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Martínez López JA, García Vivar ML, Cáliz R, Freire M, Galindo M, Hernández MV, López Longo FJ, Martínez Taboada V, Pego Reigosa JM, Rubio E, Trujillo E, Vela-Casasempere P. Recommendations for the evaluation and management of patients with rheumatic autoimmune and inflammatory diseases during the reproductive age, pregnancy, postpartum and breastfeeding. ACTA ACUST UNITED AC 2016; 13:264-281. [PMID: 27321859 DOI: 10.1016/j.reuma.2016.05.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 05/02/2016] [Accepted: 05/07/2016] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To develop recommendations on the evaluation and management of patients with rheumatic autoimmune and inflammatory diseases during the reproductive age, pregnancy, post-partum and breastfeeding based on the best evidence and experience. METHODS Recommendations were generated using nominal group and Delphi techniques. An expert panel of 12 rheumatologists was established. A systematic literature review and a narrative review (websites, clinical guidelines and other relevant documentation) were performed and presented to the panel in its 1st meeting to be discussed and to help define recommendations. A first draft of recommendations was generated and circulated for comments and wording refinement. A national survey analyzing different aspects of this topic was undertaken separately, followed by a Delphi process (2 rounds). Agreement with each recommendation was ranked on a scale of 1 (total disagreement) to 10 (total agreement), and was considered to be achieved if at least 70% voted≥7. The level of evidence and grade of recommendation were assessed using the Oxford Centre for Evidence-based Medicine Levels of Evidence. RESULTS A total of 14 recommendations were generated for the preconception period (oral and hormonal contraception, reproductive techniques), pregnancy (planning, treatment and follow-up), and breastfeeding (treatment and follow-up). High-risk situations such as lupus or antiphospholipid syndrome were included. A consensus>90% was reached for all but one recommendation. CONCLUSIONS These recommendations are intended to provide rheumatologists, patients, families and other stakeholders with a consensus on the evaluation and management of patients with autoimmune and inflammatory diseases during the reproductive age, pregnancy, postpartum and breastfeeding.
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Affiliation(s)
| | - M Luz García Vivar
- Servicio de Reumatología, Hospital Universitario Basurto, Bilbao, España
| | - Rafael Cáliz
- Unidad de Gestión de Reumatología, Complejo Hospitalario Universitario de Granada, Granada, España
| | - Mercedes Freire
- Servicio de Reumatología, Complexo hospitalario Universitario A Coruña (CHUAC), A Coruña, España
| | - María Galindo
- Servicio de Reumatología, Hospital Universitario 12 de Octubre, Madrid, España
| | | | | | - Víctor Martínez Taboada
- Servicio de Reumatología, Hospital Universitario Marqués de Valdecilla, Santander, España; Facultad de Medicina, Universidad de Cantabria, Santander, España
| | - Jose María Pego Reigosa
- Servicio de Reumatología, Hospital Meixoeiro-Complexo Hospitalario Universitario de Vigo, Vigo, España
| | - Esteban Rubio
- Servicio de Reumatología, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - Elisa Trujillo
- Servicio de Reumatología, Hospital Universitario de Canarias, Santa Cruz de Tenerife, España
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Sheibani S, Cohen R, Kane S, Dubinsky M, Church JA, Mahadevan U. The Effect of Maternal Peripartum Anti-TNFα Use on Infant Immune Response. Dig Dis Sci 2016; 61:1622-7. [PMID: 26725061 DOI: 10.1007/s10620-015-3992-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 12/08/2015] [Indexed: 01/11/2023]
Abstract
BACKGROUND Infliximab (IFX) and adalimumab (ADA) cross the placenta in the third trimester and can be detectable in infants for up to 12 months. AIM The aim of this study was to determine whether in utero IFX or ADA exposure results in an impaired immune response in infants, as measured by immunoglobulin levels and antibody responses to routine primary immunizations. METHODS Infants who were exposed to in utero anti-TNFα agents were prospectively evaluated. Immunoglobulin levels (IgG, IgM, IgA) and antibodies to standard vaccinations, including tetanus toxoid (tetanus) and Haemophilus influenza type b (Hib), were measured in infants of at least 6 months of age. RESULTS Twelve infants were prospectively studied: 10 exposed to in utero IFX and 2 exposed to ADA with at least one dose administered in the third trimester. Immunoglobulin levels were available on 10/12 patients, with all showing adequate immunoglobulin levels, except for low IgM levels in 5 (50 %) infants. Adequate responses to both the tetanus and Hib vaccines were seen in 11 of 12 (92 %) infants. CONCLUSIONS Infants exposed to anti-TNFα agents in utero demonstrate appropriate response to two commonly administered neonatal vaccines and show adequate immunoglobulin levels, except for IgM. Newborns with a history of exposure to anti-TNFα agents should follow a standard vaccination schedule for inactive vaccines.
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Affiliation(s)
- Sarah Sheibani
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA.
- Division of Gastroenterology, University of Southern California, Keck School of Medicine, 1520 San Pablo Street, Suite 1000, Los Angeles, CA, 90033-5312, USA.
| | - Russell Cohen
- Division of Gastroenterology, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Sunanda Kane
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Marla Dubinsky
- Division of Gastroenterology, Department of Medicine, Mt. Sinai Medical Center, New York, NY, USA
| | - Joseph A Church
- Division of Clinical Immunology and Allergy, Department of Pediatrics, Children's Hospital Los Angeles and Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Uma Mahadevan
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
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Carlucci JG, Halasa N, Creech CB, Dulek DE, Gómez-Duarte OG, Nelson GE, Talbot HK, Scalise ML, Scott PL, Mahadevan U, Beaulieu DB. Vertical Transmission of Histoplasmosis Associated With Anti-Tumor Necrosis Factor Therapy. J Pediatric Infect Dis Soc 2016; 5:e9-e12. [PMID: 27012275 PMCID: PMC6280983 DOI: 10.1093/jpids/piw001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Accepted: 01/05/2016] [Indexed: 01/17/2023]
Abstract
Therapeutics blocking the activity of tumor necrosis factor (anti-TNF) are a risk factor for invasive fungal infections; however, infectious risks to infants born to mothers receiving anti-TNF therapy are not well defined. We report a case of vertical transmission of disseminated histoplasmosis in a mother-infant pair exposed to anti-TNF therapy.
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Affiliation(s)
- James G Carlucci
- Division of Pediatric Infectious Diseases, Department of Pediatrics
| | - Natasha Halasa
- Division of Pediatric Infectious Diseases, Department of Pediatrics
| | - C Buddy Creech
- Division of Pediatric Infectious Diseases, Department of Pediatrics
| | - Daniel E Dulek
- Division of Pediatric Infectious Diseases, Department of Pediatrics
| | | | | | | | | | | | - Uma Mahadevan
- Division of Gastroenterology, Department of Medicine, UCSF Medical Center, San Francisco, California
| | - Dawn B Beaulieu
- Division of Gastroenterology, Department of Medicine, Vanderbilt University School of Medicine
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Pregnancy and the Patient with Inflammatory Bowel Disease: Fertility, Treatment, Delivery, and Complications. Gastroenterol Clin North Am 2016; 45:285-301. [PMID: 27261899 DOI: 10.1016/j.gtc.2016.02.006] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
For many women with inflammatory bowel disease (IBD), the illness coincides with their childbearing years. IBD increases the risk of pregnancy complications and adverse pregnancy outcomes. The multidisciplinary care team should emphasize the importance of medication adherence to achieve preconception disease control and maintain corticosteroid-free remission throughout pregnancy. Medication adjustments to reduce fetal exposure may be considered on an individualized basis in quiescent disease; however, any benefits of such adjustments remain theoretic and there is risk of worsening disease activity. Mode of delivery is determined by obstetric indications, except for women with active perianal disease who should consider cesarean delivery.
