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Seppälä LK, Madanat‐Harjuoja L, Troisi R, Sampson JN, Leinonen MK, Vettenranta K. Maternal autoimmune disease is not associated with cancer in the offspring. Acta Paediatr 2021; 110:2259-2266. [PMID: 33638889 DOI: 10.1111/apa.15821] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 02/23/2021] [Accepted: 02/25/2021] [Indexed: 12/22/2022]
Abstract
AIM Autoimmune disease and its medication are associated with increased cancer risk in adults, but it is unknown whether maternal autoimmune disease and/or medication use in pregnancy are associated with increased cancer risk in offspring. METHODS In this case-control study, we identified all patients under 20 years of age with their first cancer diagnosis in 1996-2014 from the Finnish Cancer Registry (n = 2029) and 1:5 population-based controls (n = 10,103) from the Medical Birth Register. We obtained information on maternal autoimmune disease and its medication from the relevant Finnish registries and used conditional logistic regression to analyse the risk of offspring cancer after maternal autoimmune disease exposure. RESULTS The odds ratio (OR) for cancer in offspring following maternal autoimmune exposure was 0.76 (95% confidence interval [CI] 0.47-1.23). Individual ORs for inflammatory bowel and connective tissue diseases were 1.08 (95% CI 0.56-2.01) and 0.50 (95% CI 0.23-1.08), respectively. The OR for maternal autoimmune medication was 0.95 (95% CI 0.80-1.14) overall and similar by drug subtype. There was an increased risk with medication in late pregnancy but the ORs were unstable owing to small numbers. CONCLUSION Our study does not support an increased cancer risk among offspring of women with autoimmune disease or its medication during pregnancy.
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Affiliation(s)
- Laura K. Seppälä
- Pediatrics University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Laura‐Maria Madanat‐Harjuoja
- Pediatrics University of Helsinki and Helsinki University Hospital Helsinki Finland
- Finnish Cancer Registry Helsinki Finland
| | - Rebecca Troisi
- Division of Cancer Epidemiology and Genetics Transdivisional Research ProgramNational Cancer Institute Rockville United States
| | - Joshua N. Sampson
- Biostatistics Branch Division of Cancer Epidemiology and Genetics National Cancer Institute Rockville United States
| | - Maarit K. Leinonen
- Unit of Data and Analytics Information Services Department Finnish Institute of Health and Welfare Helsinki Finland
| | - Kim Vettenranta
- Pediatrics University of Helsinki and Helsinki University Hospital Helsinki Finland
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52
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Kanis SL, Modderman S, Escher JC, Erler N, Beukers R, de Boer N, Bodelier A, Depla ACT, Dijkstra G, van Dijk ABRM, Gilissen L, Hoentjen F, Jansen JM, Kuyvenhoven J, Mahmmod N, Mallant-Hent RC, van der Meulen-de Jong AE, Noruzi A, Oldenburg B, Oostenbrug LE, Ter Borg PC, Pierik M, Romberg- Camps M, Thijs W, West R, de Lima A, van der Woude CJ. Health outcomes of 1000 children born to mothers with inflammatory bowel disease in their first 5 years of life. Gut 2021; 70:1266-1274. [PMID: 33046558 PMCID: PMC8223671 DOI: 10.1136/gutjnl-2019-319129] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 09/02/2020] [Accepted: 09/05/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The aim of this study was to describe the long-term health outcomes of children born to mothers with inflammatory bowel disease (IBD) and to assess the impact of maternal IBD medication use on these outcomes. DESIGN We performed a multicentre retrospective study in The Netherlands. Women with IBD who gave birth between 1999 and 2018 were enrolled from 20 participating hospitals. Information regarding disease characteristics, medication use, lifestyle, pregnancy outcomes and long-term health outcomes of children was retrieved from mothers and medical charts. After consent of both parents, outcomes until 5 years were also collected from general practitioners. Our primary aim was to assess infection rate and our secondary aims were to assess adverse reactions to vaccinations, growth, autoimmune diseases and malignancies. RESULTS We included 1000 children born to 626 mothers (381 (61%) Crohn's disease, 225 (36%) ulcerative colitis and 20 (3%) IBD unclassified). In total, 196 (20%) had intrauterine exposure to anti-tumour necrosis factor-α (anti-TNF-α) (60 with concomitant thiopurine) and 240 (24%) were exposed to thiopurine monotherapy. The 564 children (56%) not exposed to anti-TNF-α and/or thiopurine served as control group. There was no association between adverse long-term health outcomes and in utero exposure to IBD treatment. We did find an increased rate of intrahepatic cholestasis of pregnancy (ICP) in case thiopurine was used during the pregnancy without affecting birth outcomes and long-term health outcomes of children. All outcomes correspond with the general age-adjusted population. CONCLUSION In our study, we found no association between in utero exposure to anti-TNF-α and/or thiopurine and the long-term outcomes antibiotic-treated infections, severe infections needing hospital admission, adverse reactions to vaccinations, growth failure, autoimmune diseases and malignancies.
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Affiliation(s)
- Shannon Linda Kanis
- Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Sanne Modderman
- Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Johanna C Escher
- Pediatric Gastroenterology, Erasmus MC Sophia Children Hospital, Rotterdam, The Netherlands
| | - Nicole Erler
- Biostatistics, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Ruud Beukers
- Gastroenterology and Hepatology, Albert Schweitzer Ziekenhuis, Dordrecht, The Netherlands
| | - Nanne de Boer
- Gastroenterology and Hepatology, Amsterdam UMC, Amsterdam, The Netherlands
| | - Alexander Bodelier
- Gastroenterology and Hepatology, Amphia Hospital site Molengracht, Breda, The Netherlands
| | | | - Gerard Dijkstra
- Gastroenterology and Hepatology, University of Groningen, Groningen, The Netherlands
| | | | - Lennard Gilissen
- Gastroenterology and Hepatology, Catharina Ziekenhuis, Eindhoven, The Netherlands
| | - Frank Hoentjen
- Gastroenterology and Hepatology, Radboudumc, Nijmegen, The Netherlands
| | - Jeroen M Jansen
- Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Johan Kuyvenhoven
- Gastroenterology and Hepatology, Spaarne Hospital, Haarlem, The Netherlands
| | - Nofel Mahmmod
- Gastroenterology and Hepatology, Sint Antonius Ziekenhuis, Nieuwegein, The Netherlands
| | | | | | - Anahita Noruzi
- Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Bas Oldenburg
- Gastroenterology and Hepatology, Utrecht Hospital, Utrecht, The Netherlands
| | - Liekele E Oostenbrug
- Gastroenterology and Hepatology, Zuyderland Medisch Centrum Heerlen, Heerlen, The Netherlands
| | | | - Marieke Pierik
- Gastroenterology and Hepatology, Maastricht Universitair Medisch Centrum+, Maastricht, The Netherlands
| | - Mariëlle Romberg- Camps
- Gastroenterology and Hepatology, Zuyderland Medical Centre Sittard-Geleen, Sittard-Geleen, The Netherlands
| | - Willem Thijs
- Gastroenterology and Hepatology, Martini Hospital, Groningen, The Netherlands
| | - Rachel West
- Gastroenterology and Hepatology, Franciscus Gasthuis, Rotterdam, New Caledonia
| | - Alison de Lima
- Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
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53
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Chaparro M, Gisbert JP. Surgery for Crohn's disease during pregnancy: a difficult decision. United European Gastroenterol J 2021; 8:633-634. [PMID: 32628893 DOI: 10.1177/2050640620928181] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Affiliation(s)
- María Chaparro
- Inflammatory Bowel Disease Unit of Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid, and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Javier P Gisbert
- Inflammatory Bowel Disease Unit of Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid, and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
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54
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Kucharzik T, Ellul P, Greuter T, Rahier JF, Verstockt B, Abreu C, Albuquerque A, Allocca M, Esteve M, Farraye FA, Gordon H, Karmiris K, Kopylov U, Kirchgesner J, MacMahon E, Magro F, Maaser C, de Ridder L, Taxonera C, Toruner M, Tremblay L, Scharl M, Viget N, Zabana Y, Vavricka S. ECCO Guidelines on the Prevention, Diagnosis, and Management of Infections in Inflammatory Bowel Disease. J Crohns Colitis 2021; 15:879-913. [PMID: 33730753 DOI: 10.1093/ecco-jcc/jjab052] [Citation(s) in RCA: 164] [Impact Index Per Article: 54.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- T Kucharzik
- Department of Gastroenterology, Klinikum Lüneburg, University of Hamburg, Lüneburg, Germany
| | - P Ellul
- Department of Medicine, Division of Gastroenterology, Mater Dei Hospital, Msida, Malta
| | - T Greuter
- University Hospital Zürich, Department of Gastroenterology and Hepatology, Zürich, Switzerland, and Division of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois CHUV, University Hospital Lausanne, Lausanne, Switzerland
| | - J F Rahier
- Department of Gastroenterology and Hepatology, CHU UCL Namur, Yvoir, Belgium
| | - B Verstockt
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium, and Department of Chronic Diseases, Metabolism and Ageing, TARGID-IBD, KU Leuven, Leuven, Belgium
| | - C Abreu
- Infectious Diseases Service, Centro Hospitalar Universitário São João, Porto, Portugal.,Instituto de Inovação e Investigação em Saúde [I3s], Faculty of Medicine, Department of Medicine, University of Porto, Portugal
| | - A Albuquerque
- Gastroenterology Department, St James University Hospital, Leeds, UK
| | - M Allocca
- Humanitas Clinical and Research Center - IRCCS -, Rozzano [Mi], Italy.,Humanitas University, Department of Biomedical Sciences, Milan, Italy
| | - M Esteve
- Hospital Universitari Mútua Terrassa, Digestive Diseases Department, Terrassa, Catalonia, and Centro de Investigación Biomédica en red de Enfermedades Hepáticas y Digestivas CIBERehd, Madrid, Spain
| | - F A Farraye
- Inflammatory Bowel Disease Center, Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - H Gordon
- Department of Gastroenterology, Barts Health NHS Trust, Royal London Hospital, London, UK
| | - K Karmiris
- Department of Gastroenterology, Venizeleio General Hospital, Heraklion, Greece
| | - U Kopylov
- Department of Gastroenterology, Sheba Medical Center, Ramat Gan, Israel, and Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - J Kirchgesner
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Saint-Antoine, Department of Gastroenterology, Paris, France
| | - E MacMahon
- Department of Infectious Diseases, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - F Magro
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal.,Institute of Pharmacology and Therapeutics, Faculty of Medicine, University of Porto, Portugal
| | - C Maaser
- Outpatient Department of Gastroenterology, Department of Geriatrics, Klinikum Lüneburg, University of Hamburg, Lüneburg, Germany
| | - L de Ridder
- Department of Paediatric Gastroenterology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - C Taxonera
- IBD Unit, Department of Gastroenterology, Hospital Clínico San Carlos and Instituto de Investigación del Hospital Clínico San Carlos [IdISSC], Madrid, Spain
| | - M Toruner
- Ankara University School of Medicine, Department of Gastroenterology, Ankara, Turkey
| | - L Tremblay
- Centre Hospitalier de l'Université de Montréal [CHUM] Pharmacy Department and Faculty of Pharmacy, Université de Montréal, Montréal, QC, Canada
| | - M Scharl
- University Hospital Zürich, Department of Gastroenterology and Hepatology, Zürich, Switzerland
| | - N Viget
- Department of Infectious Diseases, Tourcoing Hospital, Tourcoing, France
| | - Y Zabana
- Hospital Universitari Mútua Terrassa, Digestive Diseases Department, Terrassa, Catalonia, and Centro de Investigación Biomédica en red de Enfermedades Hepáticas y Digestivas CIBERehd, Madrid, Spain
| | - S Vavricka
- University Hospital Zürich, Department of Gastroenterology and Hepatology, Zürich, Switzerland
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55
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Barenbrug L, Groen MT, Hoentjen F, van Drongelen J, Reek JMPAVD, Joosten I, de Jong EMGJ, van der Molen RG. Pregnancy and neonatal outcomes in women with immune mediated inflammatory diseases exposed to anti-tumor necrosis factor-α during pregnancy: A systemic review and meta-analysis. J Autoimmun 2021; 122:102676. [PMID: 34126302 DOI: 10.1016/j.jaut.2021.102676] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 05/27/2021] [Accepted: 05/29/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Anti-TNFα is increasingly used as treatment for immune mediated inflammatory diseases (IMID), such as inflammatory bowel disease (IBD), rheumatoid arthritis (RA) and psoriasis (PS). However, the impact of anti-TNFα during pregnancy on mother and newborn is under debate. This requires a sound knowledge of the effects of this treatment on pregnancy and neonatal outcomes. OBJECTIVES To assess pregnancy and neonatal outcomes after anti-TNFα therapy during pregnancy in women with IMID, specifically IBD, RA and PS. METHODS We performed a systematic review and meta-analysis of 39 studies assessing pregnancy and neonatal outcomes of women with IMID exposed to anti-TNFα agents during pregnancy. We used a random-effects model to determine pooled outcome measures. RESULTS An increased risk of preterm births (OR 1.45, 95% CI = 1.16 to 1.82, p = 0.001) and infections in newborns (OR 1.12, 95% CI = 1.00 to 1.27, p = 0.05)) was seen for women in the combined group of IMID exposed to anti-TNFα compared to diseased controls. Specifically for IBD patients exposed to anti-TNFα, the risk was increased for preterm birth (OR 1.66, 95% CI = 1.14 to 2.42, p = 0.009), and low birth weight (OR 1.49, 95% CI = 1.01 to 2.20, p = 0.047) compared to diseased controls. Combined data from studies of women with RA and PS, showed no increased risk for adverse pregnancy outcome after exposure to anti-TNFα. Most children of mothers with IMID received vaccination according to national vaccination schemes and only minor adverse events were reported. CONCLUSION Exposure to anti-TNFα agents during pregnancy is associated with increased risk of preterm birth and infections in newborns of women with IMID compared to diseased controls. The risk of preterm birth and low birth weight was increased in women with IBD specifically. The increased risk of infections in newborns underlines the importance of vaccination, which seems to be safe in children exposed to anti-TNFα. Delay of vaccination is therefore unnecessary in these children. These data may aid in balancing the continuing anti-TNFα therapy versus the risk of adverse pregnancy outcomes.
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Affiliation(s)
- Liana Barenbrug
- Laboratory of Medical Immunology, Department of Laboratory Medicine, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Maarten Te Groen
- Inflammatory Bowel Disease Centre, Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Frank Hoentjen
- Inflammatory Bowel Disease Centre, Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Joris van Drongelen
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Irma Joosten
- Laboratory of Medical Immunology, Department of Laboratory Medicine, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Elke M G J de Jong
- Department of Dermatology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Renate G van der Molen
- Laboratory of Medical Immunology, Department of Laboratory Medicine, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands.
