypertension and osteonecrosis have been responsible for a great deal of the morbidity associated with systemic lupus erythematosus and must be aggressively managed. In addition to 'traditional' agents, newer medications such as rituximab, abatacept and B-lymphocyte stimulator antagonists are showing great promise and will probably be an an important part of the management of severe lupus in the future.

Thyroid function testing in pregnancy and thyroid disease: trimester-specific reference intervals

During pregnancy the thyroid is hyperstimulated, resulting in changes in thyroid hormone concentrations. Accurate assessment of thyroid function during pregnancy is critical, for both the initiation of thyroid hormone therapy, and for the adjustment of thyroid hormone dose in those already receiving thyroid hormone. Trimester-specific intervals are especially important during pregnancy when thyroid insufficiency may be associated with adverse obstetric outcome and fetal neurodevelopmental deficits. Gestational age-specific reference intervals are now available for thyroid function tests. Knowing the expected normal changes in hormone concentrations throughout pregnancy allows individualized supplementation when necessary.