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Kiely CJ, Subramaniam K, Platten J, Pavli P. Safe and effective: anti-tumour necrosis factor therapy use in pregnant patients with Crohn disease and ulcerative colitis. Intern Med J 2016; 46:616-9. [DOI: 10.1111/imj.13057] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Revised: 02/17/2016] [Accepted: 02/17/2016] [Indexed: 11/29/2022]
Affiliation(s)
- C. J. Kiely
- Gastroenterology and Hepatology Unit; Canberra Hospital; Canberra Australian Capital Territory Australia
- ANU Medical School; Australian National University; Canberra Australian Capital Territory Australia
| | - K. Subramaniam
- Gastroenterology and Hepatology Unit; Canberra Hospital; Canberra Australian Capital Territory Australia
| | - J. Platten
- Gastroenterology and Hepatology Unit; Canberra Hospital; Canberra Australian Capital Territory Australia
| | - P. Pavli
- Gastroenterology and Hepatology Unit; Canberra Hospital; Canberra Australian Capital Territory Australia
- ANU Medical School; Australian National University; Canberra Australian Capital Territory Australia
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Porter C, Armstrong-Fisher S, Kopotsha T, Smith B, Baker T, Kevorkian L, Nesbitt A. Certolizumab pegol does not bind the neonatal Fc receptor (FcRn): Consequences for FcRn-mediated in vitro transcytosis and ex vivo human placental transfer. J Reprod Immunol 2016; 116:7-12. [PMID: 27123565 DOI: 10.1016/j.jri.2016.04.284] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 03/13/2016] [Accepted: 04/05/2016] [Indexed: 02/06/2023]
Abstract
Antibodies to tumor necrosis factor (anti-TNF) are used to treat inflammatory diseases, which often affect women of childbearing age. The active transfer of these antibodies across the placenta by binding of the Fc-region to the neonatal Fc receptor (FcRn) may result in adverse fetal or neonatal effects. In contrast to other anti-TNFs, certolizumab pegol lacks an Fc-region. The objective of this study was to determine whether the structure of certolizumab pegol limits active placental transfer. Binding affinities of certolizumab pegol, infliximab, adalimumab and etanercept to human FcRn and FcRn-mediated transcytosis were determined using in vitro assays. Human placentas were perfused ex vivo to measure transfer of certolizumab pegol and positive control anti-D IgG from the maternal to fetal circulation. FcRn binding affinity (KD) was 132nM, 225nM and 1500nM for infliximab, adalimumab and etanercept, respectively. There was no measurable certolizumab pegol binding affinity, similar to that of the negative control. FcRn-mediated transcytosis across a cell layer (mean±SD; n=3) was 249.6±25.0 (infliximab), 159.0±20.2 (adalimumab) and 81.3±13.1ng/mL (etanercept). Certolizumab pegol transcytosis (3.2±3.4ng/mL) was less than the negative control antibody (5.9±4.6ng/mL). No measurable transfer of certolizumab pegol from the maternal to the fetal circulation was observed in 5 out of 6 placentas that demonstrated positive-control IgG transport in the ex vivo perfusion model. Together these results support the hypothesis that the unique structure of certolizumab pegol limits its transfer through the placenta to the fetus and may be responsible for previously reported differences in transfer of other anti-TNFs from mother to fetus.
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Affiliation(s)
- Charlene Porter
- Department of Immunopathology, NHS Grampian, Aberdeen Royal Hospital Trust, Aberdeen, UK.
| | - Sylvia Armstrong-Fisher
- Academic Transfusion Medicine Unit, University of Aberdeen, Aberdeen, UK; Scottish National Blood Transfusion Service, Aberdeen, UK.
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Cantini F, Niccoli L, Nannini C, Cassarà E, Kaloudi O, Giulio Favalli E, Becciolini A, Biggioggero M, Benucci M, Li Gobbi F, Grossi V, Infantino M, Meacci F, Manfredi M, Guiducci S, Bellando-Randone S, Matucci-Cerinic M, Foti R, Di Gangi M, Mosca M, Tani C, Palmieri F, Goletti D. Tailored first-line biologic therapy in patients with rheumatoid arthritis, spondyloarthritis, and psoriatic arthritis. Semin Arthritis Rheum 2016; 45:519-32. [DOI: 10.1016/j.semarthrit.2015.10.001] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 10/07/2015] [Accepted: 10/07/2015] [Indexed: 02/08/2023]
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Gaidos JKJ, Kane SV. Overcoming challenges of treating inflammatory bowel disease in pregnancy. Expert Rev Clin Immunol 2016; 12:871-8. [PMID: 26981845 DOI: 10.1586/1744666x.2016.1166958] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Inflammatory bowel disease (IBD) is frequently diagnosed before or during the peak reproductive years. Overall management of inflammatory bowel disease is becoming more complex given the nuances involved with multiple mechanisms of action of the current treatment and need for therapeutic monitoring for safety and efficacy; another layer of complexity is added in the setting of a pregnancy. In this review, we have identified several key challenges that health care providers face when caring for patients with IBD during pregnancy. The goal of this review is to provide the most up-to-date evidence and provide our expert recommendations so that providers can more comfortably address patients' questions about pregnancy in IBD and the associated risks as well as optimize their care to ensure the best outcomes possible.
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Affiliation(s)
- Jill K J Gaidos
- a McGuire VA Medical Center , Virginia Commonwealth University , Richmond , VA , USA
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59
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Nguyen GC, Seow CH, Maxwell C, Huang V, Leung Y, Jones J, Leontiadis GI, Tse F, Mahadevan U, van der Woude CJ. The Toronto Consensus Statements for the Management of Inflammatory Bowel Disease in Pregnancy. Gastroenterology 2016; 150:734-757.e1. [PMID: 26688268 DOI: 10.1053/j.gastro.2015.12.003] [Citation(s) in RCA: 314] [Impact Index Per Article: 39.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS The management of inflammatory bowel disease (IBD) poses a particular challenge during pregnancy because the health of both the mother and the fetus must be considered. METHODS A systematic literature search identified studies on the management of IBD during pregnancy. The quality of evidence and strength of recommendations were rated using the Grading of Recommendation Assessment, Development and Evaluation (GRADE) approach. RESULTS Consensus was reached on 29 of the 30 recommendations considered. Preconception counseling and access to specialist care are paramount in optimizing disease management. In general, women on 5-ASA, thiopurine, or anti-tumor necrosis factor (TNF) monotherapy for maintenance should continue therapy throughout pregnancy. Discontinuation of anti-TNF therapy or switching from combination therapy to monotherapy may be considered in very select low-risk patients. Women who have a mild to moderate disease flare while on optimized 5-ASA or thiopurine therapy should be managed with systemic corticosteroid or anti-TNF therapy, and those with a corticosteroid-resistant flare should start anti-TNF therapy. Endoscopy or urgent surgery should not be delayed during pregnancy if indicated. Decisions regarding cesarean delivery should be based on obstetric considerations and not the diagnosis of IBD alone, with the exception of women with active perianal Crohn's disease. With the exception of methotrexate, the use of medications for IBD should not influence the decision to breast-feed and vice versa. Live vaccinations are not recommended within the first 6 months of life in the offspring of women who were on anti-TNF therapy during pregnancy. CONCLUSIONS Optimal management of IBD before and during pregnancy is essential to achieving favorable maternal and neonatal outcomes.
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Affiliation(s)
- Geoffrey C Nguyen
- Mount Sinai Hospital Centre for Inflammatory Bowel Disease, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
| | - Cynthia H Seow
- Departments of Medicine & Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Cynthia Maxwell
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada
| | - Vivian Huang
- Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Yvette Leung
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
| | - Jennifer Jones
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | | | - Frances Tse
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Uma Mahadevan
- Department of Medicine, University of California, San Francisco, San Francisco, California
| | - C Janneke van der Woude
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
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Abstract
Research regarding fertility, medication safety, and pregnancy outcomes is increasing, but there are still many knowledge gaps in these areas. Women with ulcerative colitis and Crohn's disease may have decreased fertility because of voluntary childlessness and inflammatory bowel disease (IBD) surgery, and women with Crohn's disease may also have decreased ovarian reserve. Initial studies show that in vitro fertilization is a viable option, and laparoscopic ileoanal pouch anastomosis surgery improves fertility rates. Additional research is needed on the effect of disease activity on fertility and on the rates of pregnancy loss and ectopic pregnancies. We do not know how to reliably measure disease activity during pregnancy or the effect of pregnancy on the microbiome. Although immunomodulators and anti-tumor necrosis factor medications are relatively safe during pregnancy, the long-term effects of these medications on the child are unknown. The recommended mode of delivery is still debated, especially for women after ileoanal pouch anastomosis. There are multiple studies on the relative safety of immunomodulators and anti-tumor necrosis factor medications during pregnancy, and we know how to safely treat a pregnant patient with a disease flare. The best way to manage women with IBD who are pregnant or contemplating pregnancy is a multidisciplinary approach. Team members often include a gastroenterologist, a high-risk obstetrician, an infertility specialist, a colorectal surgeon, and a pediatrician with experience in caring for children of mothers with IBD. By integrating expertise from these disciplines, women with even very complex IBD should be able to have a healthy pregnancy and delivery.