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56
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Chaparro M, Donday MG, Abad-Santos F, Martín de Carpi FJ, Maciá-Martínez MÁ, Montero D, Acosta D, Brenes Y, Gisbert JP. The safety of drugs for inflammatory bowel disease during pregnancy and breastfeeding: the DUMBO registry study protocol of GETECCU. Therap Adv Gastroenterol 2021; 14:17562848211018097. [PMID: 34158835 PMCID: PMC8182220 DOI: 10.1177/17562848211018097] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 04/13/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Active disease during conception and pregnancy in women with inflammatory bowel disease (IBD) increases the risk of pregnancy complications and adverse neonatal outcomes. The use of IBD treatments during pregnancy should be weighed against their adverse effects on the neonate, but longer-term safety data and data on serious infection rates and malignancies postnatally are lacking, particularly for newer drugs, such as tofacitinib, vedolizumab and ustekinumab. METHODS This ongoing, prospective registry study being conducted at 70 centres in Spain is enrolling pregnant women who are ⩾18 years, are at any point in pregnancy up to the end of the second trimester and have a diagnosis of Crohn's disease, ulcerative colitis or unclassified IBD. Patients will receive treatment decided independently by their IBD specialist. Each incident gestation will be followed up through pregnancy and the first 4 years postnatally. Three cohorts will be compared: biologicals exposed, immunomodulatory exposed and non-exposed. The primary endpoint is the risk of severe infection in newborns postnatally up to 4 years of age; other endpoints include serious adverse events (SAEs) such as pregnancy and delivery complications, neonatal SAEs, development [Ages and Stages Questionnaire-3 (ASQ3)], and malignancy incidence, up to 4 years of age. IBD specialists will collect maternal data (baseline/end of each trimester/1 month post-delivery), neonatal birth data, and the SAE and ASQ3 data in children exposed during pregnancy, reported every 3 months by the mother. Statistical analysis will include summary statistics for quantitative variables, comparisons of qualitative variables with significance set at p < 0.025 and a binary logistic regression model to determine the risk factors for severe infections. RESULTS Enrolment began in September 2019 and study completion is expected in September 2028. CONCLUSIONS This prospective, controlled study will provide evidence on the long-term safety profile in children after intrauterine and lactation exposure to biological and immunomodulatory IBD treatments, including data on postnatal severe infections, development and malignancies. CLINICALTRIALSGOV IDENTIFIER NCT03894228.
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Affiliation(s)
- María Chaparro
- Inflammatory Bowel Disease Unit, Department of
Gastroenterology, Hospital Universitario de La Princesa, Instituto de
Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid
(UAM), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y
Digestivas (CIBEREHD), Diego de León, 62, Madrid 28006, Spain
| | - María G. Donday
- Inflammatory Bowel Disease Unit, Department of
Gastroenterology, Hospital Universitario de La Princesa, Instituto de
Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid
(UAM), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y
Digestivas (CIBEREHD), Madrid, Spain
| | - Francisco Abad-Santos
- Clinical Pharmacology Department, Hospital
Universitario de La Princesa, Instituto Teófilo Hernando, Facultad de
Medicina, UAM, Instituto de Investigación Sanitaria La Princesa (IP),
CIBEREHD, Madrid, Spain
- UICEC Hospital Universitario de La Princesa,
Plataforma SCReN (Spanish Clinical Research Network), IP, Madrid,
Spain
| | | | - Miguel Ángel Maciá-Martínez
- Pharmacoepidemiology and Pharmacovigilance
Division, Medicines for Human Use Department, Spanish Agency for Medicines
and Medical Devices (AEMPS), Madrid, Spain
| | - Dolores Montero
- Pharmacoepidemiology and Pharmacovigilance
Division, Medicines for Human Use Department, Spanish Agency for Medicines
and Medical Devices (AEMPS), Madrid, Spain
| | - Diana Acosta
- Inflammatory Bowel Disease Unit, Department of
Gastroenterology, Hospital Universitario de La Princesa, Instituto de
Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid
(UAM), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y
Digestivas (CIBEREHD), Madrid, Spain
| | - Yanire Brenes
- Inflammatory Bowel Disease Unit, Department of
Gastroenterology, Hospital Universitario de La Princesa, Instituto de
Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid
(UAM), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y
Digestivas (CIBEREHD), Madrid, Spain
| | - Javier P. Gisbert
- Inflammatory Bowel Disease Unit, Department of
Gastroenterology, Hospital Universitario de La Princesa, Instituto de
Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid
(UAM), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y
Digestivas (CIBEREHD), Madrid, Spain
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Guerrero Vinsard D, Kane SV. Biologics and pregnancy: a clinician's guide to the management of IBD in pregnant women. Expert Rev Gastroenterol Hepatol 2021; 15:633-641. [PMID: 33440996 DOI: 10.1080/17474124.2021.1876562] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: Women with inflammatory bowel disease (IBD) endorse a tremendous amount of concern about medication exposure during pregnancy and their effects on the fetus. Medical providers caring for this patient population should be well informed and feel comfortable counseling their patients for the best pregnancy outcome possible.Areas covered: It is of particular importance to understand the implications of use of biologics in preconception, pregnancy, and postpartum timeframes. Herein, we aim to inform the clinician about the impact of uncontrolled inflammation during pregnancy, the mechanisms of biologic transport through the placenta, the effects of biologics in maternal and neonatal outcomes, and additional postpartum considerations such as breastfeeding and vaccination safety.Expert opinion: The groundwork already set by previous research in terms of safety of biologic therapy during pregnancy has been reassuring. With the advent of more mechanisms of action but similar protein structure, i.e. they are IgG1 antibodies; the authors anticipate the recommendation of continuation of therapy throughout pregnancy will be sustained.
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Affiliation(s)
| | - Sunanda V Kane
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, MN, USA
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58
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Singh G, Prentice R, Langsford D, Christensen B, Garg M. Altered bowel habit and rectal bleeding in pregnancy: the importance of recognising undiagnosed inflammatory bowel disease. Intern Med J 2021; 51:424-427. [PMID: 33738932 DOI: 10.1111/imj.15231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 09/21/2020] [Accepted: 10/05/2020] [Indexed: 11/29/2022]
Abstract
Worsening of disease activity during pregnancy in patients with known inflammatory bowel disease, especially ulcerative colitis (UC), is well recognised, but the diagnosis of new-onset or previously undiagnosed UC in pregnancy has been inadequately studied to date. Recognition of gastrointestinal symptoms in pregnancy as potentially indicating UC is of paramount importance, as this allows appropriate investigation and instigation of therapies to optimise maternal and foetal outcomes. Here, we report three cases of women with gastrointestinal symptoms in pregnancy with disparate outcomes.
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Affiliation(s)
- Gurpreet Singh
- Department of Gastroenterology, Northern Hospital, Melbourne, Victoria, Australia
| | - Ralley Prentice
- Department of Gastroenterology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - David Langsford
- Department of Nephrology and Obstetric Medicine, Northern Hospital, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Britt Christensen
- Department of Gastroenterology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Mayur Garg
- Department of Gastroenterology, Northern Hospital, Melbourne, Victoria, Australia.,Department of Gastroenterology, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
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59
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Gisbert JP, Chaparro M. Safety of New Biologics (Vedolizumab and Ustekinumab) and Small Molecules (Tofacitinib) During Pregnancy: A Review. Drugs 2021; 80:1085-1100. [PMID: 32562207 DOI: 10.1007/s40265-020-01346-4] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Two new biological drugs (vedolizumab and ustekinumab) and one small molecule (tofacitinib) have been recently approved for the treatment of inflammatory bowel disease. Therefore, we must be familiar with the safety of these "new" drugs during pregnancy and breastfeeding. In the present article, we critically review available data on the safety of new biologics (vedolizumab and ustekinumab) and small molecules (tofacitinib) during pregnancy and breastfeeding, with special focus on women with inflammatory bowel disease. Bibliographical searches (MEDLINE) up to April 2020 were performed. The timing and mechanisms of placental transfer of vedolizumab and ustekinumab are expected to be similar to anti-TNF agents. Animal studies show no evidence of adverse effects on pre- or post-natal development after administration of vedolizumab and ustekinumab. Just a few studies including patients treated with vedolizumab or ustekinumab during pregnancy have been published, reporting uneventful pregnancies in most cases. The clinical programme of both drugs and post-marketing studies showed no new safety concerns. Due to the expected safety of vedolizumab and ustekinumab during pregnancy, it may be recommended to plan the final pregnancy dose approximately 8 or 12 weeks, respectively, before the estimated date of delivery. Live vaccines should be avoided for up to a year in children exposed in utero to vedolizumab or ustekinumab unless drug elimination has been documented. Miniscule amounts of vedolizumab and ustekinumab are transferred to breast milk, so breastfeeding is probably safe. There is no evidence of adverse effect of vedolizumab or ustekinumab paternal exposure. Regarding tofacitinib, it is reasonable to assume that this molecule crosses the placenta from the beginning of pregnancy. In animal studies, tofacitinib was feticidal and teratogenic in rats and rabbits, although at exposures many times greater than the standard human dose. Reported outcomes of pregnancy cases identified from tofacitinib randomised controlled trials, post-approval and non-interventional studies, and spontaneous adverse-event reporting appear similar to those observed in the general population. Nevertheless, at present, the use of tofacitinib during pregnancy should be avoided. Although no human studies have reported outcomes of breastfeeding with small molecules such as tofacitinib, this drug is present in lactating rat milk so, at present, breastfeeding should be avoided. Pregnancy among patients with paternal exposure to tofacitinib appears to be safe. In summary, we can conclude that new biologic agents (vedolizumab and ustekinumab) and small molecules (tofacitinib) should be used during pregnancy only if the benefits to the mother outweigh the risks to the mother and unborn child.
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Affiliation(s)
- Javier P Gisbert
- Gastroenterology Unit, Hospital Universitario de la Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Diego de León, 62, 28006, Madrid, Spain.
| | - María Chaparro
- Gastroenterology Unit, Hospital Universitario de la Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Diego de León, 62, 28006, Madrid, Spain
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Tandon P, Lee EY, Maxwell C, Hitz L, Ambrosio L, Dieleman L, Halloran B, Kroeker K, Huang VM. Fecal Calprotectin May Predict Adverse Pregnancy-Related Outcomes in Patients with Inflammatory Bowel Disease. Dig Dis Sci 2021; 66:1639-1649. [PMID: 32533542 DOI: 10.1007/s10620-020-06381-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 05/30/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND The role of fecal calprotectin in predicting pregnancy-related outcomes in inflammatory bowel disease (IBD) remains unknown. AIM To determine whether increased fecal calprotectin during pregnancy is associated with adverse pregnancy outcomes in IBD. METHODS This is a multicenter cohort study of women with IBD who underwent fecal calprotectin monitoring during pregnancy. Fecal calprotectin levels were stratified by trimester, and adverse pregnancy-related outcomes were recorded. The Mann-Whitney U test assessed differences between continuous variables, whereas categorical variables were compared using the Chi-squared test. RESULTS Eighty-five women with IBD were included. First trimester fecal calprotectin was higher in patients who underwent emergency Cesarean birth compared to those who had a vaginal delivery (503 ug/g, IQR 1554.3 ug/g vs. 130 ug/g, IQR 482 ug/g, p = .030, respectively) and in those who delivered infants with low birth weight compared to normal birth weight (1511 ug/g, IQR 579 ug/g vs. 168 ug/g, IQR 413 ug/g, p = .049, respectively). Third trimester fecal calprotectin was higher in those with non-elective induction of labor (334.5 ug/g, IQR 1411.0 ug/g) compared to those with spontaneous delivery (116.5 ug/g, IQR 227.1 ug/g) (p = .025). Those with a fecal calprotectin ≥ 250 ug/g in the second trimester had an increased incidence of infants with low birth weight (35.3% vs. 3.8%) (p = .049), whereas those with a fecal calprotectin ≥ 250 ug/g in the third trimester had an increased incidence of non-elective induction of labor (43.8% vs. 10.3%, p = .030). CONCLUSIONS Fecal calprotectin may be a useful noninvasive marker to predict adverse pregnancy-related outcomes in patients with IBD.
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Affiliation(s)
- Parul Tandon
- Division of Gastroenterology, Mount Sinai Hospital, Sinai Health System, University of Toronto, Suite 441-600 University Avenue, Toronto, ON, M5G 1X5, Canada.,Department of Medicine, University of Toronto, 441-600 University Avenue, Toronto, ON, M5G 1X5, Canada
| | - Eugenia Y Lee
- Department of Medicine, University of Toronto, 441-600 University Avenue, Toronto, ON, M5G 1X5, Canada
| | - Cynthia Maxwell
- Department of Obstetrics and Gynaecology, University of Toronto, 901-700 University Avenue, Toronto, ON, M5G 1Z5, Canada
| | - Lara Hitz
- Division of Gastroenterology, Mount Sinai Hospital, Sinai Health System, University of Toronto, Suite 441-600 University Avenue, Toronto, ON, M5G 1X5, Canada
| | - Lindsy Ambrosio
- Division of Gastroenterology, University of Alberta, Edmonton, AB, Canada
| | - Levinus Dieleman
- Division of Gastroenterology, University of Alberta, 2-24A Zeidler Building, Edmonton, AB, T6G 2X8, Canada
| | - Brendan Halloran
- Division of Gastroenterology, University of Alberta, 130 University Campus NW, Edmonton, AB, T6G 2X8, Canada
| | - Karen Kroeker
- Division of Gastroenterology, University of Alberta, 8540 112th Street NW, Edmonton, AB, T6G 2X8, Canada
| | - Vivian M Huang
- Division of Gastroenterology, Mount Sinai Hospital, Sinai Health System, University of Toronto, Suite 441-600 University Avenue, Toronto, ON, M5G 1X5, Canada. .,Department of Medicine, University of Toronto, 441-600 University Avenue, Toronto, ON, M5G 1X5, Canada.
