Update on safety during pregnancy of biological agents and some immunosuppressive anti-rheumatic drugs

[Biologics during pregnancy and breast--feeding]

Over the past years, biological therapies, especially anti-TNF-α antibody therapy has emerged as a treatment approach in patients who have failed to achieve or maintain remission with tradional DMARDs. Women suffering from inflammatory arthritis may need to continue therapy throughout pregnancy and/or in the lactation period, hence the increased concern over the safety of antirheumatic drugs during pregnancy. Anti-TNF agents fall within the US FDA category B concerning fetal risk, indicating that no adequate and well-controlled studies have been conducted in pregnant or lactating women. However, in the last decade, numerous case series and registry data of pregnancies exposed to anti-TNF therapy have accumulated in the literature. According to these data, TNF inhibitor therapies appear to be safe in pregnancy, since no increased risk of malformations has been demonstrated. Ceasing therapy after conception should be considered, but treatment may be continued during pregnancy when indicated.The use of these agents is likely compatible with breast-feeding. The extent of fetal risk is not clarified for exposure to other biologics, such as Rituximab.

Anti-TNF therapies and pregnancy: outcome of 130 pregnancies in the British Society for Rheumatology Biologics Register

Objective

The British Society for Rheumatology Biologics Register (BSRBR) has collected data on adverse events including pregnancies in patients with rheumatoid arthritis treated with anti-tumour necrosis factor (anti-TNF) therapy. The purpose of this report is to summarise the pregnancy outcomes in women treated with anti-TNF in the BSRBR.

Methods

Patients were categorised according to anti-TNF exposure as follows: (1) exposure to anti-TNF and to methotrexate (MTX) and/or leflunomide (LEF) at conception (n=21 pregnancies); (2) exposure to anti-TNF at conception (n=50); (3) exposure to anti-TNF prior to conception (n=59); (4) no exposure to anti-TNF (control group; n=10).

Results

Eighty-eight live births in a total of 130 pregnancies were reported in patients who received anti-TNF before or during pregnancy. The rate of spontaneous abortion was highest among patients exposed to anti-TNF at the time of conception (with MTX/LEF 33% and without MTX/LEF 24%). This compared with 17% spontaneous abortions in those with prior exposure to anti-TNF and 10% spontaneous abortions in the control group. Ten terminations were performed.

Conclusion

Although the results to date have been promising, no firm conclusions can be drawn about the safety of anti-TNF during pregnancy and, without further evidence, guidelines which suggest these drugs should be avoided at the time of conception cannot yet be changed.

[Chronic inflammatory and autoimmune mediated dermatoses during pregnancy. Course and prognosis for mother and child]

Chronic inflammatory dermatoses during pregnancy can take varying courses in mother and child. The dominant Th2-response characteristic for pregnancy may explain why atopic eczema or lupus erythematosus may deteriorate while psoriasis vulgaris may improve. In contrast, impetigo herpetiformis frequently shows a severe course. Lupus erythematosus and other autoantibody-triggered dermatoses like pemphigus vulgaris pose an increased risk for the child because of placental transfer of autoantibodies with specific skin changes or systemic manifestations of the disease as well as placental insufficiency, growth retardation and premature birth. Such risks are not associated with linear IgA dermatosis. A severe pityriasis rosea during the first 20 weeks of pregnancy may lead to an increased risk of abortion or premature delivery. Early diagnosis and individually adjusted therapy of skin diseases is mandatory to avoid any risk for mother or child.

Mycophenolate mofetil: a possible therapeutic agent for children with juvenile dermatomyositis

OBJECTIVE

To determine if mycophenolate mofetil (MMF) diminishes skin and muscle disease activity in children with juvenile dermatomyositis (DM), thereby permitting a decrease in corticosteroid dose.

METHODS

A retrospective data review for 50 children with juvenile DM (mean ± SD age 12.2 ± 5.0 years) who had received MMF for 12 months identified the following characteristics: 38 (76%) were girls, 39 (78%) were white, 10 (20%) were Hispanic, and 1 (2%) was African American. The MMF dose and frequency, type of infection, white blood cell (WBC) count, corticosteroid dose, and the validated disease activity score (DAS) subscores for skin (DAS-S) and muscle (DAS-M) were obtained.