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61
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Shand AW, Chen JS, Selby W, Solomon M, Roberts CL. Inflammatory bowel disease in pregnancy: a population-based study of prevalence and pregnancy outcomes. BJOG 2016; 123:1862-70. [DOI: 10.1111/1471-0528.13946] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2016] [Indexed: 02/06/2023]
Affiliation(s)
- AW Shand
- Clinical and Population Perinatal Health Research; Kolling Institute; University of Sydney; Sydney NSW Australia
- Department of Maternal Fetal Medicine; Royal Hospital for Women; Randwick NSW Australia
| | - JS Chen
- Clinical and Population Perinatal Health Research; Kolling Institute; University of Sydney; Sydney NSW Australia
| | - W Selby
- AW Morrow Gastroenterology and Liver Centre; Royal Prince Alfred Hospital; Camperdown NSW Australia
- Faculty of Medicine; Central Clinical School; University of Sydney; Sydney NSW Australia
| | - M Solomon
- SOuRCe (Surgical Outcomes Research Centre); The Institute of Academic Surgery; Royal Prince Alfred Hospital; University of Sydney; Camperdown Sydney NSW Australia
| | - CL Roberts
- Clinical and Population Perinatal Health Research; Kolling Institute; University of Sydney; Sydney NSW Australia
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Huang V, Fedorak R. A 29-year-old woman with Crohn disease considering pregnancy. CMAJ 2016; 188:131-132. [PMID: 26438019 DOI: 10.1503/cmaj.150640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Vivian Huang
- Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, Alta.
| | - Richard Fedorak
- Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, Alta
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Abstract
Immunomodulators and biologic medications, alone or in combination, form the core therapeutic strategy for managing moderate-to-severe inflammatory bowel disease (IBD). IBD incidence peaks during the prime reproductive years, raising concerns about the impact of disease and its treatment on fertility, maternal and fetal health during pregnancy, breastfeeding safety, and childhood development. Although IBD increases risk of pregnancy complications independent of disease activity, adverse pregnancy outcomes are more common when disease is active. To mitigate fetal risk, women should conceive while disease is quiescent. Aside from methotrexate, immunomodulators and biologics may be used during pregnancy to achieve and maintain disease control. Based on available safety data, there is no increased risk of congenital anomalies among infants exposed to these medications. Active thiopurine metabolites and most monoclonal antibodies cross the placenta and are detectable in neonates. They are detectable in breast milk in minute levels as well. The impact of this exposure on neonatal outcomes is discussed. Adjusted dosing schedules during gestation may reduce fetal drug exposure, though the maternal risks of such manipulation require careful consideration. Ongoing prospective studies will further inform risk assessment, including for newer medications such as the anti-integrin agents.
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Management of Inflammatory Bowel Disease during Pregnancy and Breastfeeding Varies Widely: A Need for Further Education. Can J Gastroenterol Hepatol 2016; 2016:6193275. [PMID: 27725926 PMCID: PMC5048030 DOI: 10.1155/2016/6193275] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2015] [Accepted: 08/25/2016] [Indexed: 12/16/2022] Open
Abstract
Background. Inflammatory bowel disease (IBD) affects patients in their young reproductive years. Women with IBD require maintenance therapies during pregnancy and breastfeeding. However, physician management of IBD during pregnancy and breastfeeding has not been well characterized. Objective. To characterize physician perceptions and management of IBD during pregnancy and breastfeeding. Methods. A cross-sectional survey of Canadian physicians who are involved in the care of women with IBD was conducted. The survey included multiple-choice and Likert scale questions about perceptions and practice patterns regarding the management of IBD during pregnancy and breastfeeding. Results. 183 practicing physicians completed the questionnaire: 97/183 (53.0%) gastroenterologists; 75/183 (41.0%) general practitioners; and 11/183 (6.0%) other physicians. Almost half (87/183, 47.5%) of the physicians felt comfortable managing pregnant IBD patients. For specified IBD medications, proportions of physicians who indicated they would continue them during pregnancy were as follows: sulfasalazine, 47.4%; oral mesalamine, 67.0%; topical mesalamine, 70.3%; oral prednisone, 68.0%; topical prednisone, 78.0%; oral budesonide, 61.6%; topical budesonide, 75.0%; ciprofloxacin, 15.3%; metronidazole, 31.4%; azathioprine, 57.1%; methotrexate, 2.8%; infliximab, 55.6%; adalimumab, 78.1%. Similar proportions of physicians would continue these medications during breastfeeding. A higher proportion of gastroenterologists than nongastroenterologists indicated appropriate use of these IBD medications during pregnancy and breastfeeding. Conclusions. Physician management of IBD during pregnancy and breastfeeding varies widely. Relative to other physicians, responses of gastroenterologists more frequently reflected best practices pertaining to medications for control of IBD during pregnancy and breastfeeding. There is a need for further education regarding the management of IBD during pregnancy and breastfeeding.
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65
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Grouin A, Brochard C, Siproudhis L, Leveque J, Bretagne JF, Poulain P, Bouguen G. Perianal Crohn's disease results in fewer pregnancies but is not exacerbated by vaginal delivery. Dig Liver Dis 2015; 47:1021-6. [PMID: 26342947 DOI: 10.1016/j.dld.2015.08.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Revised: 07/30/2015] [Accepted: 08/03/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Despite a high prevalence of Crohn's disease in women of childbearing age, disease-related factors that may impact fertility and perianal Crohn's disease after delivery remain unclear. METHODS Self-administered questionnaires related to childbirth were completed by women with Crohn's disease referred to a single gastroenterology unit. A survival analysis was performed for statistical purposes. RESULTS A total of 184 patients were assessed, including 63 nulliparous women. The cumulative probabilities of having a child were 30%, 51% and 72% at the ages of 25, 30 and 35 years, respectively. Women with colonic disease, prior abdominal surgery and perianal disease were less likely to experience childbirth. After a median follow-up of 165 weeks post-delivery, the cumulative probabilities of fistulizing perianal Crohn's disease occurrence were 8%, 12% and 21% at 1, 2 and 5 years following childbirth, respectively. Contrary to a prior history of perianal Crohn's disease and colonic location, mode of delivery was not associated with perianal fistula. An episiotomy in the group of women with prior anal lesions did not result in a higher rate of fistula recurrence. CONCLUSION Perianal Crohn's disease is associated with fewer pregnancies, however perianal fistulas were less affected by obstetric events than their own natural history.
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Affiliation(s)
- Amélie Grouin
- Department of Gynaecology & Obstetrics, University Hospital of Rennes, France; University of Rennes 1, Rennes, France
| | - Charlène Brochard
- Gastroenterology Unit, University Hospital of Pontchaillou, University of Rennes 1, Rennes, France; INSERM U991, University of Rennes 1, Rennes, France
| | - Laurent Siproudhis
- Gastroenterology Unit, University Hospital of Pontchaillou, University of Rennes 1, Rennes, France; INSERM U991, University of Rennes 1, Rennes, France
| | - Jean Leveque
- Department of Gynaecology & Obstetrics, University Hospital of Rennes, France; University of Rennes 1, Rennes, France
| | - Jean-François Bretagne
- Gastroenterology Unit, University Hospital of Pontchaillou, University of Rennes 1, Rennes, France
| | - Patrice Poulain
- Department of Gynaecology & Obstetrics, University Hospital of Rennes, France; University of Rennes 1, Rennes, France
| | - Guillaume Bouguen
- Gastroenterology Unit, University Hospital of Pontchaillou, University of Rennes 1, Rennes, France; INSERM U991, University of Rennes 1, Rennes, France.