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Mountifield R. Anti-tumor necrosis factors (TNFs) are outdated-It's time to move on: Session three summary. J Gastroenterol Hepatol 2021; 36 Suppl 1:25-26. [PMID: 33817852 DOI: 10.1111/jgh.15455] [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: 12/09/2022]
Affiliation(s)
- Réme Mountifield
- Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia, Australia.,Department of Medicine, Flinders University, Bedford Park, South Australia, Australia
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Nalli C, Galli J, Lini D, Merlini A, Piantoni S, Lazzaroni MG, Bitsadze V, Khizroeva J, Zatti S, Andreoli L, Fazzi E, Franceschini F, Makatsariya A, Shoenfeld Y, Tincani A. The Influence of Treatment of Inflammatory Arthritis During Pregnancy on the Long-Term Children's Outcome. Front Pharmacol 2021; 12:626258. [PMID: 33815108 PMCID: PMC8013697 DOI: 10.3389/fphar.2021.626258] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 01/29/2021] [Indexed: 12/16/2022] Open
Abstract
The management of reproductive issues in women with inflammatory arthritis has greatly changed over decades. In the 1980–1990s, women with refractory forms of arthritis were either not able to get pregnant or did choose not to get pregnant because of their disabling disease. Hence, the traditional belief that pregnancy can induce a remission of arthritis. The availability of biologic agents has allowed a good control of aggressive forms of arthritis. The main topic of discussion during preconception counselling is the use of drugs during pregnancy and breastfeeding. Physicians are now supported by international recommendations released by the European League Against Rheumatism and the American College of Rheumatology, but still they must face with cultural reluctance in accepting that a pregnant woman can take medications. Patient-physician communication should be centered on the message that active maternal disease during pregnancy is detrimental to fetal health. Keeping maternal disease under control with drugs which are not harmful to the fetus is the best way to ensure the best possible outcome for both the mother and the baby. However, there might be concerns about the influence of the in utero exposure to medications on the newborn’s health conditions. Particularly, studies suggesting an increased risk of autism-spectrum-disorders in children born to women with rheumatoid arthritis has raised questions about neuropsychological impairment in the offspring of women with chronic arthritis. As a multidisciplinary group of rheumatologists and child neuropsychiatrists, we conducted a study on 16 women with chronic forms of arthritis whose diagnosis was determined before pregnancy and their 18 school-age children. The children underwent a complete neurological examination and validated tests/questionnaires. Behavioral aspects of somatization and anxiety/depression (internalizing problem) or an “adult profile” were found in nearly one third of children. Children at a high risk of neurodevelopmental problems were born to mothers with a longer history of arthritis and were breastfeed for less than 6 months of age or were not breastfeed at all. No association was found with other maternal characteristics such as autoantibody existence and disease activity during and after the pregnancy.
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Affiliation(s)
- Cecilia Nalli
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili and University of Brescia, Brescia, Italy
| | - Jessica Galli
- Child Neurology and Psychiatry Unit, Department of Clinical and Experimental Sciences, ASST Spedali Civili and University of Brescia, Brescia, Italy
| | - Daniele Lini
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili and University of Brescia, Brescia, Italy.,Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Angela Merlini
- Child Neurology and Psychiatry Unit, Department of Clinical and Experimental Sciences, ASST Spedali Civili and University of Brescia, Brescia, Italy
| | - Silvia Piantoni
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili and University of Brescia, Brescia, Italy.,Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Maria Grazia Lazzaroni
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili and University of Brescia, Brescia, Italy.,Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Victoria Bitsadze
- Department of Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - Jamilya Khizroeva
- Department of Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - Sonia Zatti
- Obstetric and Gynecology Unit, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Laura Andreoli
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili and University of Brescia, Brescia, Italy.,Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Elisa Fazzi
- Child Neurology and Psychiatry Unit, Department of Clinical and Experimental Sciences, ASST Spedali Civili and University of Brescia, Brescia, Italy
| | - Franco Franceschini
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili and University of Brescia, Brescia, Italy.,Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Alexander Makatsariya
- Department of Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - Yehuda Shoenfeld
- Department of Medicine 'B', The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Ramat Gan, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel.,I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - Angela Tincani
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili and University of Brescia, Brescia, Italy.,Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.,I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
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Leung KK, Tandon P, Govardhanam V, Maxwell C, Huang V. The Risk of Adverse Neonatal Outcomes With Maternal Inflammatory Bowel Disease: A Systematic Review and Meta-analysis. Inflamm Bowel Dis 2021; 27:550-562. [PMID: 32469057 DOI: 10.1093/ibd/izaa122] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Patients with inflammatory bowel disease (IBD) may be at increased risk of adverse neonatal outcomes. The aim of this study was to determine pooled incidences and risk factors for these outcomes. METHODS Medline, Embase, and Cochrane Library were searched through May 2019 for studies reporting adverse neonatal outcomes in IBD. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. RESULTS The pooled incidence of preterm birth, low birth weight, congenital anomalies, and infants transferred to the neonatal intensive care unit was 8.6% (95% CI, 7.0%-10.1%), 8.9% (95% CI, 7.3%-10.5%), 2.1% (95% CI, 1.6%-2.6%), and 4.9% (95% CI, 2.9%-6.9), respectively. Compared with healthy controls, patients with IBD were more likely to deliver infants with low birth weight (<2500 grams; OR, 2.78; 95% CI, 1.16-6.66) and infants admitted to the intensive care unit (OR, 3.33; 95% CI, 1.83-6.05). Patients with Crohn's disease had an increased incidence of congenital anomalies (OR, 3.03; 95% CI, 1.43-6.42). Among IBD patients, active disease was associated with increased incidence of preterm birth (OR, 2.06; 95% CI, 1.21-3.51), low birth weight (OR, 2.96; 95% CI, 1.54-5.70), and small for gestational age (OR, 2.62; 95% CI, 1.18-5.83). Antitumor necrosis factor (anti-TNF) use during pregnancy was associated with an increased incidence of neonatal intensive care unit admission (OR, 2.42; 95% CI, 1.31-4.45) and low birth weight (OR, 1.54; 95% CI, 1.01-2.35). CONCLUSIONS Patients with IBD, particularly with active disease or requiring anti-TNF therapy, may be at increased risk of developing adverse neonatal outcomes.
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Affiliation(s)
- Kristel K Leung
- Division of Gastroenterology, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Parul Tandon
- Division of Gastroenterology, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Vivek Govardhanam
- Division of Gastroenterology, University of Toronto, Toronto, Ontario, Canada
| | - Cynthia Maxwell
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Vivian Huang
- Division of Gastroenterology, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Romanowska-Próchnicka K, Felis-Giemza A, Olesińska M, Wojdasiewicz P, Paradowska-Gorycka A, Szukiewicz D. The Role of TNF-α and Anti-TNF-α Agents during Preconception, Pregnancy, and Breastfeeding. Int J Mol Sci 2021; 22:ijms22062922. [PMID: 33805757 PMCID: PMC7998738 DOI: 10.3390/ijms22062922] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 03/11/2021] [Indexed: 12/15/2022] Open
Abstract
Tumor necrosis factor-alpha (TNF-α) is a multifunctional Th1 cytokine and one of the most important inflammatory cytokines. In pregnancy, TNF-α influences hormone synthesis, placental architecture, and embryonic development. It was also shown that increased levels of TNF-α are associated with pregnancy loss and preeclampsia. Increased TNF-α levels in complicated pregnancy draw attention to trophoblast biology, especially migratory activity, syncytialisation, and endocrine function. Additionally, elevated TNF-α levels may affect the maternal-fetal relationship by altering the secretory profile of placental immunomodulatory factors, which in turn affects maternal immune cells. There is growing evidence that metabolic/pro-inflammatory cytokines can program early placental functions and growth in the first trimester of pregnancy. Furthermore, early pregnancy placenta has a direct impact on fetal development and maternal immune system diseases that release inflammatory (e.g., TNF-α) and immunomodulatory factors, such as chronic inflammatory rheumatic, gastroenterological, or dermatological diseases, and may result in an abnormal release of cytokines and chemokines in syncytiotrophoblasts. Pregnancy poses a challenge in the treatment of chronic disease in patients who plan to have children. The activity of the disease, the impact of pregnancy on the course of the disease, and the safety of pharmacotherapy, including anti-rheumatic agents, in pregnancy should be considered.
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Affiliation(s)
- Katarzyna Romanowska-Próchnicka
- Department of Biophysics and Human Physiology, Faculty of Health Sciences, Warsaw Medical University, 02-091 Warsaw, Poland; (K.R.-P.); (P.W.); (D.S.)
- Department of Connective Tissue Diseases, National Institute of Geriatrics, Rheumatology and Rehabilitation, 02-637 Warsaw, Poland;
| | - Anna Felis-Giemza
- Department of Connective Tissue Diseases, National Institute of Geriatrics, Rheumatology and Rehabilitation, 02-637 Warsaw, Poland;
- Correspondence:
| | - Marzena Olesińska
- Department of Connective Tissue Diseases, National Institute of Geriatrics, Rheumatology and Rehabilitation, 02-637 Warsaw, Poland;
| | - Piotr Wojdasiewicz
- Department of Biophysics and Human Physiology, Faculty of Health Sciences, Warsaw Medical University, 02-091 Warsaw, Poland; (K.R.-P.); (P.W.); (D.S.)
| | - Agnieszka Paradowska-Gorycka
- Department of Molecular Biology, National Institute of Geriatrics, Rheumatology and Rehabilitation, 02-637 Warsaw, Poland;
| | - Dariusz Szukiewicz
- Department of Biophysics and Human Physiology, Faculty of Health Sciences, Warsaw Medical University, 02-091 Warsaw, Poland; (K.R.-P.); (P.W.); (D.S.)
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65
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Taulaigo AV, Moschetti L, Ganhão S, Gerardi MC, Franceschini F, Tincani A, Andreoli L. Safety considerations when using drugs in pregnant patients with systemic lupus erythematosus. Expert Opin Drug Saf 2021; 20:523-536. [PMID: 33599570 DOI: 10.1080/14740338.2021.1893298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: Systemic lupus erythematosus (SLE) mainly affects young females during childbearing age; therefore, reproductive issues are of major interest.Areas covered: Pregnancy planning is crucial to adjust the treatment toward drugs that are safe throughout pregnancy and breastfeeding. The evidence about drug safety is limited to post-marketing surveillance, registries, case series, and case reports, as pregnant patients are excluded from randomized clinical trials. The aim of this review is to report the safety considerations when treating pregnant SLE patients. Regarding maternal side effects of drugs, we focused on metabolic, infectious, and hemorrhagic complications. Fetal safety was analyzed looking at drugs teratogenicity, their possible effects on immune system, and on the long-term neuropsychological development of children.Expert opinion: The management of pregnancy in SLE has changed when knowledge about the safety of drugs has become available. Keeping SLE disease activity under control before, during and after pregnancy is of fundamental importance to ensure the best possible outcomes for mother and child. All these issues must be discussed with the patient and her family during preconception counseling. International efforts in terms of pregnancy registries and reproductive health guidelines help physicians improve their communication with SLE patients.
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Affiliation(s)
- Anna Viola Taulaigo
- Unidade De Doenças Auto-imunes/Medicina 7.2, Hospital Curry Cabral, Centro Hospitalar Universitário De Lisboa Central, Lisboa, Portugal
| | - Liala Moschetti
- Unit of Rheumatology and Clinical Immunology, ASST Spedali Civili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Sara Ganhão
- Rheumatology Department, Centro Hospitalar E Universitário De São João, Porto, Portugal
| | - Maria-Chiara Gerardi
- Unit of Rheumatology and Clinical Immunology, ASST Spedali Civili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Franco Franceschini
- Unit of Rheumatology and Clinical Immunology, ASST Spedali Civili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Angela Tincani
- Unit of Rheumatology and Clinical Immunology, ASST Spedali Civili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.,Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Laura Andreoli
- Unit of Rheumatology and Clinical Immunology, ASST Spedali Civili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
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66
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Laube R, Paramsothy S, Leong RW. Use of medications during pregnancy and breastfeeding for Crohn's disease and ulcerative colitis. Expert Opin Drug Saf 2021; 20:275-292. [PMID: 33412078 DOI: 10.1080/14740338.2021.1873948] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Introduction: The peak age of diagnosis of inflammatory bowel disease (IBD) occurs during childbearing years, therefore management of IBD during pregnancy is a frequent occurrence. Maintenance of disease remission is crucial to optimize pregnancy outcomes, and potential maternal or fetal toxicity from medications must be balanced against the risks of untreated IBD.Areas covered: This review summarizes the literature on safety and use of medications for IBD during pregnancy and lactation.Expert opinion: 5-aminosalicylates, corticosteroids and thiopurines are safe for use during pregnancy, while methotrexate and tofacitinib should only be used with extreme caution. Anti-TNF agents (except certolizumab), vedolizumab, ustekinumab and tofacitinib readily traverse the placenta via active transport, therefore theoretically may affect fetal development. Certolizumab only undergoes passive transfer across the placenta, thus has markedly lower cord blood levels making it likely the safest biologic agent for infants. There is reasonable evidence to support the safety of anti-TNF monotherapy and combination therapy during pregnancy and lactation. Vedolizumab and ustekinumab are also thought to be safe in pregnancy and lactation, while tofacitinib is generally avoided due to teratogenic effects in animal studies.
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Affiliation(s)
- Robyn Laube
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia.,Department of Gastroenterology, Macquarie University Hospital, Sydney, Australia
| | - Sudarshan Paramsothy
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia.,Department of Gastroenterology, Macquarie University Hospital, Sydney, Australia.,Department of Gastroenterology and Hepatology, Concord Repatriation General Hospital, Sydney, Australia
| | - Rupert W Leong
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia.,Department of Gastroenterology, Macquarie University Hospital, Sydney, Australia.,Department of Gastroenterology and Hepatology, Concord Repatriation General Hospital, Sydney, Australia
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67
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Biologics During Pregnancy in Women With Inflammatory Bowel Disease and Risk of Infantile Infections: A Systematic Review and Meta-Analysis. Am J Gastroenterol 2021; 116:243-253. [PMID: 33110017 PMCID: PMC8628857 DOI: 10.14309/ajg.0000000000000910] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 08/20/2020] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Biologics, such as tumor necrosis factor inhibitors, anti-integrins and anticytokines, are therapies for inflammatory bowel disease (IBD) that may increase the risk of infection. Most biologics undergo placental transfer during pregnancy and persist at detectable concentrations in exposed infants. Whether this is associated with an increased risk of infantile infections is controversial. We performed a systematic review and meta-analysis evaluating the risk of infantile infections after in utero exposure to biologics used to treat IBD. METHODS We searched PubMed, Embase, Scopus, Web of Science, and CENTRAL from inception to June 2020 to evaluate the association of biologic therapy during pregnancy in women with IBD and risk of infantile infections. Odds ratios of outcomes were pooled and analyzed using a random effects model. RESULTS Nine studies met the inclusion criteria comprising 8,013 women with IBD (5,212 Crohn's disease, 2,801 ulcerative colitis) who gave birth to 8,490 infants. Biologic use during pregnancy was not associated with an increased risk of all infantile infections (odds ratio [OR] 0.91, 95% confidence interval [CI] 0.73-1.14, I2 = 30%). In a subgroup analysis for the type of infection, biologic use was associated with increased infantile upper respiratory infections (OR 1.57, 95% CI 1.02-2.40, I2 = 4%). Biologic use during pregnancy was not associated with infantile antibiotic use (OR 0.91, 95% CI 0.73-1.14, I2 = 30%) or infection-related hospitalizations (OR 1.33, 95% CI 0.95-1.86, I2 = 26%). DISCUSSION Biologics use during pregnancy in women with IBD is not associated with the overall risk of infantile infections or serious infections requiring antibiotics or hospitalizations but is associated with an increased risk of upper respiratory infections.