RESULTS

Twelve months after the start of MMF, the mean ± SD DAS-S decreased from 5.24 ± 0.29 to 3.72 ± 0.29 (P = 0.001), and the mean ± SD DAS-M decreased from 2.44 ± 0.39 to 1.17 ± 0.28 (P = 0.002). The mean ± SD prednisone dosage decreased from 0.39 ± 0.06 to 0.23 ± 0.02 mg/kg/day (P = 0.0001), with resumption of linear growth (P = 0.008). The WBC/lymphocyte count was unchanged over the 12 months on MMF. The infection rate was assessed in a subset of 26 children with juvenile DM who were observed for 12 months before the start of MMF and then compared with the ensuing 12 months of MMF therapy. There was no significant difference between the pretreatment period and the first 6 months of MMF therapy (P = 0.44), but the infection rate decreased in months 7-12 (P = 0.001).

CONCLUSION

MMF appears to be worthy of consideration as an additional therapeutic modality for treatment of children with juvenile DM. These data suggest that the use of MMF decreases skin and muscle disease activity and is steroid sparing. MMF appears to be well tolerated, but patients should be monitored for infection.

Pregnancy in autoimmune rheumatic diseases: the importance of counselling for old and new challenges

Rheumatic diseases can affect women during their childbearing age. Therefore, physicians should introduce a discussion with the patients about pregnancy and its problems. Lupus pregnancies can be successful, even in patients with renal disease, when planned in remission state; the use of low dose aspirin was shown to be an independent predictor of good outcome, so it can be suggested as a preventive measure. Pregnancies in women with Antiphospholipid Syndrome can fail even if properly treated, especially when associated with a systemic autoimmune disease, a history of both thrombosis and pregnancy morbidity, and a triple positivity of antiphospholipid antibody assays. Women with systemic sclerosis have generally a good obstetric outcome, except for an increase rate of preterm deliveries. Severe disease complications were sometimes reported, but their relationship with gestation is not clear yet. Although data on human pregnancy are still preliminary, anti-TNF agents are classified as non teratogens in contrast to methotrexate and leflunomide. So women affected by aggressive chronic arthritis may be treated with anti-TNF in the pre-conceptional period, discontinuing the drug as soon as pregnancy starts. In order to increase maternal compliance and cope with difficult cases, a multidisciplinary team (rheumatologists/internists, obstetricians and neonatologists) should take care of patients during pregnancy.

Contemporary treatment of systemic lupus erythematosus: an update for clinicians

The prognosis for patients with systemic lupus erythematosus (SLE) has improved significantly, with 20-year survival now approximately 80% owing partly to effective treatment. SLE treatment has evolved from the use of conventional drugs such as hydroxychloroquine and corticosteroids, nonspecific immunosuppressants including mycophenolate mofetil, to targeting selective components of the immune cascade with a view to increased efficacy, tolerability and safety profile. These novel treatments include B-cell-depleting antibodies and fusion proteins that block the costimulatory pathways of B and T cells. A discussion of these pharmacological options and ongoing research forms the basis of this review.

Management of rheumatic diseases during pregnancy

Systemic rheumatic diseases commonly affect women during the childbearing years. Many women with these diseases may be contemplating pregnancy or discover an inadvertent pregnancy, leading to concerns regarding medication use, changes in disease activity during pregnancy, safety of lactation, and future ability to care for a child given the presence of chronic illnesses. There are outstanding reviews that summarize the safety and use of immunosuppressive medications during pregnancy. However, in addition to medication use, providers need to be aware of the available data regarding fertility, pregnancy outcomes, delivery, and lactation issues that may be specific to individual diseases. Optimally, women should plan pregnancies to occur around times of disease quiescence, several months after potentially teratogenic medications have been discontinued. The course of the underlying rheumatic disease during pregnancy is variable, and there are no specific clinical or laboratory variables that consistently predict disease improvement or worsening during pregnancy. Recent data suggest that increased disease activity in women with most autoimmune diseases during pregnancy may lead to increased risk of premature delivery, low-birth-weight infants, and other adverse pregnancy outcomes. Arthritis involving the cervical spine and hips may impact delivery and must be considered by both obstetricians and obstetric anesthesiologists. Data are mixed regarding the impact of breastfeeding on underlying autoimmune diseases; the choice to continue breastfeeding is a personal decision.