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Clowse ME, Wolf DC, Förger F, Cush JJ, Golembesky A, Shaughnessy L, De Cuyper D, Mahadevan U. Pregnancy Outcomes in Subjects Exposed to Certolizumab Pegol. J Rheumatol 2015; 42:2270-8. [DOI: 10.3899/jrheum.140189] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/13/2015] [Indexed: 02/08/2023]
Abstract
Objective.To provide information on pregnancy outcomes in women receiving certolizumab pegol (CZP).Methods.The UCB Pharma safety database was searched for pregnancies through to September 1, 2014. Reports for maternal and paternal CZP exposure were included and outcomes examined, and data on CZP exposure, pregnancy, comorbidities, and infant events were extracted by 2 independent reviewers. Concomitant medications and disease activity were reviewed for clinical trial patients.Results.Of 625 reported pregnancies, 372 (59.5%) had known outcomes. Paternal exposure pregnancies (n = 33) reported 27 live births, 4 miscarriages, 1 induced abortion, and 1 stillbirth. Maternal exposure pregnancies (n = 339) reported 254 live births, 52 miscarriages, 32 induced abortions, and 1 stillbirth. Almost all reported pregnancies had exposure to CZP in the first trimester, when organogenesis takes place, and a third of them continued the drug into the second and/or third trimesters. The most frequent indications for maternal CZP use were Crohn disease (192/339) and rheumatic diseases (118/339). Twelve cases of congenital malformation and a single neonatal death were reported.Conclusion.Analysis of pregnancy outcomes after exposure to CZP supports previous reports, suggesting a lack of harmful effect of maternal CZP exposure on pregnancy outcomes. However, additional data from a larger number of outcomes after exposure and studies including an unexposed comparison group are required to fully evaluate CZP safety and tolerability in pregnancy.
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67
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Beery RMM, Kane SV. Management of Crohn's disease in pregnancy. Br J Hosp Med (Lond) 2015; 76:455-63. [PMID: 26255915 DOI: 10.12968/hmed.2015.76.8.455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Crohn's disease is a chronic inflammatory bowel disease commonly diagnosed during the reproductive years. Disease management involves advocating conception during periods of stable clinical remission and continuing safe medications throughout pregnancy to achieve optimal maternal and fetal outcomes.
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Affiliation(s)
- Renée M Marchioni Beery
- Advanced Fellow in Inflammatory Bowel Disease in the Department of Medicine, Division of Gastroenterology, Hepatology and Endoscopy at Brigham and Women's Hospital, Boston, Massachusetts 02115, USA
| | - Sunanda V Kane
- Professor of Medicine in the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, United States
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Cordero-Coma M, Sobrin L. Anti-tumor necrosis factor-α therapy in uveitis. Surv Ophthalmol 2015; 60:575-89. [PMID: 26164735 DOI: 10.1016/j.survophthal.2015.06.004] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Revised: 06/14/2015] [Accepted: 06/15/2015] [Indexed: 12/14/2022]
Abstract
Since the first reported use in 2001 of an anti-tumor necrosis factor-alpha (TNF-α) agent, infliximab, for the treatment of uveitis, several new anti-TNF-α agents have emerged for the treatment of refractory noninfectious uveitides, although their use remains off-label in the US. These agents have demonstrated remarkable clinical antiinflammatory efficacy and a potential immunoregulatory role in selected uveitis patients, but it is currently unclear whether they can modify the natural history of disease. We review the rationale and clinical indications for this therapy, the differences between agents, how to manage dosing and intervals, and how to screen for and identify potential side effects. We also present a summary of the science behind the use of anti-TNF-α agents in ocular inflammation and the evidence for their efficacy.
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Affiliation(s)
- Miguel Cordero-Coma
- Head of the Uveitis Unit, Department of Ophthalmology, University Hospital of León, León, Spain; Instituto Biomedicina (IBIOMED), University of León, León, Spain.
| | - Lucia Sobrin
- Uveitis and Retina Services, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA; Associate Professor of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
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Khan N, Asim H, Lichtenstein GR. Safety of anti-TNF therapy in inflammatory bowel disease during pregnancy. Expert Opin Drug Saf 2015; 13:1699-708. [PMID: 25406728 DOI: 10.1517/14740338.2014.973399] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION The highest incidence of inflammatory bowel disease (IBD) is seen between the second and fourth decades of life, which is the most fertile age for women. Increased disease activity has been shown to effect female fertility and pregnancy outcomes, stressing the need for drugs that can safely induce and maintain clinical remission without harming either the mother or fetus. AREAS COVERED Anti-TNF-α agents have been shown to be effective in both inducing and maintaining remission among IBD patients. This review highlights the results of previous studies conducted on pregnant women who were exposed to anti-TNF-α agents during the course of their pregnancy. The drugs reviewed include infliximab (IFX), adalimumab (ADA), certolizumab pegol (CZP) and golimumab (GMB). Of > 200 articles reviewed, 105 were included in the manuscript based on relevance. The keywords used were anti-TNF, infliximab, adalimumab, certolizumab, golimumab, biologics, pregnancy and inflammatory bowel disease. EXPERT OPINION Anti-TNF agents have been studied extensively during pregnancy from the early case reports to the more recent prospective Pregnancy in IBD and Neonatal Outcomes study. A comprehensive review of the literature has shown that biologics can be safely used during pregnancy. In view of this safety data, it is recommended to maintain therapy during pregnancy.
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Affiliation(s)
- Nabeel Khan
- University of Pennsylvania Perelman School of Medicine, Department of Gastroenterology , Philadelphia, PA , USA
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Mosli MH, Al-Harbi O, Feagan BG, Almadi MA. A Saudi Gastroenterology association position statement on the use of tumor necrosis factor-alfa antagonists for the treatment of inflammatory bowel disease. Saudi J Gastroenterol 2015; 21:185-97. [PMID: 26228361 PMCID: PMC4542416 DOI: 10.4103/1319-3767.161635] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Accepted: 04/29/2015] [Indexed: 12/16/2022] Open
Abstract
The objective of this position statement from the Saudi Gastroenterology Association is to guide gastroenterologists on the use of tumor necrosis factor-alfa (TNF-α) antagonists for the treatment of the idiopathic inflammatory bowel diseases, Crohn's disease, and ulcerative colitis. In this article, we summarize the relevant literature regarding the safety and efficacy of TNF-α antagonists, highlight relevant safety concerns specific to the environment in Saudi Arabia, and provide specific recommendations for the use of these agents.
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Affiliation(s)
- Mahmoud H. Mosli
- Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
- Department of Medicine, University of Western Ontario, London, Ontario, Canada
| | - Othman Al-Harbi
- Department of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Brian G. Feagan
- Department of Medicine, University of Western Ontario, London, Ontario, Canada
| | - Majid A. Almadi
- Department of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
- Division of Gastroenterology, The McGill University Health Center, Montreal General Hospital, McGill University, Montreal, Canada
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71
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Randall CW, Vizuete JA, Martinez N, Alvarez JJ, Garapati KV, Malakouti M, Taboada CM. From historical perspectives to modern therapy: a review of current and future biological treatments for Crohn's disease. Therap Adv Gastroenterol 2015; 8:143-59. [PMID: 25949527 PMCID: PMC4416294 DOI: 10.1177/1756283x15576462] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Crohn's disease (CD) is a debilitating, systemic inflammatory disorder with both gastrointestinal and extraintestinal manifestations. Its existence predates modern medicine, but its precise etiology remains incompletely understood. Most authorities suggest a multifactorial pathogenesis owing to a mixture of genetic disorders, immunologic dysregulation, microbiota disequilibrium and environmental influences. Of these factors, the overactive immunologic response seen in CD appears to be the most promising target of medical therapy. Biological agents comprise a relatively new class of drugs that can induce and maintain remission in moderate to severe CD, as well as in ulcerative colitis. This review will provide an overview of CD, its history, clinical features, pathophysiology, and treatment options focusing on current and future biological agents with an emphasis on drug development, dosage and administration.