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Tsao NW, Rebic N, Lynd LD, De Vera MA. Maternal and neonatal outcomes associated with biologic exposure before and during pregnancy in women with inflammatory systemic diseases: a systematic review and meta-analysis of observational studies. Rheumatology (Oxford) 2021; 59:1808-1817. [PMID: 32118278 DOI: 10.1093/rheumatology/keaa064] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 12/23/2019] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVE To determine the association between exposure to biologics in pregnant women with inflammatory systemic diseases and maternal and neonatal outcomes through a meta-analysis of findings from studies identified in a systematic review. METHODS We conducted a systematic review of Medline, Embase, and Cochrane Database of Systematic Reviews to identify observational studies assessing the perinatal impacts of biologic in women with inflammatory systemic disease. Findings were meta-analysed across included studies with random-effects models. Crude risk estimates and, where possible, adjusted risk estimates were pooled to determine the impact on results when confounding is addressed. RESULTS Overall, 24 studies were included in the meta-analysis. Meta-analyses of crude risk estimates resulted in pooled odds ratios (OR) for the association of biologic use during pregnancy and the following respective outcomes: congenital anomalies (1.30, 95% CI: 1.02, 1.67), preterm birth (OR 1.61, 95% CI: 1.37, 1.89), and low birth weight (OR 1.68, 95% CI: 1.21, 2.31). However, in pooled analyses of adjusted risk estimates we observed that the association between biologics use during pregnancy in disease-matched exposed and unexposed pregnant women was no longer statistically significant for congenital anomalies (adjusted OR 1.18, 95% CI: 0.88, 1.57). CONCLUSION Pooled results from studies reporting adjusted risk estimates showed no increased risk of congenital anomalies associated with biologics use, suggesting that increased rates of adverse outcomes may be due to disease activity itself or other confounders.
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Affiliation(s)
- Nicole W Tsao
- University of British Columbia Faculty of Pharmaceutical SciencesVancouver, BC, Canada.,Collaboration for Outcomes Research and Evaluation, Vancouver, BC, Canada.,Arthritis Research Canada, Richmond, Vancouver, BC, Canada
| | - Nevena Rebic
- University of British Columbia Faculty of Pharmaceutical SciencesVancouver, BC, Canada.,Collaboration for Outcomes Research and Evaluation, Vancouver, BC, Canada.,Arthritis Research Canada, Richmond, Vancouver, BC, Canada
| | - Larry D Lynd
- Collaboration for Outcomes Research and Evaluation, Vancouver, BC, Canada.,Centre for Health Evaluation & Outcomes Sciences, Vancouver, BC, Canada
| | - Mary A De Vera
- University of British Columbia Faculty of Pharmaceutical SciencesVancouver, BC, Canada.,Collaboration for Outcomes Research and Evaluation, Vancouver, BC, Canada.,Arthritis Research Canada, Richmond, Vancouver, BC, Canada
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Pfaller B, José Yepes‐Nuñez J, Agache I, Akdis CA, Alsalamah M, Bavbek S, Bossios A, Boyman O, Chaker A, Chan S, Chatzipetrou A, Toit G, Jutel M, Kauppi P, Kolios A, Li C, Matucci A, Marson A, Bendien S, Palomares O, Rogala B, Szepfalusi Z, Untersmayr E, Vultaggio A, Eiwegger T. Biologicals in atopic disease in pregnancy: An EAACI position paper. Allergy 2021; 76:71-89. [PMID: 32189356 DOI: 10.1111/all.14282] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 03/10/2020] [Accepted: 03/15/2020] [Indexed: 12/12/2022]
Abstract
Biologicals have transformed the management of severe disease phenotypes in asthma, atopic dermatitis, and chronic spontaneous urticaria. As a result, the number of approved biologicals for the treatment of atopic diseases is continuously increasing. Although atopic diseases are among the most common diseases in the reproductive age, investigations, and information on half-life, pharmacokinetics defining the neonatal Fc receptors (FcRn) and most important safety of biologicals in pregnancy are lacking. Given the complex sequence of immunological events that regulate conception, fetal development, and the intrauterine and postnatal maturation of the immune system, this information is of utmost importance. We conducted a systematic review on biologicals in pregnancy for indications of atopic diseases. Evidence in this field is scarce and mainly reserved to reports on the usage of omalizumab. This lack of evidence demands the establishment of a multidisciplinary approach for the management of pregnant women who receive biologicals and multicenter registries for long-term follow-up, drug trial designs suitable for women in the reproductive age, and better experimental models that represent the human situation. Due to the very long half-life of biologicals, preconception counseling and healthcare provider education are crucial to offer the best care for mother and fetus. This position paper integrates available data on safety of biologicals during pregnancy in atopic diseases via a systematic review with a detailed review on immunological considerations how inhibition of different pathways may impact pregnancy.
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Affiliation(s)
- Birgit Pfaller
- Division of Cardiology Department of Medicine University of Toronto Pregnancy and Heart Disease Research Program Mount Sinai and Toronto General Hospitals Toronto ON Canada
| | | | - Ioana Agache
- Faculty of Medicine Department of Allergy and Clinical Immunology Transylvania University Brasov Brasov Romania
| | - Cezmi A. Akdis
- Swiss Institute of Allergy and Asthma Research (SIAF) Davos Switzerland
| | - Mohammad Alsalamah
- Division of Immunology and Allergy Food Allergy and Anaphylaxis Program The Hospital for Sick Children Toronto ON Canada
- College of Medicine King Saud Bin Abdulaziz University for Health Sciences Riyadh Saudi Arabia
- Clinical Immunology and Allergy Division Pediatrics Department King Abdullah Specialists Children’s Hospital Riyadh Saudi Arabia
| | - Sevim Bavbek
- Division of Immunology and Allergy Department of Chest Disease School of Medicine Ankara University Ankara Turkey
- Department of Respiratory Medicine and Allergy Karolinska University Hospital Huddinge Sweden
| | - Apostolos Bossios
- Department of Medicine Huddinge Stockholm Sweden
- Centre for Allergy Research Karolinska Institutet Stockholm Sweden
| | - Onur Boyman
- Department of Immunology University Hospital Zurich Zurich Switzerland
- Faculty of Medicine University of Zurich Zurich Switzerland
| | - Adam Chaker
- Department of Otolaryngology and Center for Allergy and Environment Technical University of Munich TUM School of Medicine Klinikum rechts der Isar Munich Germany
| | - Susan Chan
- Guy’s and St. Thomas’ NHS Foundation Trust London UK
- King’s College London School of Life Course Sciences School of Immunology Microbial Sciences King’s Health Partners UK
| | - Alexia Chatzipetrou
- Allergy Unit “D. Kalogeromitros Department of Dermatology and Venereology Medical School Attikon” University Hospital University of Athens Athens Greece
- Paediatric Allergy Group Department of Women and Children's Health King's College London London UK
- Paediatric Allergy Group Peter Gorer Dept of Immunobiology School of Immunology & Microbial Sciences King's College London Guys' Hospital London UK
- Children's Allergy Service Evelina Children's Hospital Guy's and St Thomas' Hospital NHS Foundation Trust London UK
| | - George Toit
- Asthma UK Centre in Allergic Mechanisms of Asthma London UK
| | - Marek Jutel
- Department of Clinical Immunology Wroclaw Medical University Wrocław Poland
- ALL‐MED Medical Research Institute Wroclaw Poland
| | - Paula Kauppi
- Department of Allergy Skin and Allergy Hospital Inflammation Center Helsinki University Hospital and University of Helsinki Helsinki Finland
| | - Antonios Kolios
- Department of Immunology University Hospital Zurich Zurich Switzerland
- Faculty of Medicine University of Zurich Zurich Switzerland
| | - Carmen Li
- Division of Immunology and Allergy Food Allergy and Anaphylaxis Program The Hospital for Sick Children Toronto ON Canada
| | - Andrea Matucci
- Immunoallergology Unit Careggi University Hospital Florence Italy
| | - Alanna Marson
- Division of Immunology and Allergy Food Allergy and Anaphylaxis Program The Hospital for Sick Children Toronto ON Canada
| | - Sarah Bendien
- Department of respiratory medicine Haga Teaching Hospital The Hague The Netherlands
| | - Oscar Palomares
- Department of Biochemistry and Molecular Biology Chemistry School Complutense University of Madrid Madrid Spain
| | - Barbara Rogala
- Department of Internal Diseases Allergology & Clinical Immunology Medical University of Silesia Katowice Poland
| | - Zsolt Szepfalusi
- Division of Ped. Pulmonology, Allergology and Endocrinology Dpt. of Pediatrics Medical University of Vienna Vienna Austria
| | - Eva Untersmayr
- Institute of Pathophysiology and Allergy Research Center for Pathophysiology, Infectiology and Immunology Medical University of Vienna Vienna Austria
| | - Alessandra Vultaggio
- Department of Allergy Skin and Allergy Hospital Inflammation Center Helsinki University Hospital and University of Helsinki Helsinki Finland
| | - Thomas Eiwegger
- Division of Immunology and Allergy Food Allergy and Anaphylaxis Program The Hospital for Sick Children Toronto ON Canada
- Department of Immunology University of Toronto Toronto ON Canada
- Translational Medicine Program, Research Institute Hospital for Sick Children Toronto ON Canada
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Clark-Snustad K, Butnariu M, Afzali A. Women's Health and Ulcerative Colitis. Gastroenterol Clin North Am 2020; 49:769-789. [PMID: 33121695 DOI: 10.1016/j.gtc.2020.07.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Although ulcerative colitis affects males and females at similar rates, certain sex-specific differences influence the disease-related risks and experiences of females with ulcerative colitis. This article reviews topics that affect females with ulcerative colitis, including the impact of disease on the menstrual cycle, fertility, child bearing, sexual health, and recommendations for health care maintenance.
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Affiliation(s)
- Kindra Clark-Snustad
- Inflammatory Bowel Disease Program, Division of Gastroenterology, University of Washington, 1959 Northeast Pacific Street, Box 356424, Seattle, WA 98195, USA
| | - Madalina Butnariu
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, 410 W. 10(th) Ave. 2(nd) floor, Columbus, OH 43210, USA
| | - Anita Afzali
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, 395 West 12(th) Avenue, Room 280, Columbus, OH 43210, USA.
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71
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Babuna Kobaner G, Polat Ekinci A. Use of biologic therapies for psoriasis during pregnancy and long-term outcomes of exposed children: A 14-year real-life experience at a tertiary center in Turkey and review of the literature. Dermatol Ther 2020; 33:e14420. [PMID: 33068029 DOI: 10.1111/dth.14420] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 09/24/2020] [Accepted: 10/06/2020] [Indexed: 11/28/2022]
Abstract
Data regarding the use of biologic therapies for psoriasis during pregnancy are scarce with even more limited knowledge about the long-term safety of in utero exposure. We retrospectively evaluated nine pregnancies in six women with psoriasis who were exposed to biologic therapies between 2006 and 2019 in our psoriasis clinic, a tertiary referral center in Turkey. Pregnancy outcomes included the delivery of seven healthy babies without any complications, one elective abortion, and one ectopic pregnancy. All exposed children, aged between 14 months and 13 years (median age: 4.0 years), showed normal growth and neuropsychological development without immunodeficiencies, allergies, malignancies or other diseases. Based on up-to-date collective data in the literature and our real-life clinical experience presented here, exposure to biologic therapies during pregnancy for psoriasis does not seem to be associated with adverse pregnancy or neonatal outcomes. Our results are also reassuring with respect to long-term outcomes of exposed children, but need to be confirmed through further large prospective studies. Nevertheless, use of biologic therapies during late pregnancy, particularly during the third trimester, should be reserved for high-need patients with psoriasis and definitely requires a delicate risk/benefit balance on a case-by-case basis.
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Affiliation(s)
- Goncagul Babuna Kobaner
- Department of Dermatology and Venereology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Algun Polat Ekinci
- Department of Dermatology and Venereology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
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72
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Ali MF, He H, Friedel D. Inflammatory bowel disease and pregnancy: fertility, complications and treatment. Ann Gastroenterol 2020; 33:579-590. [PMID: 33162735 PMCID: PMC7599341 DOI: 10.20524/aog.2020.0536] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 07/27/2020] [Indexed: 12/30/2022] Open
Abstract
Inflammatory bowel disease (IBD) is commonly diagnosed and treated in the young population. Therefore, it is common that women anticipating or undergoing pregnancy will have to cope with the additional burden of their IBD. Pregnancy in an IBD patient also presents challenges for the practitioner, in that the usual diagnostic and therapeutic armamentarium of potential tests and therapies is disrupted. This review covers the implications of IBD for fertility, pregnancy and offspring, and discusses the management of IBD in pregnancy.
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Affiliation(s)
- Mohammad Fahad Ali
- Department of Gastroenterology and Hepatology, Guthrie Cortland Medical Center (Mohammad Fahad Ali)
| | - Harry He
- Department of Medicine, NYU Winthrop University Hospital (Harry He)
| | - David Friedel
- Department of Gastroenterology, NYU Winthrop University Hospital (David Friedel), USA
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73
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Ghalandari N, Dolhain RJEM, Hazes JMW, van Puijenbroek EP, Kapur M, Crijns HJMJ. Intrauterine Exposure to Biologics in Inflammatory Autoimmune Diseases: A Systematic Review. Drugs 2020; 80:1699-1722. [PMID: 32852745 PMCID: PMC7568712 DOI: 10.1007/s40265-020-01376-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Inflammatory autoimmune diseases are chronic diseases that often affect women of childbearing age. Therefore, detailed knowledge of the safety profile of medications used for management of inflammatory autoimmune diseases during pregnancy is important. However, in many cases the potential harmful effects of medications (especially biologics) during pregnancy (and lactation) on mother and child have not been fully identified. OBJECTIVE Our aim was to update the data on the occurrence of miscarriages and (major) congenital malformations when using biologics during pregnancy based on newly published articles. Additionally, we selected several different secondary outcomes that may be of interest for clinicians, especially information on adverse events in the use of a specific biologic during pregnancy. MATERIAL AND METHODS A search was conducted from 1 January 2015 until 4 July 2019 in Embase.com, Medline Ovid, Web of Science, Cochrane CENTRAL, and Google Scholar with specific search terms for each database. Selection of publications was based on title/abstract and followed by full text (double blinded, two researchers). An overview was made based on outcomes of interest. References of the included publications were reviewed to include and minimize the missing publications. RESULTS A total of 143 publications were included. The total number of cases ranged from nine for canakinumab to 4276 for infliximab. The rates of miscarriages and major congenital malformations did not show relevant differences from those rates in the general population. CONCLUSION Despite limitations to our study, no major safety issues were reported and no trend could be identified in the reported malformations.
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Affiliation(s)
- N Ghalandari
- Department of Rheumatology, Erasmus University Medical Center, Rotterdam, The Netherlands.