Mycophenolate mofetil for ocular inflammation

PURPOSE

To evaluate mycophenolate mofetil as a single noncorticosteroid immunosuppressive treatment for noninfectious ocular inflammatory diseases.

DESIGN

Retrospective cohort study.

METHODS

Characteristics of patients with noninfectious ocular inflammation treated with mycophenolate mofetil at 4 subspecialty clinics from 1995 to 2007 were abstracted by expert reviewers in a standardized chart review of every eye at every visit. Main outcomes measured were control of inflammation, corticosteroid-sparing effects, and discontinuation of mycophenolate mofetil (including the reasons for discontinuation). Survival analysis was used to estimate the incidence of outcomes, and to identify risk factors for each.

RESULTS

Among 236 patients (397 eyes) treated with mycophenolate mofetil monotherapy, 20.3%, 11.9%, and 39.8% had anterior uveitis, intermediate uveitis, and posterior uveitis or panuveitis respectively; 14% had scleritis; 7.6% had mucous membrane pemphigoid; and 6.4% had other ocular inflammatory diseases. By Kaplan-Meier estimation, complete control of inflammation--sustained over consecutive visits spanning at least 28 days--was achieved in 53% and 73% of patients within 6 months and 1 year respectively. Systemic corticosteroid dosage was reduced to 10 mg of prednisone or less, while maintaining sustained control of inflammation, in 41% and 55% of patients in 6 months and 1 year respectively. Twelve percent of patients discontinued mycophenolate mofetil within the first year because of side effects of therapy.

CONCLUSIONS

Given sufficient time, mycophenolate mofetil was effective in managing ocular inflammation in approximately half of the treated patients. Treatment-limiting side effects were observed in 12% of patients and typically were reversible.

Guidelines of care for the management of psoriasis and psoriatic arthritis: section 4. Guidelines of care for the management and treatment of psoriasis with traditional systemic agents

Psoriasis is a common, chronic, inflammatory, multisystem disease with predominantly skin and joint manifestations affecting approximately 2% of the population. In this fourth of 6 sections of the guidelines of care for psoriasis, we discuss the use of traditional systemic medications for the treatment of patients with psoriasis. Treatment should be tailored to meet individual patients' needs. We will discuss in detail the efficacy and safety, and offer recommendations for the use of the 3 most commonly used, and approved, traditional systemic agents: methotrexate, cyclosporine, and acitretin. We will also briefly discuss the available data for the use of azathioprine, fumaric acid esters, hydroxyurea, leflunomide, mycophenolate mofetil, sulfasalazine, tacrolimus, and 6-thioguanine in psoriasis.

Placental transport of immunoglobulins: a clinical review for gastroenterologists who prescribe therapeutic monoclonal antibodies to women during conception and pregnancy

The introduction of biologic therapy with therapeutic monoclonal antibodies to the treatment strategies of inflammatory bowel disease (IBD) has significantly changed the way clinicians practice. Antibodies are cleared differently than small molecules, and knowledge about the pharmacology and immunology of immunoglobulins is helpful when using these agents in women preconception and during pregnancy. The most commonly used antibody therapies in patients with IBD are IgG1 molecules, but others are under development. When treating patients who are pregnant or contemplating pregnancy, it is important to remember that immunoglobulin G (IgG) is the predominant means of fetal immunity and that it is transported across the placenta. This transport happens in a linear fashion as the pregnancy progresses, with the largest amount transferred in the third trimester. Preferential transport occurs for IgG1, followed by IgG4, and IgG3, with IgG2 being the least detected. Understanding the mechanism for immunoglobulin transfer will help to understand how to minimize risk of exposure of the fetus to the therapeutic monoclonal antibody both in utero and after delivery.