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Affiliation(s)
| | - John A Vizuete
- University of Texas Health Science Center - San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229, USA
| | - Nicholas Martinez
- University of Texas Health Science Center - San Antonio, San Antonio, TX, USA
| | - John J Alvarez
- University of Texas Health Science Center - San Antonio, San Antonio, TX, USA
| | - Karthik V Garapati
- University of Texas Health Science Center - San Antonio, San Antonio, TX, USA
| | - Mazyar Malakouti
- University of Texas Health Science Center - San Antonio, San Antonio, TX, USA
| | - Carlo M Taboada
- Gastroenterology Research of San Antonio, San Antonio, TX, USA
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72
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Hoffman MB, Farhangian M, Feldman SR. Psoriasis during pregnancy: characteristics and important management recommendations. Expert Rev Clin Immunol 2015; 11:709-20. [DOI: 10.1586/1744666x.2015.1037742] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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73
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Hendy P, Chadwick G, Hart A. Republished curriculum based clinical review: IBD: reproductive health, pregnancy and lactation. Postgrad Med J 2015; 91:230-5. [DOI: 10.1136/postgradmedj-2014-100430rep] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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74
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Objective structured clinical examination as a novel tool in inflammatory bowel disease fellowship education. Inflamm Bowel Dis 2015; 21:759-65. [PMID: 25633560 DOI: 10.1097/mib.0000000000000317] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Experiential learning in medical education, as exemplified by objective structured clinical examinations (OSCEs), is a well-validated approach for improving trainee performance. Furthermore, the Accreditation Council for Graduate Medical Education has identified OSCEs as an ideal method for assessing the core competency of interpersonal and communication skills. Here, we describe a novel educational tool, the inflammatory bowel disease OSCE (IBD OSCE), to assess and improve this clinical skill set in Gastroenterology fellows. METHODS We developed a 4-station IBD OSCE that assessed shared decision making, physician-physician communication, and physician-patient consultative skills specifically related to the care of patients with IBD. Each station was videotaped and observed live by faculty gastroenterologists. Behaviorally anchored checklists were scored independently by a faculty observer and the standardized patient/physician, who both provided feedback to the fellow immediately after each case. Post-OSCE, fellows attended a debriefing session on patient communication and were surveyed to assess their perspective on the examination's educational value. RESULTS Twelve second-year gastroenterology fellows from 5 fellowship programs participated in the IBD OSCE. Fellows performed well in all measured domains and rated the experience highly for its educational value. Fellows cited IBD as an area of relative deficiency in their education compared with other knowledge areas within gastroenterology. CONCLUSIONS To our knowledge, this is the first OSCE designed specifically for the evaluation of skills as they relate to IBD management. Using OSCEs for IBD education provides an opportunity to robustly assess core competencies and the role of the physician as an educator.
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Mode of childbirth and long-term outcomes in women with inflammatory bowel diseases. Dig Dis Sci 2015; 60:471-7. [PMID: 25213079 PMCID: PMC4304947 DOI: 10.1007/s10620-014-3353-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Accepted: 09/01/2014] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Inflammatory bowel diseases [IBD; Crohn's disease (CD), ulcerative colitis] often affect women in their reproductive years. Few studies have analyzed the impact of mode of childbirth on long-term IBD outcomes. METHODS We used a multi-institutional IBD cohort to identify all women in the reproductive age-group with a diagnosis of IBD prior to pregnancy. We identified the occurrence of a new diagnosis code for perianal complications, IBD-related hospitalization and surgery, and initiation of medical therapy after either a vaginal delivery or caesarean section (CS). Cox proportional hazards models adjusting for potential confounders were used to estimate independent effect of mode of childbirth on IBD outcomes. RESULTS Our cohort included 360 women with IBD (161 CS). Women in the CS group were likely to be older and more likely to have complicated disease behavior prior to pregnancy. During follow-up, there was no difference in the likelihood of IBD-related surgery (multivariate hazard ratio 1.75, 95 % confidence interval (CI) 0.40-7.75), IBD-related hospitalization (HR 1.39), initiation of immunomodulator therapy (HR 1.45), or anti-TNF therapy (HR 1.11). Among the 133 CD pregnancies with no prior perianal disease, we found no excess risk of subsequent new diagnosis perianal fistulae with vaginal delivery compared to CS (HR 0.19, 95 % CI 0.04-1.05). CONCLUSIONS Mode of delivery did not influence natural history of IBD. In our cohort, vaginal delivery was not associated with increased risk of subsequent perianal disease in women with CD.
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76
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Hendy P, Chadwick G, Hart A. IBD: reproductive health, pregnancy and lactation. Frontline Gastroenterol 2015; 6:38-43. [PMID: 28839793 PMCID: PMC5369556 DOI: 10.1136/flgastro-2014-100430] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Revised: 03/26/2014] [Accepted: 04/01/2014] [Indexed: 02/04/2023] Open
Abstract
The peak incidence of inflammatory bowel diseases (IBD) occurs during the child-bearing years, and so questions about fertility, pregnancy and breast feeding are often asked by patients. It is known that patients with IBD receive twice as much information about pregnancy-related issues from gastroenterologists as from any other source (including the internet). Therefore, the role of the gastroenterologist in correctly educating patients to avoid misconceptions is paramount, and this should be done proactively prior to planning pregnancy so that the patient's health and medications can be optimised. A clear understanding of medication safety during pregnancy and lactation will improve clinical management.
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Affiliation(s)
- Philip Hendy
- Gastroenterology SPRs, St Mark's Hospital, Harrow, UK
| | | | - Ailsa Hart
- Gastroenterology, St Mark's Hospital, Harrow, UK
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78
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Pagnini C, Arseneau KO, Cominelli F. Safety considerations when using anti-TNFα therapy to treat Crohn's disease. Expert Opin Drug Saf 2014; 14:31-44. [PMID: 25400161 DOI: 10.1517/14740338.2015.976610] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Over the past decade, the introduction of a new class of anti-TNFα drugs has dramatically changed the approach taken to the management of Crohn's disease (CD). An increasing number of patients are receiving treatment with these advanced biological therapies, and the risk of adverse events that may be associated with their use must be carefully evaluated. AREAS COVERED Safety data about the three anti-TNFα drugs currently approved for use in CD patients (infliximab, adalimumab, and certolizumab pegol) is critically evaluated, including data coming from randomized clinical trials and post-marketing reports. Possible side effects of anti-TNFα agents are presented as drug-, class- and disease-specific adverse events. Management strategies to minimize the occurrence of side effects are summarized. EXPERT OPINION The safety profile of the three anti-TNFα drugs approved for clinical use in CD patients appears to be comparable among drugs. Data from clinical trials and a growing body of information from post-marketing surveillance indicate that anti-TNFα agents are generally safe, and that most of the observed side effects are mild and easily manageable. Nonetheless, serious short- and long-term adverse events may occur. Accurate selection of patients, careful pre-treatment evaluation, and regular follow-up during therapy could potentially reduce the rate of adverse events related to the use of anti-TNFα drugs.
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Affiliation(s)
- Cristiano Pagnini
- "Sapienza" University of Rome, S. Andrea Hospital, Faculty of Medicine and Psychology , Rome , Italy
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Kobayashi I, Mori M, Yamaguchi KI, Ito S, Iwata N, Masunaga K, Shimojo N, Ariga T, Okada K, Takei S. Pediatric Rheumatology Association of Japan recommendation for vaccination in pediatric rheumatic diseases. Mod Rheumatol 2014; 25:335-43. [DOI: 10.3109/14397595.2014.969916] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Ruiz V, Manubens E, Puig L. Psoriasis In Pregnancy: A Review (II). ACTAS DERMO-SIFILIOGRAFICAS 2014. [DOI: 10.1016/j.adengl.2014.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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81
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Deepak P, Stobaugh DJ. Maternal and foetal adverse events with tumour necrosis factor-alpha inhibitors in inflammatory bowel disease. Aliment Pharmacol Ther 2014; 40:1035-43. [PMID: 25164260 DOI: 10.1111/apt.12936] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Revised: 01/30/2014] [Accepted: 08/07/2014] [Indexed: 12/17/2022]
Abstract
BACKGROUND Transplacental transfer of tumour necrosis factor-alpha (TNF-α) inhibitors has been shown in mothers receiving therapy for inflammatory bowel disease (IBD). AIM To examine reports of adverse events of these medications in pregnancy. METHODS Individual Safety Reports of adverse events (Jan 2003-June 2012) were accessed from the Food and Drug Administration Adverse Event Reporting System. The study data set was constructed by searching for cases with an indication for medication usage of IBD. The data set was then queried for key terms indicating pregnancy, followed by elimination of cases with potentially teratogenic exposures (FDA category X concomitant medications) as well exposures to study medications through partner or if the medications were discontinued prior to pregnancy. Logistic regression analysis was performed to detect signals for maternal/foetal adverse events with TNF-α inhibitors and/or thiopurines (compared to aminosalicylates). RESULTS A total of 1097 individual Safety Reports in pregnant IBD patients were identified with the majority reported among patients receiving TNF-α inhibitor monotherapy (783 cases, 71.4%). Thiopurine monotherapy (OR 2.55, CI 0.95-6.88) and in combination with TNF-α inhibitors (OR 0.97, CI 0.49-1.93) were not associated with increased odds of maternal/foetal adverse events. Decreased odds for maternal/foetal adverse events were seen with TNF-α inhibitor monotherapy (overall) and specifically with certolizumab monotherapy (OR 0.11, CI 0.05-0.23). CONCLUSIONS In this analysis of adverse events from the Food and Drug Administration Adverse Event Reporting System, use of thiopurine monotherapy or in combination with TNF-α inhibitors was not associated with an increase in maternal/foetal adverse events. Certolizumab monotherapy was associated with a decrease in maternal/foetal adverse events.