- Medicines Evaluation Board (MEB), Graadt van Roggenweg 500, 3531 AH, Utrecht, The Netherlands.
- Academic Center of Inflammunity, Erasmus University Medical Center, Rotterdam, The Netherlands.
| | - R J E M Dolhain
- Department of Rheumatology, Erasmus University Medical Center, Rotterdam, The Netherlands
- Academic Center of Inflammunity, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - J M W Hazes
- Department of Rheumatology, Erasmus University Medical Center, Rotterdam, The Netherlands
- Medicines Evaluation Board (MEB), Graadt van Roggenweg 500, 3531 AH, Utrecht, The Netherlands
- Academic Center of Inflammunity, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - E P van Puijenbroek
- Netherlands Pharmacovigilance Centre Lareb, 's Hertogenbosch, The Netherlands
| | - M Kapur
- Utrecht University of Medical Sciences, Utrecht, The Netherlands
| | - H J M J Crijns
- Medicines Evaluation Board (MEB), Graadt van Roggenweg 500, 3531 AH, Utrecht, The Netherlands
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Terjung B, Schmelz R, Ehehalt R, Klaus J, Knop J, Schwind S, Wilke T, Stallmach A. Safety of vedolizumab in the treatment of pregnant women with inflammatory bowel disease: a targeted literature review. Therap Adv Gastroenterol 2020; 13:1756284820952592. [PMID: 33149762 PMCID: PMC7580131 DOI: 10.1177/1756284820952592] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 07/31/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Crohn's disease (CD) and ulcerative colitis (UC) commonly affect women in their childbearing years. Vedolizumab (VDZ) is approved for treatment of moderate-to-severe CD and UC, but there is a knowledge gap regarding its use during pregnancy. This targeted literature review describes available evidence on safety of VDZ in pregnant patients in order to offer physicians a detailed and balanced view on persistent data during their decision-making process for an individualized treatment concept. METHODS The search included literature from the MEDLINE database and abstracts of five gastroenterological conferences published until November 2019. Publications were included if pregnancy outcomes in women receiving VDZ or neonatal outcomes in newborns of women previously exposed to VDZ were reported. RESULTS Out of 196 initially identified records, 18 publications reporting results of five different studies were identified. In total, for 213 of 284 VDZ-exposed documented pregnancies the following pregnancy outcomes were reported: 167 live births (172 infants due to twin births), 1 stillbirth, 35 miscarriages, 10 elective terminations (1 due to detected Down syndrome). Furthermore, during pregnancy, the following complications were observed: seven cases of (pre) eclampsia, three cases of premature rupture of membranes and one case each of placenta previa, chorioamnionitis, pneumonia, first-trimester bleeding, cholestasis, sepsis, or neonatal intraventricular hemorrhage. Based on 172 infants, 30 preterm deliveries (17.4%), 9 cases of low birth weight (5.2%), 5 infections (2.9%), and 6 cases (3.8%) with congenital anomalies were reported. CONCLUSION There was no evidence for safety concerns regarding pregnancy outcomes associated with VDZ therapy. Due to the limited scope of included records, further research is needed to understand the safety profile regarding the use of VDZ during pregnancy.
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Affiliation(s)
- Birgit Terjung
- Department of Internal Medicine - Gastroenterology, GFO Kliniken Bonn, Nordrhein-Westfalen, Germany
| | - Renate Schmelz
- Medical Department 1, University Hospital Dresden, TU Dresden, Germany
| | - Robert Ehehalt
- Gastroenterology Outpatient Clinic Heidelberg, Heidelberg, Germany
| | - Jochen Klaus
- Innere Medizin I, Universitätsklinikum Ulm, Ulm, Germany
| | - Jana Knop
- Takeda Pharma Vertrieb GmbH & Co. KG, Berlin, Germany
| | | | - Thomas Wilke
- Institut für Pharmakoökonomie und Arzneimittellogistik (IPAM) an der Hochschule Wismar, Wismar, Germany
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Duricova D, Mitrova K. Editorial: safety of prenatal exposure to anti-TNF therapy on postnatal infectious complications. Aliment Pharmacol Ther 2020; 52:1216-1217. [PMID: 33016561 DOI: 10.1111/apt.16029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
LINKED CONTENTThis article is linked to Bröms et al paper. To view this article, visit https://doi.org/10.1111/apt.15971
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Affiliation(s)
- Dana Duricova
- IBD Clinical and Research Centre, ISCARE, a.s., Prague, Czech Republic
- Institute of Pharmacology, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Katarina Mitrova
- IBD Clinical and Research Centre, ISCARE, a.s., Prague, Czech Republic
- Department of Paediatrics, 2nd Faculty of Medicine, Charles University in Prague and University Hospital Motol, Prague, Czech Republic
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Törüner M, Akpınar H, Akyüz F, Dağlı Ü, Över Hamzaoğlu H, Tezel A, Ünsal B, Yıldırım S, Çelik AF. 2019 Expert opinion on biological treatment use in inflammatory bowel disease management. TURKISH JOURNAL OF GASTROENTEROLOGY 2020; 30:S913-S946. [PMID: 32207688 DOI: 10.5152/tjg.2019.061119] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Murat Törüner
- Department of Gastroenterology, Ankara University School of Medicine, Ankara, Turkey
| | - Hale Akpınar
- Department of Gastroenterology, Dokuz Eylül University School of Medicine, İzmir, Turkey
| | - Filiz Akyüz
- Department of Gastroenterology, İstanbul University Cerrahpaşa School of Medicine, İstanbul, Turkey
| | - Ülkü Dağlı
- Department of Gastroenterology, Başkent University School of Medicine, İstanbul, Turkey
| | - Hülya Över Hamzaoğlu
- Department of Gastroenterology, İstanbul Acıbadem Fulya Hospital, İstanbul, Turkey
| | - Ahmet Tezel
- Department of Gastroenterology, Trakya University School of Medicine, Edirne, Turkey
| | - Belkıs Ünsal
- Department of Gastroenterology, Katip Çelebi University School of Medicine, İzmir, Turkey
| | - Süleyman Yıldırım
- Department of Gastroenterology, İstanbul University-Cerrahpaşa Cerrahpaşa School of Medicine, İstanbul, Turkey
| | - Aykut Ferhat Çelik
- Department of Gastroenterology, İstanbul University-Cerrahpaşa Cerrahpaşa School of Medicine, İstanbul, Turkey
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Bröms G, Kieler H, Ekbom A, Gissler M, Hellgren K, Leinonen MK, Pedersen L, Schmitt-Egenolf M, Sørensen HT, Granath F. Paediatric infections in the first 3 years of life after maternal anti-TNF treatment during pregnancy. Aliment Pharmacol Ther 2020; 52:843-854. [PMID: 32706178 DOI: 10.1111/apt.15971] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 04/26/2020] [Accepted: 06/26/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Most anti-tumour necrosis factor (anti-TNF) agents are transferred across the placenta and may increase paediatric susceptibility to infections. AIMS To assess the risk of paediatric infections after maternal anti-TNF treatment. METHODS Population-based cohort study in Denmark, Finland and Sweden 2006-2013 in which 1027 children born to women with rheumatoid arthritis, psoriasis, psoriatic arthritis, ankylosing spondylitis or inflammatory bowel disease, treated with anti-TNF, and 9346 children to women with non-biologic systemic treatment, were compared to 1 617 886 children of the general population. Children were followed for 3 years. RESULTS Adjusted by maternal age, parity, smoking, body mass index, country and calendar year, the incidence rate ratios with 95% confidence interval (CI) for hospital admissions for infection in the first year were 1.43 (1.23-1.67) for anti-TNF and 1.14 (1.07-1.21) for non-biologic systemic treatment, and 1.29 (1.11-1.50) and 1.09 (1.02-1.15), respectively, when additionally adjusting for adverse birth outcomes. There was a slight increase in antibiotic prescriptions in the second year for anti-TNF, 1.19 (1.11-1.29), and for non-biologic systemic treatment, 1.10 (1.07-1.13). There was no difference among anti-TNF agents, treatment in the third trimester, or between mono/combination therapy with non-biologic systemic treatment. CONCLUSIONS Both anti-TNF and non-biologic systemic treatment were associated with an increased risk of paediatric infections. However, reassuringly, the increased risks were present regardless of treatment in the third trimester, or with combination treatment, and were not persistent during the first 3 years of life. Our findings may indicate a true risk, but could also be due to unadjusted confounding by disease severity and healthcare-seeking behaviour. This may in turn shift the risk-benefit equation towards continuation of treatment even in the third trimester.
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78
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Nørgård BM, Nielsen J, Friedman S. In utero exposure to thiopurines/anti-TNF agents and long-term health outcomes during childhood and adolescence in Denmark. Aliment Pharmacol Ther 2020; 52:829-842. [PMID: 32677731 DOI: 10.1111/apt.15956] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 05/15/2020] [Accepted: 06/20/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Data on long-term health outcomes of children exposed in utero to thiopurines and anti-TNF medications are lacking. AIMS To examine the association between in utero exposure to thiopurines and anti-TNF medications and child health outcomes of site-specific groups of infections, using a composite endpoint including psychiatric diagnoses/autism spectrum disorder (ASD)/attention deficit hyperactivity disorder (ADHD), and malignancies during childhood/adolescence. METHODS A nationwide cohort study based on Danish health registries included 1 311 009 live born children during 1995 through 2015. Outcomes were based on hospital diagnoses (in-patients/out-patients/emergency department contacts). RESULTS In total, 1048 children were exposed in utero to thiopurines and 1 309 961 were unexposed. The adjusted hazard ratios (HRs) for site-specific groups of infections in the first 3 years of life were close to unity. The adjusted HR of psychiatric diagnoses/ASD/ADHD was 1.11 (95% CI 0.81-1.52). The HR of malignancies was not calculated (only two events among the exposed). In total, 493 children were exposed in utero to anti-TNF medications and 728 055 were unexposed. Within the first year of life, the adjusted HR of respiratory, urological/gynaecological infections and other infections were 1.34 (95% CI 1.03-1.74), 2.36 (95% CI 1.15-4.81) and 1.61 (95% CI 1.21-2.13), respectively. We found no increased risk of other adverse outcomes. CONCLUSIONS After in utero exposure to thiopurines, we found no increased risk of infections, psychiatric diagnoses/ASD/ADHD, or malignancies during childhood/adolescence. After in utero exposure to anti-TNF medications, the risk of respiratory, urological/gynaecological infections and other infections was increased during the first year of life.
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Affiliation(s)
- Bente Mertz Nørgård
- Center for Clinical Epidemiology, Odense University Hospital, and Research Unit of Clinical Epidemiology, University of Southern Denmark, Odense, Denmark.,Center for Crohn's and Colitis, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jan Nielsen
- Center for Clinical Epidemiology, Odense University Hospital, and Research Unit of Clinical Epidemiology, University of Southern Denmark, Odense, Denmark
| | - Sonia Friedman
- Center for Clinical Epidemiology, Odense University Hospital, and Research Unit of Clinical Epidemiology, University of Southern Denmark, Odense, Denmark.,Center for Crohn's and Colitis, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Ciobanu AM, Dumitru AE, Gica N, Botezatu R, Peltecu G, Panaitescu AM. Benefits and Risks of IgG Transplacental Transfer. Diagnostics (Basel) 2020; 10:E583. [PMID: 32806663 PMCID: PMC7459488 DOI: 10.3390/diagnostics10080583] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 08/07/2020] [Accepted: 08/10/2020] [Indexed: 12/13/2022] Open
Abstract
Maternal passage of immunoglobulin G (IgG) is an important passive mechanism for protecting the infant while the neonatal immune system is still immature and ineffective. IgG is the only antibody class capable of crossing the histological layers of the placenta by attaching to the neonatal Fc receptor expressed at the level of syncytiotrophoblasts, and it offers protection against neonatal infectious pathogens. In pregnant women with autoimmune or alloimmune disorders, or in those requiring certain types of biological therapy, transplacental passage of abnormal antibodies may cause fetal or neonatal harm. In this review, we will discuss the physiological mechanisms and benefits of transplacental transfer of maternal antibodies as well as pathological maternal situations where this system is hijacked, potentially leading to adverse neonatal outcomes.
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Affiliation(s)
- Anca Marina Ciobanu
- Carol Davila University of Medicine and Pharmacy, Bucharest 020021, Romania; (A.M.C.); (N.G.); (R.B.); (G.P.)
- Filantropia Clinical Hospital, Bucharest 11171, Romania;
| | | | - Nicolae Gica
- Carol Davila University of Medicine and Pharmacy, Bucharest 020021, Romania; (A.M.C.); (N.G.); (R.B.); (G.P.)
- Filantropia Clinical Hospital, Bucharest 11171, Romania;
| | - Radu Botezatu
- Carol Davila University of Medicine and Pharmacy, Bucharest 020021, Romania; (A.M.C.); (N.G.); (R.B.); (G.P.)
- Filantropia Clinical Hospital, Bucharest 11171, Romania;
| | - Gheorghe Peltecu
- Carol Davila University of Medicine and Pharmacy, Bucharest 020021, Romania; (A.M.C.); (N.G.); (R.B.); (G.P.)
- Filantropia Clinical Hospital, Bucharest 11171, Romania;
| | - Anca Maria Panaitescu
- Carol Davila University of Medicine and Pharmacy, Bucharest 020021, Romania; (A.M.C.); (N.G.); (R.B.); (G.P.)
- Filantropia Clinical Hospital, Bucharest 11171, Romania;
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The exposure to biologic and targeted synthetic disease-modifying antirheumatic drugs in pregnancy and lactation. Postepy Dermatol Alergol 2020; 37:306-312. [PMID: 32774212 PMCID: PMC7394167 DOI: 10.5114/ada.2020.96294] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 06/03/2019] [Indexed: 02/07/2023] Open
Abstract
Chronic inflammatory diseases often affect women of childbearing age. Since biologic and targeted synthetic disease-modifying antirheumatic drugs (bDMARDs and tsDMARDs) are more available, their use during conception, pregnancy and lactation has become a matter of concern. Current studies prove the safety of innovative therapy in pregnant women and may contribute to its wider use than before in pregnancy and lactation. It mainly concerns tumour necrosis factor α (TNF-α) inhibitors. We searched PubMed using Medical Subject Headings (MeSH) terms and identified relevant studies and guidelines. We present up-to-date knowledge of bDMARDs and tsDMARDs safety in pregnant and breastfeeding women.