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Affiliation(s)
- P Deepak
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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82
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Schulze H, Esters P, Dignass A. Review article: the management of Crohn's disease and ulcerative colitis during pregnancy and lactation. Aliment Pharmacol Ther 2014; 40:991-1008. [PMID: 25200000 DOI: 10.1111/apt.12949] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2014] [Revised: 02/24/2014] [Accepted: 08/14/2014] [Indexed: 12/14/2022]
Abstract
BACKGROUND Inflammatory bowel diseases (IBD) commonly affect young patients in the reproductive phase of their lives. The chronic and relapsing nature of IBD and the potential need for medical or surgical interventions raise concerns about family planning issues. AIM To review the current knowledge on IBD management in pregnant and nursing IBD patients. METHODS A PubMed literature search was performed using the search terms 'reproduction' and 'inflammatory bowel disease' and using the headers and main subjects of each section of this article as search terms. RESULTS Male and female fertility are not impaired in the majority of IBD patients. In IBD patients with quiescent disease pregnancy outcomes are not impaired in comparison to the general population, however, an increased incidence of pregnancy complications is observed in active IBD patients. As methotrexate (MTX) has been demonstrated to be teratogenic, the use of MTX is contraindicated in patients, who wish to conceive, throughout pregnancy and when nursing. However, normal pregnancies following MTX treatment at conception and later have been reported. Most of the other currently approved IBD medications are not associated with adverse pregnancy outcomes and may be used to maintain quiescent disease or to induce a rapid remission in patients with flares and active disease. Breast-feeding in IBD patients is possible and recommended. CONCLUSIONS The overall outcome of pregnancies in IBD patients is favourable and not different to healthy controls, thus patients with IBD should not be discouraged from having children.
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Affiliation(s)
- H Schulze
- Department of Medicine I - Gastroenterology, Hepatology, Oncology and Nutrition, Agaplesion Markus Hospital, Goethe University, Frankfurt, Germany
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83
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Khan N, Asim H, Lichtenstein GR. Safety of anti-TNF therapy in inflammatory bowel disease during pregnancy. Expert Opin Drug Saf 2014. [DOI: 10.1517/14740338.2015.973399] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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84
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Management of the pregnant inflammatory bowel disease patient on anti-tumour necrosis factor: state of the art and future directions. Can J Gastroenterol Hepatol 2014; 28:505-9. [PMID: 25101334 PMCID: PMC4205908 DOI: 10.1155/2014/967598] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Antitumour necrosis factor (anti-TNF) therapy has been a major advance in the treatment of inflammatory bowel disease (IBD) by improving rates of mucosal healing, steroid-free remission, and decreasing rates of hospitalization and surgery. Because IBD affects women in their reproductive years, clinicians have and will continue to be asked in the future about the safety profile of these agents and their potential impact on pregnancy, the developing fetus and newborn. Immunoglobulin G transfer from the mother to fetus begins in the second trimester, with an elevation starting at 22 weeks of gestation and the largest amount transferred in the third trimester. Although research investigating the long-term outcomes of children exposed to anti-TNF therapy in utero is limited, there is no known adverse effect on either pregnancy or newborn outcomes including infectious complications with this class of drugs. The World Congress of Gastroenterology consensus statement on biological therapy for IBD considered infliximab and adalimumab to be low risk and compatible with use during conception and during pregnancy in at least the first two trimesters. Based on a clinical algorithm used at the University of Calgary Pregnancy and IBD clinic (Calgary, Alberta), recommendations have been provided on the management of pregnant patients on anti-TNF therapy, particularly with regard to third-trimester dosing, taking into account disease characteristics of individual patients. When educated about the safety of anti-TNF therapy during pregnancy, patients often choose to continue on therapy during the third trimester.
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85
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Anti-TNFα therapies are safe during pregnancy in women with inflammatory bowel disease: a systematic review and meta-analysis. Inflamm Bowel Dis 2014; 20:1862-9. [PMID: 24983985 DOI: 10.1097/mib.0000000000000092] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The use of TNFα antagonists is well described for inflammatory bowel disease (IBD), but their safety profile during pregnancy is yet to be fully elucidated. A systematic review and meta-analysis were performed to identify studies that explored the safety of anti-TNFα therapy during pregnancy in patients with IBD. METHODS A systematic literature search was conducted to identify studies that investigated the pregnancy outcomes among women with IBD on anti-TNFα therapy. The primary outcome was the overall rate of unfavourable pregnancy-related outcomes among women with IBD on anti-TNFα therapy. Secondary outcomes included rates of abortions (spontaneous or elective), preterm delivery, low birth weight, and congenital malformations. Odds ratios (OR) with 95% confidence interval (CI) are reported. Eligible studies used an observational or interventional design, enrolled subjects with IBD on anti-TNFα therapy for at least 1 trimester and compared outcomes with appropriately matched controls. RESULTS Overall, 5 studies with a total of 1216 participants were eligible for inclusion in the meta-analysis. There was no significant difference in the rates of total unfavourable pregnancy outcomes between pregnant women with IBD who were on anti-TNFα therapy and controls not on anti-TNFα therapy (OR, 1.00 [95% CI, 0.72-1.41]). Similarly, there were no statistically significant differences in the rates of abortion (OR, 1.53 [95% CI, 0.97-2.41]), preterm birth (OR, 1.00 [95% CI, 0.62-1.62]), low birth weight (OR, 1.05 [95% CI, 0.62-1.78]), or congenital malformation (OR, 1.10 [95% CI, 0.58-2.09]). CONCLUSIONS The use of anti-TNFα therapy does not seem to increase the risk of unfavorable pregnancy outcomes among women with IBD, although the optimal timing of therapy through pregnancy and the postpartum period was not assessed in this analysis. These data can help counsel patients around family planning and perinatal management.
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86
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Chaparro M, Gisbert JP. How safe is infliximab therapy during pregnancy and lactation in inflammatory bowel disease? Expert Opin Drug Saf 2014; 13:1749-62. [DOI: 10.1517/14740338.2014.959489] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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87
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Juverdeanu RG, Alegre C. [Anti-tumoral necrosis factor-α medications and pregnancy]. Med Clin (Barc) 2014; 143:236. [PMID: 24529880 DOI: 10.1016/j.medcli.2013.10.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Revised: 10/16/2013] [Accepted: 10/17/2013] [Indexed: 02/07/2023]
Affiliation(s)
| | - Cayetano Alegre
- Unitat de Reumatologia, Hospital Universitari Vall d́Hebron, Barcelona, España
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88
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Matz H. Biologics in the Treatment of Skin Diseases During Pregnancy and Lactation. CURRENT DERMATOLOGY REPORTS 2014. [DOI: 10.1007/s13671-014-0085-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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89
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Abstract
Biologic therapies, including anti-tumor necrosis factor antibody therapy and anti-integrin antibodies, are currently approved for the treatment of and are increasingly being used in patients with moderate to severe inflammatory bowel disease, including Crohn disease and ulcerative colitis. Because patients who require these medications are often in their child-bearing years, knowledge of the safety of these medications before and after pregnancy is imperative. This article summarizes the available data regarding the use of biologic therapy during and after pregnancy, highlighting such issues as safety for mother and newborn, length of medication use during pregnancy, and breastfeeding after pregnancy while on biologic therapy.
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Affiliation(s)
- Sara Horst
- Vanderbilt University Medical Center, 1211 21st Avenue, South 220 Medical Arts Building, Nashville, TN 37232, USA
| | - Sunanda Kane
- Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
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90
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Yiu ZZN, Griffiths CEM, Warren RB. Safety of biological therapies for psoriasis: effects on reproductive potential and outcomes in male and female patients. Br J Dermatol 2014; 171:485-91. [PMID: 24749725 DOI: 10.1111/bjd.13060] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2014] [Indexed: 02/06/2023]
Abstract
The effects of biological therapies for psoriasis on pregnancy outcomes and lactation, and male fertility and mutagenicity are common concerns in the clinical setting. There is relatively little evidence to guide the clinician and patient. Here, we review the safety profile of the commonly used biological therapies for psoriasis in individuals of reproductive potential. Safety data were derived from large-scale registries, adverse event reporting databases, clinical trials and case reports. We assessed the effect of each therapy on adverse pregnancy outcomes including congenital malformations, and lactation with maternal administration, and male fertility and potential mutagenicity with paternal administration. We provide applicable guidance to inform clinician and patient before and after conception.
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Affiliation(s)
- Z Z N Yiu
- The Dermatology Centre, Salford Royal NHS Foundation Trust, University of Manchester, Manchester Academic Health Science Centre, Manchester, M6 8HD, U.K
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Seirafi M, de Vroey B, Amiot A, Seksik P, Roblin X, Allez M, Peyrin-Biroulet L, Marteau P, Cadiot G, Laharie D, Boureille A, De Vos M, Savoye G, Rahier JF, Carbonnel F, Bonaz B, Colombel JF, Bouhnik Y. Factors associated with pregnancy outcome in anti-TNF treated women with inflammatory bowel disease. Aliment Pharmacol Ther 2014; 40:363-73. [PMID: 24980270 DOI: 10.1111/apt.12833] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Revised: 12/11/2013] [Accepted: 05/21/2014] [Indexed: 12/20/2022]
Abstract
BACKGROUND The safety of anti-tumour necrosis factor (TNF) agents during pregnancy is a major concern for child-bearing women and physicians. AIM To assess the impact of anti-TNF therapy on adverse pregnancy and foetal outcomes in women with inflammatory bowel disease (IBD). METHODS Pregnancies occurring during anti-TNF treatment or less than 3 months after its cessation in IBD patients followed in GETAID centres were recorded from January 2009 to December 2010. Ninety-nine pregnancies in women without anti-TNF treatment were identified from the CESAME registry. We compared pregnancy and neonatal outcomes by a case-control study. RESULTS In the 124 IBD patients followed, 133 pregnancies were reported. At the conception time, 23% of patients had active disease. Eighty-eight per cent (n = 117) of the 133 pregnancies followed until delivery resulted in 118 liveborns (one twin pregnancy). Complications were observed in 47 (35%) women and 24 (20%) newborns. In multivariate analysis, factors associated with pregnancy complications were: current smoking (P = 0.004), a B2 (stenotic) phenotype in CD women (P = 0.004), occurrence of a flare during pregnancy (P = 0.006) and a past history of complicated pregnancy (P = 0.007). Current smoking was the only factor associated with severe (i.e. potentially lethal) pregnancy complications (P = 0.02). Having IBD for more than 10 years prior to conception was associated with newborn complications (P = 0.007). No difference was found with the control group for any of the pregnancy and neonatal outcomes. CONCLUSION In our series, the safety profile of anti-TNF therapy during pregnancy and the neonatal period appears similar to control group of IBD women not treated with anti-TNF therapy.
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Affiliation(s)
- M Seirafi
- Beaujon University Hospital Paris VII University, Clichy, France; Geneva University Hospital, Geneva, Switzerland
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92
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Palomba S, Sereni G, Falbo A, Beltrami M, Lombardini S, Boni MC, Fornaciari G, Sassatelli R, La Sala GB. Inflammatory bowel diseases and human reproduction: a comprehensive evidence-based review. World J Gastroenterol 2014; 20:7123-36. [PMID: 24966584 PMCID: PMC4064059 DOI: 10.3748/wjg.v20.i23.7123] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Revised: 02/13/2014] [Accepted: 02/26/2014] [Indexed: 02/06/2023] Open
Abstract
To evaluate the effects of inflammatory bowel diseases (IBDs) on human reproduction, we reviewed the current literature using a systematic search for published studies (articles and/or abstracts) without limits for English language. We searched on Medline (through PubMed), the Institute for Scientific Information, the Web of Science and the websites for the registration of controlled trials (http://controlled-trials.com/). Bibliographies of retrieved articles, books, expert opinion review articles and reviewed bibliographies from subject experts were manually searched. Titles and abstracts were screened initially, and potential relevant articles were identified and reviewed. Whenever possible, data were analyzed by comparing IBD patients vs healthy controls, and patients with active IBDs vs those with disease in remission. The effects of IBDs on female fertility, fertility in infertile couples, pregnancy and male infertility were examined separately. Patients with IBDs in remission have normal fertility. At the moment, there is no established guideline for the preservation of fertility in women with IBD undergoing surgery. Further data are needed regarding guidelines for the management of these patients. Data regarding IBDs and infertility are currently completely lacking. Considering the prevalence of intestinal pathology in young adults of childbearing age, this field is of great scientific and clinical interest, opening up important future perspectives. Another important and as yet unexplored point is the response to treatments for infertility in patients with IBDs. In particular, the question is whether the reproductive outcomes (clinical and biological) can be influenced by the IBD of one of the partners. The goals for successful reproductive outcomes in IBD population are correct counseling and disease remission. IBDs significantly affect several reproductive aspects of human (female, male, couple) reproduction. Further data are needed to develop guidelines for the clinical management of subjects of reproductive age with IBDs.
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93
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Pediatric UC drug development: a GREAT idea now needs a GRAND conversation. J Pediatr Gastroenterol Nutr 2014; 58:677-8. [PMID: 24625967 DOI: 10.1097/mpg.0000000000000367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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94
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Huang VW, Habal FM. From conception to delivery: managing the pregnant inflammatory bowel disease patient. World J Gastroenterol 2014; 20:3495-506. [PMID: 24707132 PMCID: PMC3974516 DOI: 10.3748/wjg.v20.i13.3495] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Revised: 01/12/2014] [Accepted: 02/26/2014] [Indexed: 02/06/2023] Open
Abstract
Inflammatory bowel disease (IBD) typically affects patients during their adolescent and young adult years. As these are the reproductive years, patients and physicians often have concerns regarding the interaction between IBD, medications and surgery used to treat IBD, and reproduction, pregnancy outcomes, and neonatal outcomes. Studies have shown a lack of knowledge among both patients and physicians regarding reproductive issues in IBD. As the literature is constantly expanding regarding these very issues, with this review, we provide a comprehensive, updated overview of the literature on the management of the IBD patient from conception to delivery, and provide action tips to help guide the clinician in the management of the IBD patient during pregnancy.