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Abstract
Inflammatory bowel disease (IBD) is an immune-mediated disease, which often require lifetime treatment with immunomodulators and immunosuppressive drugs. Both IBD and its treatments are associated with an increased risk of infectious disease and mortality. Several of these diseases are vaccine preventable and could be avoided, reducing morbidity and mortality. However, vaccination rates among patients with IBD are lower than in the general population and both patients and doctors are not fully aware of the problem. Education campaigns and well planned vaccination schemes are necessary to improve vaccination coverage in patients with IBD. Immunomodulators and immunosuppressive drugs may reduce the seroprotection levels. For this reason, new vaccination schemes are being studied in patients with IBD. It is therefore important to understand which and when vaccines can be administrated based on immunocompetence or immunosuppression of patients. Usually, live-attenuated vaccines should be avoided in immunosuppressed patients, so assessing vaccination status and planning vaccination before immunosuppressive treatments are pivotal to reduce infection risk. The aim of this review is to increase the awareness of the problem and provide a quick reference for vaccination plan tailoring, especially for gastroenterologists and primary care physicians, who have the skills and knowledge to implement vaccination strategies.
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82
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Rosen MH, Axelrad J, Hudesman D, Rubin DT, Chang S. Management of Acute Severe Ulcerative Colitis in a Pregnant Woman With COVID-19 Infection: A Case Report and Review of the Literature. Inflamm Bowel Dis 2020; 26:971-973. [PMID: 32393973 PMCID: PMC7239163 DOI: 10.1093/ibd/izaa109] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Indexed: 12/13/2022]
Abstract
First detected in Wuhan, China, the novel 2019 severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is an enveloped RNA beta-coronavirus responsible for an unprecedented, worldwide pandemic caused by COVID-19. Optimal management of immunosuppression in inflammatory bowel disease (IBD) patients with COVID-19 infection currently is based on expert opinion, given the novelty of the infection and the corresponding lack of high-level evidence in patients with immune-mediated conditions. There are limited data regarding IBD patients with COVID-19 and no data regarding early pregnancy in the era of COVID-19. This article describes a patient with acute severe ulcerative colitis (UC) during her first trimester of pregnancy who also has COVID-19. The case presentation is followed by a review of the literature to date on COVID-19 in regard to inflammatory bowel disease and pregnancy, respectively.
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Affiliation(s)
- Melissa H Rosen
- Division of Gastroenterology and Hepatology, NYU Langone Health, New York, NY
| | - Jordan Axelrad
- Division of Gastroenterology and Hepatology, NYU Langone Health, New York, NY
| | - David Hudesman
- Division of Gastroenterology and Hepatology, NYU Langone Health, New York, NY
| | - David T Rubin
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL
| | - Shannon Chang
- Division of Gastroenterology and Hepatology, NYU Langone Health, New York, NY
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83
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Yeung J, Gooderham MJ, Grewal P, Hong CH, Lansang P, Papp KA, Poulin Y, Turchin I, Vender R. Management of Plaque Psoriasis With Biologic Therapies in Women of Child-Bearing Potential Consensus Paper. J Cutan Med Surg 2020; 24:3S-14S. [PMID: 32500730 DOI: 10.1177/1203475420928376] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Plaque psoriasis (PsO) is a chronic inflammatory disease that often presents at peak reproductive age in women of child-bearing potential (WOCBP). With the emergence of biologic therapies to treat PsO, guidance on disease management in WOCBP is needed to inform treatment decisions before, during, and after pregnancy. OBJECTIVES To develop a practical, up-to-date consensus document, based on available evidence and expert opinion where evidence was lacking, in order to guide both Canadian and international clinicians treating PsO in WOCBP. METHODS A panel of 9 Canadian dermatologists with extensive clinical experience managing PsO reviewed the relevant literature from the past 25 years in 3 key domains: overview of PsO in WOCBP and clinical considerations, treatment considerations, and postpartum considerations. The structured literature search focused on WOCBP treated with TNF-alpha inhibitors (adalimumab, certolizumab, etanercept, golimumab, infliximab), IL-23 inhibitors (guselkumab, risankizumab, tildrakizumab), IL-12/23 inhibitors (ustekinumab), and IL-17 inhibitors (brodalumab, ixekizumab, secukinumab). This literature review, along with clinical expertise and opinion, was used to develop concise and clinically relevant consensus statements to guide practical management of PsO in WOCBP. Experts voted on the statements using a modified Delphi process and prespecified agreement cut-off of 75%. RESULTS AND IMPLICATIONS After review, discussion, and voting on 19 draft consensus statements at an in-person meeting and remotely, 12 consensus statements were approved by the expert panel. The statements presented here will guide healthcare providers in practical disease management using biologic therapies for the treatment of PsO in WOCBP.
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Affiliation(s)
- Jensen Yeung
- Division of Dermatology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,468790 2129 Probity Medical Research, Waterloo, ON, Canada.,Division of Dermatology, Women's College Hospital, Toronto, ON, Canada.,7938 Division of Dermatology, Faculty of Medicine, University of Toronto, ON, Canada
| | - Melinda J Gooderham
- 468790 2129 Probity Medical Research, Waterloo, ON, Canada.,SKiN Centre for Dermatology, Peterborough, ON, Canada.,Queen's University, Kingston, ON, Canada
| | - Parbeer Grewal
- 468790 2129 Probity Medical Research, Waterloo, ON, Canada.,3158 Division of Dermatology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada.,Stratica Medical Centre for Dermatology, Edmonton, AB, Canada
| | - Chih-Ho Hong
- 468790 2129 Probity Medical Research, Waterloo, ON, Canada.,Dr. Chih-ho Hong Medical Inc., Surrey, BC, Canada.,Department of Dermatology and Skin Science, University of British Columbia, Vancouver, BC, Canada
| | - Perla Lansang
- Division of Dermatology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Division of Dermatology, Women's College Hospital, Toronto, ON, Canada.,7938 Division of Dermatology, Faculty of Medicine, University of Toronto, ON, Canada
| | - Kim A Papp
- 468790 2129 Probity Medical Research, Waterloo, ON, Canada.,K Papp Clinical Research, Waterloo, ON, Canada
| | - Yves Poulin
- Centre de Recherche Dermatologique du Québec Métropolitain, Quebec City, QC, Canada
| | - Irina Turchin
- 468790 2129 Probity Medical Research, Waterloo, ON, Canada.,Brunswick Dermatology Centre, Fredericton, NB, Canada.,Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Ronald Vender
- Department of Medicine, McMaster University, Hamilton, ON, Canada.,Dermatrials Research, Dermatology Centre, Hamilton, ON, Canada
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84
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Abstract
PURPOSE OF REVIEW To provide an update about the impact of infections in autoimmune rheumatic diseases (ARDs), from the analysis of the role of infections in pregnant women without ARDs, to the identification of maternal-fetal infections and their role in the maternal-fetal outcome of women with ARDs. RECENT FINDINGS Recent studies indicate that patients with ARDs and pregnancy are also susceptible to presenting infections of varying degrees, including serious infections, which contribute to the morbidity and mortality observed in pregnancy and postpartum of these patients.Any type of infectious agent will interact with a hormonal, immunological and metabolic environments modified by ARD, treatments, and by the changes inherent in pregnancy. Therefore, infections in the pregnancy of patients with ARDs should be considered as a risk factor for an unfavorable maternal-fetal outcome. SUMMARY The recognition of infections in the pregnancy of ARDs as a risk factor is the first step to prevent, identify, and treat them in a timely manner, and thus contribute to the favorable course of pregnancy in these patients. Patients with ARDs and major organ involvement, use of high doses of steroids, immunosuppressant and biological therapies, adolescence, and obesity are populations susceptible to developing infections.
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85
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Selinger CP, Nelson-Piercy C, Fraser A, Hall V, Limdi J, Smith L, Smith M, Nasur R, Gunn M, King A, Mohan A, Mulgabal K, Kent A, Kok KB, Glanville T. IBD in pregnancy: recent advances, practical management. Frontline Gastroenterol 2020; 12:214-224. [PMID: 33912333 PMCID: PMC8040511 DOI: 10.1136/flgastro-2019-101371] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 04/27/2020] [Accepted: 05/04/2020] [Indexed: 02/04/2023] Open
Abstract
Inflammatory bowel disease (IBD) poses complex issues in pregnancy, but with high-quality care excellent pregnancy outcomes are achievable. In this article, we review the current evidence and recommendations for pregnant women with IBD and aim to provide guidance for clinicians involved in their care. Many women with IBD have poor knowledge about pregnancy-related issues and a substantial minority remains voluntarily childless. Active IBD is associated with an increased risk of preterm birth, low for gestation weight and fetal loss. With the exception of methotrexate and tofacitinib the risk of a flare outweighs the risk of IBD medication and maintenance of remission from IBD should be the main of care. Most women with IBD will experience a normal pregnancy and can have a vaginal delivery. Active perianal Crohn's disease is an absolute and ileal pouch surgery a relative indication for a caesarean section. Breast feeding is beneficial to the infant and the risk from most IBD medications is negligible.
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Affiliation(s)
| | | | - Aileen Fraser
- Gastroenterology, United Hospitals Bristol, Bristol, Avon, UK
| | - Veronica Hall
- Gastroenterology, Royal Bolton Foundation NHS Trust, Bolton, UK
| | - Jimmy Limdi
- Section of iBD- Division of Gastroenterology, The Pennine Acute Hospitals NHS Trust, Manchester, UK,Gastroenterology, Manchester Academic Health Science Centre, Manchester, UK
| | - Lyn Smith
- Gastroenterology, NHS Greater Glasgow and Clyde North Glasgow University Hospitals Division, Glasgow, UK
| | - Marie Smith
- Obstetrics, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Reem Nasur
- Obstetrics, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Melanie Gunn
- Gastroenterology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, Tyne and Wear, UK
| | - Andrew King
- Gastroenterology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, Tyne and Wear, UK
| | - Aarthi Mohan
- Obstetrics, United Hospitals Bristol, Bristol, Avon, UK
| | | | - Alexandra Kent
- Gastroenterology, King's College Hospital NHS Foundation Trust, London, UK
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86
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Singh S, Picardo S, Seow CH. Management of Inflammatory Bowel Diseases in Special Populations: Obese, Old, or Obstetric. Clin Gastroenterol Hepatol 2020; 18:1367-1380. [PMID: 31712084 PMCID: PMC7183892 DOI: 10.1016/j.cgh.2019.11.009] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 10/25/2019] [Accepted: 11/04/2019] [Indexed: 02/07/2023]
Abstract
The epidemiology of inflammatory bowel disease (IBD) is progressively evolving impacting the type of patients with IBD we will see in clinical practice. In this review, we discuss specific challenges and solutions in the management of (1) obese, (2) older and (3) obstetric (pregnant) patients with IBD. With the global obesity epidemic, almost 1 in 3 patients with IBD are obese. Obesity is associated with greater difficulty in achieving remission, higher risk of disease relapse and higher burden and costs of hospitalization in patients with IBD. Obese patients also have inferior response to biologic therapy related to altered pharmacokinetics and obesity-mediated chronic inflammation. Surgical management of obese patients with IBD is also challenging. Similar to obesity, the prevalence of IBD in older patients is rising and it is anticipated that almost one-third of patients with IBD will be older than 60 years within the next decade. Older patients present unique diagnostic and therapeutic dilemmas, and management of these individuals warrants careful consideration of the risks of disease-related versus treatment-related complications, non-IBD-related extra-intestinal complications (eg, cardiovascular disease, malignancy), in the context of individual values, preferences, functional status and comorbidities. With evolving therapeutics, medical management of IBD surrounding pregnancy continues to be challenging. Overall, the management of pregnant patients requires a pro-active, multidisciplinary approach, with an emphasis on optimal disease control not just during, but prior to pregnancy. This often involves continuation of highly effective therapies, of which the vast majority are safe during pregnancy and breastfeeding, resulting in a reduction of risk of adverse maternal fetal outcomes.
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Affiliation(s)
- Siddharth Singh
- Division of Gastroenterology, University of California San Diego, La Jolla, California; Division of Biomedical Informatics, University of California San Diego, La Jolla, California.
| | - Sherman Picardo
- Inflammatory Bowel Disease Centre, Department of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
| | - Cynthia H. Seow
- Inflammatory Bowel Disease Centre, Department of Gastroenterology, University of Calgary, Calgary, Alberta, Canada,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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87
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Szymańska E, Kisielewski R, Kierkuś J. Reproduction and Pregnancy in Inflammatory Bowel Disease - Management and Treatment Based on Current Guidelines. J Gynecol Obstet Hum Reprod 2020; 50:101777. [PMID: 32315763 DOI: 10.1016/j.jogoh.2020.101777] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 01/06/2020] [Accepted: 04/16/2020] [Indexed: 02/07/2023]
Abstract
Inflammatory bowel diseases (IBD) affect mainly young population. Therefore, fertility and pregnancy are important clinical issues to be considered. Generally, fertility in IBD patients is not decreased either in males or females when compared to a healthy population. Moreover, drugs used for IBD treatment do not significantly affect fertility in humans. However, prolonged treatment with sulphasalazine may reduce semen quality and cause reversible infertility. Since the disease course and a risk of pregnancy-related complications depend mainly on disease activity at the time of conception, female patients with IBD should plan their pregnancy during a remission phase. Methotrexate, mycophenolate mofetil and thalidomide are strongly contraindicated during pregnancy. Other medications used for IBD seem to be safe provided that they are administered with caution. In 2015, European Crohn's and Colitis Organisation (ECCO) published its Consensus on Reproduction and Pregnancy in IBD. However, management of IBD during the reproductive age and during pregnancy still remains controversial, since evidence-based data come mostly from retrospective studies. The aim of this paper was to discuss the issue of reproduction and pregnancy in IBD patients based on current ECCO guidelines and literature.
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Affiliation(s)
- Edyta Szymańska
- Department of Gastroenterology, Hepatology, Nutrition Disorders and Pediatrics, The Children's Memorial Health Institute, Warsaw, Poland.
| | - Rafał Kisielewski
- Department of Gynecologic Oncology, Oncology Centre, Bialystok, Poland
| | - Jarosław Kierkuś
- Department of Gastroenterology, Hepatology, Nutrition Disorders and Pediatrics, The Children's Memorial Health Institute, Warsaw, Poland
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88
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Geldhof A, Slater J, Clark M, Chandran U, Coppola D. Exposure to Infliximab During Pregnancy: Post-Marketing Experience. Drug Saf 2020; 43:147-161. [PMID: 31677004 PMCID: PMC7007430 DOI: 10.1007/s40264-019-00881-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background Women of childbearing potential are often treated with monoclonal antibodies to control chronic and debilitating inflammatory diseases. Remicade® (innovator infliximab [IFX]) may cross the placenta after the first trimester of pregnancy. Hence, evidence is needed to optimize treatment while carefully weighing benefits and risks to the mother and child. Here, we report on birth and infant outcomes (up to 2 years) following gestational exposure to IFX based on a summary of cumulative pregnancy reports in women exposed to IFX during pregnancy from the Janssen global safety database. Methods Prospective and medically confirmed safety data on IFX-exposed pregnancies from Janssen’s global safety surveillance database since authorization in 1998 are summarized. Descriptive statistics were used to summarize pregnancy and infant outcomes overall, by disease and timing of exposure. Results As of 23 August 2018, 1850 maternally IFX-exposed pregnancies with known outcomes were identified from the safety database. Of the 1850 pregnancies (mean age 29.7 years), 1526 (82.5%) resulted in live births. When reported, most women had Crohn’s disease (67.7%) or ulcerative colitis (18.4%), and 82.8% of live births were exposed to IFX in the first trimester. Spontaneous abortion/intrauterine death/ectopic pregnancy/molar pregnancy (12.1%), preterm births (9.2%), low birth weight infants (3.6%), congenital anomalies (2.0%), and infant infections (1.2%) were documented. The type of congenital anomalies and frequency of serious infant infections observed were consistent with the general population. Frequencies of congenital anomalies and other adverse outcomes were similar in women exposed to IFX in the first trimester and those exposed in the third trimester. More preterm births (13–18.8%) and infant complications (8.7–12.5%) were reported with concomitant immunosuppressant use. Conclusions The observed prevalence of adverse pregnancy and infant outcomes including congenital anomalies following exposure to IFX did not exceed estimates reported for the general population and no unexpected patterns were observed.
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Affiliation(s)
- Anja Geldhof
- Janssen Biologics B.V., Medical Affairs, Einsteinweg 101, 2333, Leiden, CB, The Netherlands.
| | | | - Michael Clark
- Janssen Research and Development, Spring House, PA, USA
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89
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The impact of pregnancy on biologic therapies for the treatment of inflammatory bowel disease. Best Pract Res Clin Gastroenterol 2020; 44-45:101670. [PMID: 32359682 DOI: 10.1016/j.bpg.2020.101670] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 03/04/2020] [Accepted: 03/05/2020] [Indexed: 01/31/2023]
Abstract
Active inflammatory bowel disease during conception and pregnancy has been associated with adverse materno-fetal outcomes. Patients are often unduly concerned about the adverse effects of biologic medications on the growing fetus, however, continuing therapy is advised, with potential risks of therapy outweighed by the risks of active maternal disease. A number of physiological changes associated with pregnancy can alter the absorption, distribution and elimination of these therapies, which may impact on their safety and efficacy. We review the current evidence regarding the effects of pregnancy on the pharmacokinetics of biologic therapies, as well as drug concentration measurements during pregnancy and at time of delivery. A greater understanding of the impact of pregnancy on the pharmacokinetics of biologic therapies and the emerging utilisation of drug concentration monitoring during pregnancy may lead to improved materno-fetal outcomes in patients with inflammatory bowel disease.
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90
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Foulon A, Chevreau J, Yzet C, Gondry J, Fumery M. [IBD and pregnancy: From conception to birth]. ACTA ACUST UNITED AC 2020; 48:514-519. [PMID: 32145453 DOI: 10.1016/j.gofs.2020.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Indexed: 10/24/2022]
Abstract
Inflammatory Bowel Diseases (IBD) are chronic conditions affecting young people in their reproductive age. Patient misinformation can be responsible for a self-imposed infertility as well as a suboptimal observance during pregnancy. The aim of this work was to review the influence of IBD and pregnancy on one another at each gestational stage and according to current literature. IBD activity is a major influential factor. In case of a well-controlled IBD, fertility won't be affected and pregnancy will take place without increase risk of complications. With the exception of thalidomide and methotrexate, most of treatments used in IBD are compatible with pregnancy and breastfeeding. Each flare should be optimally managed. Vaginal delivery is a safe option except for patients with active anoperineal lesions. Cesarean section should be systematically discuss in patient with ileal pouch-anal anastomosis.
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Affiliation(s)
- A Foulon
- Centre de gynécologie-obstétrique, CHU Amiens-Picardie, 1, rue du Professeur-Christian-Cabrol, 80054 Amiens, France.
| | - J Chevreau
- Centre de gynécologie-obstétrique, CHU Amiens-Picardie, 1, rue du Professeur-Christian-Cabrol, 80054 Amiens, France
| | - C Yzet
- Service de gastro-entérologie, CHU Amiens-Picardie, 1, rue du Professeur-Christian-Cabrol, 80054 Amiens, France; Université Picardie-Jules-Vernes, UFR de médecine, 3, rue des Louvels, 80000 Amiens, France
| | - J Gondry
- Centre de gynécologie-obstétrique, CHU Amiens-Picardie, 1, rue du Professeur-Christian-Cabrol, 80054 Amiens, France; Université Picardie-Jules-Vernes, UFR de médecine, 3, rue des Louvels, 80000 Amiens, France
| | - M Fumery
- Service de gastro-entérologie, CHU Amiens-Picardie, 1, rue du Professeur-Christian-Cabrol, 80054 Amiens, France; Université Picardie-Jules-Vernes, UFR de médecine, 3, rue des Louvels, 80000 Amiens, France
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91
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Tandon P, Govardhanam V, Leung K, Maxwell C, Huang V. Systematic review with meta-analysis: risk of adverse pregnancy-related outcomes in inflammatory bowel disease. Aliment Pharmacol Ther 2020; 51:320-333. [PMID: 31912546 DOI: 10.1111/apt.15587] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 09/19/2019] [Accepted: 10/28/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND The effect of inflammatory bowel disease (IBD) on pregnancy-related outcomes remains unknown. AIM To determine the risk of adverse maternal, placental and obstetric outcomes in IBD METHODS: We searched Medline, Embase and Cochrane library through May 2019 for studies reporting adverse maternal, placental and obstetric outcomes in patients with IBD. Odds ratios (OR) with 95% confidence intervals (CI) were calculated for these outcomes in patients with IBD compared to healthy controls. RESULTS Fifty-three studies were included (7917 IBD pregnancies and 3253 healthy control pregnancies). Caesarean delivery was more common in patients with IBD compared to healthy controls (OR 1.79, 95% CI, 1.16-2.77). This remained significant for UC (OR 1.80, 95% CI, 1.21-2.90) but not CD (OR 1.48, 95% CI, 0.94-2.34). Similarly, gestational diabetes occurred more commonly in IBD (OR 2.96, 95% CI, 1.47-5.98). The incidences of placental diseases were 2.0% (95% CI, 0.9%-3.1%) for pre-eclampsia, 3.3% (95% CI, 0%-7.2%) for placental abruption, 0.5% (95% CI, 0.2%-0.9%) for placenta previa and 0.3% (95% CI, 0%-0.5%) for chorioamnionitis. Patients with IBD were more likely to experience preterm prelabour rupture of membranes (OR 12.10, 95% CI, 2.15-67.98), but not early pregnancy loss (OR 1.63, 95% CI 0.49-5.43). Anti-tumour necrosis factor therapy was not associated with chorioamnionitis (OR 1.12, 95% CI, 0.16-7.67), early pregnancy loss (OR 1.49, 95% CI, 0.83-2.64) or placenta previa (OR 1.58, 95% CI, 0.30-8.47). CONCLUSIONS Gestational diabetes and preterm prelabour rupture of membranes occurs more commonly in patients with IBD, although the incidence of placental diseases remains low.
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Affiliation(s)
- Parul Tandon
- Division of Gastroenterology, University of Toronto, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
| | | | - Kristel Leung
- Division of Gastroenterology, University of Toronto, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Cynthia Maxwell
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Vivian Huang
- Division of Gastroenterology, University of Toronto, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
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92
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Rottenstreich A, Bar-Gil Shitrit A. Preconception counseling of females with inflammatory bowel disease. Best Pract Res Clin Gastroenterol 2020; 44-45:101666. [PMID: 32359680 DOI: 10.1016/j.bpg.2020.101666] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Accepted: 01/14/2020] [Indexed: 02/06/2023]
Abstract
Inflammatory bowel diseases (IBD) are commonly diagnosed in women of childbearing age. As such, pregnancy is often encountered in this subset of patients. Management of pregnancy in IBD patients poses numerous challenges as ensuring the safety of the mother and the fetus is required. Disease remission prior to pregnancy is a key determinant of both the course of IBD throughout gestation and pregnancy outcome. Thus, adequate preconception care is of paramount importance in order to achieve optimal maternal and perinatal outcomes and maintain disease quiescence throughout gestation. In addition, preconception care has a major role in improving patient's knowledge, concerns and misbeliefs related to reproductive-health issues among IBD patients. In this review, we discuss the various aspects involved in the preconception care of IBD patients.
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Affiliation(s)
- Amihai Rottenstreich
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Ariella Bar-Gil Shitrit
- IBD MOM Unit, Digestive Diseases Institute, Shaare Zedek Medical Center, Affiliated with the Medical School, Hebrew University, Jerusalem, Israel.
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93
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Julsgaard M, Hvas CL, Gearry RB, Gibson PR, Fallingborg J, Sparrow MP, Bibby BM, Connell WR, Brown SJ, Kamm MA, Lawrance IC, Vestergaard T, Svenningsen L, Baekdal M, Kammerlander H, Walsh A, Boysen T, Bampton P, Radford-Smith G, Kjeldsen J, Andrews JM, Subramaniam K, Moore GT, Jensen NM, Connor SJ, Wildt S, Wilson B, Ellard K, Christensen LA, Bell SJ. Anti-TNF Therapy in Pregnant Women With Inflammatory Bowel Disease: Effects of Therapeutic Strategies on Disease Behavior and Birth Outcomes. Inflamm Bowel Dis 2020; 26:93-102. [PMID: 31141607 DOI: 10.1093/ibd/izz110] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Active inflammatory bowel disease (IBD) adversely affects pregnancy outcomes. Little is known about the risk of relapse after stopping anti-tumor necrosis factor (anti-TNF) treatment during pregnancy. We assessed the risk of relapse before delivery in women who discontinued anti-TNF treatment before gestational week (GW) 30, predictors of reduced infant birth weight, a marker associated with long-term adverse outcomes, and rates and satisfaction with counseling. METHODS Pregnant women with IBD receiving anti-TNF treatment were prospectively invited to participate in an electronic questionnaire carried out in 22 hospitals in Denmark, Australia, and New Zealand from 2011 to 2015. Risk estimates were calculated, and birth weight was investigated using t tests and linear regression. RESULTS Of 175 women invited, 153 (87%) responded. In women in remission, the relapse rate did not differ significantly between those who discontinued anti-TNF before GW 30 (1/46, 2%) compared with those who continued treatment (8/74, 11%; relative risk, 0.20; 95% confidence interval [CI], 0.02 to 1.56; P = 0.08). Relapse (P = 0.001) and continuation of anti-TNF therapy after GW 30 (P = 0.007) were independently associated with reduced mean birth weight by 367 g (95% CI, 145 to 589 g; relapse) and 274 g (95% CI, 77 to 471 g; anti-TNF exposure after GW 30). Of 134 (88%) women who received counseling, 116 (87%) were satisfied with the information provided. CONCLUSIONS To minimize fetal exposure in women in remission, discontinuation of anti-TNF before GW 30 seems safe. Relapse and continuation of anti-TNF therapy after GW 30 were each independently associated with lower birth weight, although without an increased risk for birth weight <2500 g. Most women received and were satisfied with counseling.
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Affiliation(s)
- Mette Julsgaard
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark.,Department of Medicine, Horsens Hospital, Horsens, Denmark.,Department of Gastroenterology, St Vincent's Hospital, and University of Melbourne, Melbourne, Australia
| | - Christian L Hvas
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Richard B Gearry
- Department of Medicine, Christchurch Hospital, University of Otago, Christchurch, New Zealand
| | - Peter R Gibson
- Department of Gastroenterology, Alfred Hospital, and Monash University, Melbourne, VIC, Australia
| | - Jan Fallingborg
- Department of Gastroenterology, Aalborg University Hospital, Aalborg, Denmark
| | - Miles P Sparrow
- Department of Gastroenterology, Alfred Hospital, and Monash University, Melbourne, VIC, Australia
| | - Bo M Bibby
- Department of Biostatistics, University of Aarhus, Aarhus, Denmark
| | - William R Connell
- Department of Gastroenterology, St Vincent's Hospital, and University of Melbourne, Melbourne, Australia
| | - Steven J Brown
- Department of Gastroenterology, St Vincent's Hospital, and University of Melbourne, Melbourne, Australia
| | - Michael A Kamm
- Department of Gastroenterology, St Vincent's Hospital, and University of Melbourne, Melbourne, Australia
| | - Ian C Lawrance
- School of Medicine and Pharmacology, University of Western Australia, Harry Perkins Institute for Medical Research, Murdoch, WA, Australia.,Centre for inflammatory Bowel Diseases, Saint John of God Hospital, Subiaco, WA, Australia
| | - Thea Vestergaard
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Lise Svenningsen
- Department of Medicine, Horsens Hospital, Horsens, Denmark.,Department of Medicine, Herning Hospital, Herning, Denmark
| | - Mille Baekdal
- Gastrounit, Medical Division, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark
| | - Heidi Kammerlander
- Department of Gastroenterology, Hospital of Southwest Jutland, Esbjerg, Denmark.,Department of Gastroenterology, Odense University Hospital, Odense, Denmark
| | - Alissa Walsh
- Department of Gastroenterology, St. Vincent's Hospital, Sydney, NSW, Australia
| | - Trine Boysen
- Gastrounit, Medical Division, Herlev Hospital, University of Copenhagen, Herlev, Denmark
| | - Peter Bampton
- Department of Gastroenterology, Flinders Medical Centre, Bedford Park, SA, Australia
| | - Graham Radford-Smith
- Inflammatory Bowel Diseases Unit, Royal Brisbane & Women's Hospital, University of Queensland School of Medicine, Brisbane, QLD, Australia
| | - Jens Kjeldsen
- Department of Gastroenterology, Odense University Hospital, Odense, Denmark
| | - Jane M Andrews
- Department of Gastroenterology & Hepatology, Royal Adelaide Hospital, University of Adelaide, Adelaide, SA, Australia
| | - Kavitha Subramaniam
- Gastroenterology and Hepatology Unit, The Canberra Hospital, Australian National University, Canberra, ACT, Australia
| | - Gregory T Moore
- Department of Gastroenterology, Monash Health, and School of Clinical Sciences Monash University, Melbourne, VIC, Australia
| | - Nanna M Jensen
- Abdominalcenter K, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Susan J Connor
- Department of Gastroenterology, Liverpool Hospital, Sydney, University of NSW, and Ingham Institute of Applied Medical Research, Sydney, Australia
| | - Signe Wildt
- Medical Department, Zealand University Hospital, Køge, Denmark
| | - Benedicte Wilson
- Department of Internal Medicine, Nykøbing Falster Hospital, Nykøbing, Denmark
| | - Kathrine Ellard
- Mater Hospital, Department of Gastroenterology, Sydney, Australia
| | - Lisbet A Christensen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark.,Institute of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Sally J Bell
- Department of Gastroenterology, St Vincent's Hospital, and University of Melbourne, Melbourne, Australia.,Department of Gastroenterology, Monash Health, and School of Clinical Sciences Monash University, Melbourne, VIC, Australia
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94
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Moens A, van der Woude CJ, Julsgaard M, Humblet E, Sheridan J, Baumgart DC, Gilletta De Saint-Joseph C, Nancey S, Rahier JF, Bossuyt P, Cremer A, Dewit S, Eriksson C, Hoentjen F, Krause T, Louis E, Macken E, Milenkovic Z, Nijs J, Posen A, Van Hootegem A, Van Moerkercke W, Vermeire S, Bar-Gil Shitrit A, Ferrante M. Pregnancy outcomes in inflammatory bowel disease patients treated with vedolizumab, anti-TNF or conventional therapy: results of the European CONCEIVE study. Aliment Pharmacol Ther 2020; 51:129-138. [PMID: 31692017 DOI: 10.1111/apt.15539] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 07/08/2019] [Accepted: 09/23/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Women with inflammatory bowel diseases (IBD) often receive biologicals during pregnancy to maintain disease remission. Data on outcome of vedolizumab-exposed pregnancies (VDZE) are sparse. AIMS To assess pregnancy and child outcomes of VDZE pregnancies and to compare these results to anti-TNF exposed (TNFE) or both immunomodulatory and biologic unexposed (CON IBD) pregnancies. METHODS A retrospective multicentre case-control observational study was performed. RESULTS VDZE group included 79 pregnancies in 73 IBD women. The TNFE and CON IBD group included 186 pregnancies (162 live births) in 164 IBD women and 184 pregnancies (163 live births) in 155 IBD women, respectively. At conception, cases more often had active disease ([VDZE: 36% vs TNFE: 17%, P = .002] and [VDZE: 36% vs CON IBD: 24%, P = .063]). No significant difference in miscarriage rates were found between groups (VDZE and TNFE: 16% vs 13%, P = .567; VDZE and CON IBD: 16% vs 10%, P = .216). In live-born infants, median gestational age and birthweight were similar between groups. Median Apgar score at birth was numerically equal. Prematurity was similar in the VDZE group compared to the control groups, even when correcting for disease activity during pregnancy. The frequency of congenital anomalies was comparable between groups as were the percentages of breastfed babies. During the first year of life, no malignancies were reported and infants' infection risk did not significantly differ between groups. CONCLUSION No new safety signal was detected in VDZE pregnancies although larger, prospective studies are required for confirmation.