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95
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Chakravarty E, Clowse MEB, Pushparajah DS, Mertens S, Gordon C. Family planning and pregnancy issues for women with systemic inflammatory diseases: patient and physician perspectives. BMJ Open 2014; 4:e004081. [PMID: 24500612 PMCID: PMC3918989 DOI: 10.1136/bmjopen-2013-004081] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES To identify family planning and pregnancy (FPP) issues for female patients of childbearing age living with a chronic inflammatory disease and to assess whether current clinical practice routinely provides adequate support to alleviate these concerns. SETTING Multinational survey and an analysis of online patient activity. PARTICIPANTS Premenopausal women (aged 20-45 years; N=969) were surveyed in the USA, the UK, Germany, France, Italy and Spain. Rheumatologists were surveyed in Germany (N=50), France (N=50), Italy (N=50) and the USA (N=100), and gastroenterologists were also surveyed in the USA (N=100). PRIMARY AND SECONDARY OUTCOME MEASURES Two online surveys were undertaken to identify FPP issues for physicians and patients. The surveys examined the frequency of dialogue on these topics between physicians and patients, alongside assessment of patient satisfaction regarding these conversations. Online analysis identified key themes for patient discussion outside their doctors' office/clinic/surgery. RESULTS 32-56% of physicians spontaneously reported having talked about FPP with their female patients of childbearing age. When prompted, the majority of rheumatologists (74-92%) and gastroenterologists (74%) reported having discussed conception/pregnancy with female patients; however, less than half reported consulting their patient's treating general practitioner/gynaecologist about these topics. The majority of patients reported their FPP-related concerns are not adequately addressed/settled during their medical appointments. Furthermore, only 30-40% of patients considered advice/information to be consistent across multiple healthcare professionals. Key online FPP-related patient discussions included disease state, adverse effects, treatment, switch behaviour and wash-out requirements. CONCLUSIONS Female patients who live with chronic inflammatory disease have important FPP concerns. The majority of patients, however, do not feel that their FPP concerns are adequately addressed in current clinical practice and report that they receive inconsistent advice from the various healthcare professionals who manage different aspects of their care. There is a clear need for provision of up-to-date and consistent information/support to female patients.
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Affiliation(s)
| | | | | | | | - Caroline Gordon
- School of Immunity and Infection, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
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96
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Abstract
IBD often affects patients during their peak reproductive years. Several drugs are available for the treatment of IBD and new drugs are continuously in the pipeline. As long-term administration of medications is often necessary, the safety of drug therapy during pregnancy and breast-feeding needs to be considered in daily clinical practice. The aim of this Review is to summarize the latest information concerning the safety of medications used to treat IBD during pregnancy and lactation, as well as their effect on fertility. Although only thalidomide and methotrexate are absolutely contraindicated during pregnancy and breast-feeding, alternatives to ciprofloxacin, natalizumab and sodium phosphate should also be considered for pregnant women. Breast-feeding is also discouraged while on treatment with ciclosporin, metronidazole and ciprofloxacin. However, therapy with 5-aminosalicylic acid preparations, glucocorticoids, thiopurines and TNF inhibitors are acceptable during pregnancy and lactation. Pregnant women who have symptomatic IBD or who require therapy should have the opportunity to discuss any associated risks to their pregnancy and infant with the appropriate consultants. By ensuring that the patient and her family are informed, the clinical outcome might be optimized.
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Affiliation(s)
- Ole Haagen Nielsen
- Gastroenterology, Herlev Hospital, University of Copenhagen, Herlev Ringvej 75, DK-2730 Herlev, Denmark
| | - Cynthia Maxwell
- Department of Obstetrics and Gynaecology, Maternal Fetal Medicine Division, Mount Sinai Hospital, University of Toronto, OPG-3, 600 University Avenue, Toronto, ON M5G 1X5, Canada
| | - Jakob Hendel
- Gastroenterology, Herlev Hospital, University of Copenhagen, Herlev Ringvej 75, DK-2730 Herlev, Denmark
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97
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Pichler J, Hanslik A, Dietrich Huber W, Aufricht C, Bidmon-Fliegenschnee B. Paediatric patients with inflammatory bowel disease who received infliximab experienced improved growth and bone health. Acta Paediatr 2014; 103:e69-75. [PMID: 24237381 DOI: 10.1111/apa.12448] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Accepted: 09/30/2013] [Indexed: 12/16/2022]
Abstract
AIM Children with inflammatory bowel disease (IBD) have a high prevalence of growth retardation and low bone mineral density (BMD). This retrospective study investigated whether the start of infliximab treatment (IFX) was associated with improvement of growth and bone health. METHODS Anthropometry, BMD and bone markers were measured 1 year before and after the start of IFX treatment in 33 patients (51% males), with a median age of 13.5 years at baseline. Outcomes were growth with treatment and indicators of improved bone health. RESULTS Twenty-one children (64%) experienced a positive catch-up growth after IFX. Height standard deviation scores (SDS) were significantly higher in children in remission. Treatment with IFX was associated with a statistically significant increase in 25-hydroxycholecalciferol (25-OHD, p = 0.01). IFX had no influence on BMD. Children with low BMD < -2 had significantly higher inflammation scores, lower body mass index, weight, height SDS and 25-ODH after IFX. CONCLUSION After treatment with IFX, children with IBD improved significantly in weight, with the majority achieving positive catch-up growth. Bone mass tended to remain static with time of treatment with IFX, despite a significant increase in 25-OHD. Improved nutritional status positively predicts improved bone mineralisation.
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Affiliation(s)
- Judith Pichler
- Department of Paediatrics and Adolescent Medicine; Medical University of Vienna; Vienna Austria
| | - Andreas Hanslik
- Department of Paediatrics and Adolescent Medicine; Medical University of Vienna; Vienna Austria
| | - Wolf Dietrich Huber
- Department of Paediatrics and Adolescent Medicine; Medical University of Vienna; Vienna Austria
| | - Christoph Aufricht
- Department of Paediatrics and Adolescent Medicine; Medical University of Vienna; Vienna Austria
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98
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Cardile S, Romano C. Current issues in pediatric inflammatory bowel disease-associated arthropathies. World J Gastroenterol 2014; 20:45-52. [PMID: 24415857 PMCID: PMC3886031 DOI: 10.3748/wjg.v20.i1.45] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2013] [Revised: 10/17/2013] [Accepted: 11/05/2013] [Indexed: 02/06/2023] Open
Abstract
Joint involvement is the most common extraintestinal manifestation in children with inflammatory bowel disease (IBD) and may involve 16%-33% of patients at diagnosis or during follow-up. It is possible to distinguish asymmetrical, transitory and migrating arthritis (pauciarticular and polyarticular) and spondyloarthropathy (SpA). Clinical manifestations can be variable, and peripheral arthritis often occurs before gastrointestinal symptoms develop. The inflammatory intestinal pattern is variable, ranging from sub-clinical inflammation conditions, classified as indeterminate colitis and nodular lymphoid hyperplasia of the ileum, to Crohn’s disease or ulcerative colitis. Unlike the axial form, there is an association between gut inflammation and evolution of recurrent peripheral articular disease that coincides with a flare-up of intestinal disease. This finding seems to confirm a key role of intestinal inflammation in the pathogenesis of SpA. An association between genetic background and human leukocyte antigen-B27 status is less common in pediatric than n adult populations. Seronegative sacroiliitis and SpA are the most frequent forms of arthropathy in children with IBD. In pediatric patients, a correct therapeutic approach relies on the use of nonsteroidal antiinflammatory drugs, local steroid injections, physiotherapy and anti-tumor necrosis factor therapy (infliximab). Early diagnosis of these manifestations reduces the risk of progression and complications, and as well as increasing the efficacy of the therapy.
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99
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Ruiz V, Manubens E, Puig L. Psoriasis in pregnancy: a review (II). ACTAS DERMO-SIFILIOGRAFICAS 2013; 105:813-21. [PMID: 24314892 DOI: 10.1016/j.ad.2013.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Revised: 06/10/2013] [Accepted: 06/17/2013] [Indexed: 12/16/2022] Open
Abstract
Scarce scientific evidence is available to define the precise effects that certain drugs might have on embryonic and fetal development if taken by pregnant women with psoriasis, given the ethical concerns that preclude enrolling such women in clinical trials. The little information on the use of biologics during gestation that has been published is based on retrospective and observational studies, and experience with these drugs in this context in psoriasis is still very limited. The literature seems to suggest that biologic therapy is safe during pregnancy, but there is no certainty. This detailed review of accumulated experience with biologic therapy during pregnancy relies mainly on descriptions of the management of other types of rheumatic disease, although the use of these agents in psoriasis is growing steadily.
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Affiliation(s)
- V Ruiz
- Servicio de Dermatología, Hospital de la Santa Creu i Sant Pau, Barcelona, España.
| | - E Manubens
- Servicio de Dermatología, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - L Puig
- Servicio de Dermatología, Hospital de la Santa Creu i Sant Pau, Barcelona, España
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100
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Management of fertility and pregnancy in women with inflammatory bowel disease: a practical guide. Inflamm Bowel Dis 2013; 19:2937-48. [PMID: 23945187 DOI: 10.1097/mib.0b013e3182a0ea6f] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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