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95
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Hart A. Commentary: safety of anti-TNF use in pregnancy. Aliment Pharmacol Ther 2020; 51:205-206. [PMID: 31850565 DOI: 10.1111/apt.15548] [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: 12/09/2022]
Affiliation(s)
- Ailsa Hart
- IBD Unit, St Mark's Hospital, Harrow, UK
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96
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Wieringa JW, van der Woude CJ. Effect of biologicals and JAK inhibitors during pregnancy on health-related outcomes in children of women with inflammatory bowel disease. Best Pract Res Clin Gastroenterol 2019; 44-45:101665. [PMID: 32359679 DOI: 10.1016/j.bpg.2019.101665] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 10/14/2019] [Accepted: 12/26/2019] [Indexed: 02/06/2023]
Abstract
Current guidelines advise to maintain immunomodulators and biologicals in pregnant patients because relapse of inflammatory bowel is associated with unfavourable pregnancy outcome. With the exception of Methotrexate, IBD therapy seems not to be related to an increase of congenital malformations or infections requiring hospitalisation of the babies, although the effect the on the developing immune system of the exposed infants remains unknown. In this review we will focus on the effect of IBD drugs on health-related outcomes in children taking into account possible long-term effects of biologicals and immunomodulators, which are transferred across the placenta.
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Affiliation(s)
- J W Wieringa
- Department of Pediatrics, Haaglanden Medical Center and Department of Pediatrics, Subdivision of Infectious Diseases and Immunology, Erasmus MC University Medical Center-Sophia Children's Hospital, Rotterdam, Lijnbaan 32, CK The Hague, 2501, the Netherlands.
| | - C J van der Woude
- Department of Gastroenterology, Erasmus MC University Medical Center, 's Gravendijkwal 230, 3015, CE, Rotterdam, the Netherlands.
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97
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De Lorenzo R, Ramirez GA, Punzo D, Lorioli L, Rovelli R, Canti V, Barera G, Rovere-Querini P. Neonatal outcomes of children born to mothers on biological agents during pregnancy: State of the art and perspectives. Pharmacol Res 2019; 152:104583. [PMID: 31816434 DOI: 10.1016/j.phrs.2019.104583] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Revised: 11/29/2019] [Accepted: 11/30/2019] [Indexed: 12/19/2022]
Abstract
Biologic disease-modifying anti-rheumatic drugs (bDMARDs) are used in pregnant patients with rheumatic diseases. Long-term follow-up data about newborns exposed to bDMARDs during pregnancy are however scarce. Here we summarize the published evidence and available recommendations for use of bDMARDs during pregnancy. We analyse clinical features at birth and at follow-up of 84 children, including: 16 consecutive children born to mothers with autoimmune diseases exposed to bDMARDs in utero; 32 children born to mothers with autoimmune diseases who did not receive bDMARDs; 36 children born to healthy mothers. In our monocentric cohort, children born to mothers with autoimmune diseases had lower gestational age at birth compared to those born to healthy mothers, independently of exposure to bDMARDs. At multivariate analysis, prematurity was an independent predictor of the need for antibiotic treatment, but not for hospitalisation or neonatal intensive care unit (ICU) stay during the neonatal period. Exposure to bDMARDs during pregnancy does not seem to interfere with post-natal development up to infancy. Prospective studies are needed in larger cohorts of pregnant patients to confirm that bDMARDs do not have a negative impact on psychomotor achievements in newborns.
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Affiliation(s)
- Rebecca De Lorenzo
- Università Vita-Salute San Raffaele, Milan, Italy; Department of Medicine and Division of Immunology, Transplantation and Infectious Diseases, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Giuseppe A Ramirez
- Università Vita-Salute San Raffaele, Milan, Italy; Department of Medicine and Division of Immunology, Transplantation and Infectious Diseases, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Daniele Punzo
- Università Vita-Salute San Raffaele, Milan, Italy; Department of Medicine and Division of Immunology, Transplantation and Infectious Diseases, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Laura Lorioli
- Unit of Paediatrics, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Rosanna Rovelli
- Unit of Paediatrics, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Valentina Canti
- Università Vita-Salute San Raffaele, Milan, Italy; Department of Medicine and Division of Immunology, Transplantation and Infectious Diseases, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Graziano Barera
- Unit of Paediatrics, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Patrizia Rovere-Querini
- Università Vita-Salute San Raffaele, Milan, Italy; Department of Medicine and Division of Immunology, Transplantation and Infectious Diseases, IRCCS Ospedale San Raffaele, Milan, Italy.
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98
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Lamb CA, Kennedy NA, Raine T, Hendy PA, Smith PJ, Limdi JK, Hayee B, Lomer MCE, Parkes GC, Selinger C, Barrett KJ, Davies RJ, Bennett C, Gittens S, Dunlop MG, Faiz O, Fraser A, Garrick V, Johnston PD, Parkes M, Sanderson J, Terry H, Gaya DR, Iqbal TH, Taylor SA, Smith M, Brookes M, Hansen R, Hawthorne AB. British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults. Gut 2019; 68:s1-s106. [PMID: 31562236 PMCID: PMC6872448 DOI: 10.1136/gutjnl-2019-318484] [Citation(s) in RCA: 1241] [Impact Index Per Article: 248.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 06/10/2019] [Accepted: 06/10/2019] [Indexed: 02/06/2023]
Abstract
Ulcerative colitis and Crohn's disease are the principal forms of inflammatory bowel disease. Both represent chronic inflammation of the gastrointestinal tract, which displays heterogeneity in inflammatory and symptomatic burden between patients and within individuals over time. Optimal management relies on understanding and tailoring evidence-based interventions by clinicians in partnership with patients. This guideline for management of inflammatory bowel disease in adults over 16 years of age was developed by Stakeholders representing UK physicians (British Society of Gastroenterology), surgeons (Association of Coloproctology of Great Britain and Ireland), specialist nurses (Royal College of Nursing), paediatricians (British Society of Paediatric Gastroenterology, Hepatology and Nutrition), dietitians (British Dietetic Association), radiologists (British Society of Gastrointestinal and Abdominal Radiology), general practitioners (Primary Care Society for Gastroenterology) and patients (Crohn's and Colitis UK). A systematic review of 88 247 publications and a Delphi consensus process involving 81 multidisciplinary clinicians and patients was undertaken to develop 168 evidence- and expert opinion-based recommendations for pharmacological, non-pharmacological and surgical interventions, as well as optimal service delivery in the management of both ulcerative colitis and Crohn's disease. Comprehensive up-to-date guidance is provided regarding indications for, initiation and monitoring of immunosuppressive therapies, nutrition interventions, pre-, peri- and postoperative management, as well as structure and function of the multidisciplinary team and integration between primary and secondary care. Twenty research priorities to inform future clinical management are presented, alongside objective measurement of priority importance, determined by 2379 electronic survey responses from individuals living with ulcerative colitis and Crohn's disease, including patients, their families and friends.
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Affiliation(s)
- Christopher Andrew Lamb
- Newcastle University, Newcastle upon Tyne, UK
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Nicholas A Kennedy
- Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
- University of Exeter, Exeter, UK
| | - Tim Raine
- Cambridge University Hospitals NHS FoundationTrust, Cambridge, UK
| | - Philip Anthony Hendy
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
- Imperial College London, London, UK
| | - Philip J Smith
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Jimmy K Limdi
- The Pennine Acute Hospitals NHS Trust, Manchester, UK
- University of Manchester, Manchester, UK
| | - Bu'Hussain Hayee
- King's College Hospital NHS Foundation Trust, London, UK
- King's College London, London, UK
| | - Miranda C E Lomer
- King's College London, London, UK
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Gareth C Parkes
- Barts Health NHS Trust, London, UK
- Barts and the London School of Medicine and Dentistry, London, UK
| | - Christian Selinger
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
- University of Leeds, Leeds, UK
| | | | - R Justin Davies
- Cambridge University Hospitals NHS FoundationTrust, Cambridge, UK
- University of Cambridge, Cambridge, UK
| | - Cathy Bennett
- Systematic Research Ltd, Quorn, UK
- Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
| | | | - Malcolm G Dunlop
- University of Edinburgh, Edinburgh, UK
- Western General Hospital, Edinburgh, UK
| | - Omar Faiz
- Imperial College London, London, UK
- St Mark's Hospital, Harrow, UK
| | - Aileen Fraser
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | | | | | - Miles Parkes
- Cambridge University Hospitals NHS FoundationTrust, Cambridge, UK
| | - Jeremy Sanderson
- King's College London, London, UK
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Daniel R Gaya
- Glasgow Royal Infirmary, Glasgow, UK
- University of Glasgow, Glasgow, UK
| | - Tariq H Iqbal
- Queen Elizabeth Hospital Birmingham NHSFoundation Trust, Birmingham, UK
- University of Birmingham, Birmingham, UK
| | - Stuart A Taylor
- University College London, London, UK
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Melissa Smith
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
- Brighton and Sussex Medical School, Brighton, UK
| | - Matthew Brookes
- Royal Wolverhampton NHS Trust, Wolverhampton, UK
- University of Wolverhampton, Wolverhampton, UK
| | - Richard Hansen
- Royal Hospital for Children Glasgow, Glasgow, UK
- University of Glasgow, Glasgow, UK
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99
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Health-related quality of life in the first 5 years of the children born to mothers with IBD does not differ from children born to healthy mothers. J Psychosom Res 2019; 127:109840. [PMID: 31677548 DOI: 10.1016/j.jpsychores.2019.109840] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 09/16/2019] [Accepted: 09/24/2019] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Inflammatory bowel disease (IBD) is often diagnosed in women in their reproductive years of life and therefore children are born to mothers with IBD. Health outcomes of children born to mothers with IBD seem favorable. However, little is known about the quality of life related to their health compared to children born to healthy mothers. Therefore, our first objective was to investigate the effect of having IBD during pregnancy on the health-related quality of life (HRQoL) of children born to mothers with IBD in the first 5 years of age compared to children born to healthy mothers. Secondly, we studied the effect of the different IBD related factors on the HRQoL. METHODS We prospectively followed 264 women with IBD, who visited the preconception outpatient clinic at our tertiary health center in the Netherlands from April 2013 through November 2016. Women of children aged 1-5 years were approached to fill in a 43-item validated TNO-AZL Preschool Children Quality of Life questionnaire (TAPQOL) to assess HRQoL (Fekkes et al., 2000; Bunge et al., 2005 [1,2]). Outcomes were compared to children of mothers without IBD. RESULTS One-hundred-eighty-two women completed the TAPQOL questionnaire. In total 182 children of mothers with IBD were included [median age 3.0 years (IQR 2-4)]. From 70 healthy mothers, 70 children were included as controls. There was no significant difference in the HRQoL between children who were and were not born to mothers with IBD (P = .18). Also, no effect of the different IBD related factors was found. CONCLUSION In this study, we found no effect of having IBD during pregnancy on the health-related quality of life of children in the first 5 years of life.
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100
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Abstract
Ulcerative colitis and Crohn's disease are the principal forms of inflammatory bowel disease. Both represent chronic inflammation of the gastrointestinal tract, which displays heterogeneity in inflammatory and symptomatic burden between patients and within individuals over time. Optimal management relies on understanding and tailoring evidence-based interventions by clinicians in partnership with patients. This guideline for management of inflammatory bowel disease in adults over 16 years of age was developed by Stakeholders representing UK physicians (British Society of Gastroenterology), surgeons (Association of Coloproctology of Great Britain and Ireland), specialist nurses (Royal College of Nursing), paediatricians (British Society of Paediatric Gastroenterology, Hepatology and Nutrition), dietitians (British Dietetic Association), radiologists (British Society of Gastrointestinal and Abdominal Radiology), general practitioners (Primary Care Society for Gastroenterology) and patients (Crohn's and Colitis UK). A systematic review of 88 247 publications and a Delphi consensus process involving 81 multidisciplinary clinicians and patients was undertaken to develop 168 evidence- and expert opinion-based recommendations for pharmacological, non-pharmacological and surgical interventions, as well as optimal service delivery in the management of both ulcerative colitis and Crohn's disease. Comprehensive up-to-date guidance is provided regarding indications for, initiation and monitoring of immunosuppressive therapies, nutrition interventions, pre-, peri- and postoperative management, as well as structure and function of the multidisciplinary team and integration between primary and secondary care. Twenty research priorities to inform future clinical management are presented, alongside objective measurement of priority importance, determined by 2379 electronic survey responses from individuals living with ulcerative colitis and Crohn's disease, including patients, their families and friends.
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