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Mahadevan U, Levy G, Gensler L, Ali M, Lacerda AP, Wegrzyn L, Palac H, Bhutani-Jacques T, Long M, Clowse MEB, Kimball AB, Chambers C, Scialli AR. Pregnancy Outcomes in Patients Treated with Upadacitinib: Analysis of Data from Clinical Trials and Postmarketing Reports. Drug Saf 2024; 47:1039-1049. [PMID: 39008024 PMCID: PMC11399166 DOI: 10.1007/s40264-024-01454-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2024] [Indexed: 07/16/2024]
Abstract
BACKGROUND AND OBJECTIVE Upadacitinib is indicated for diseases affecting persons of childbearing potential including rheumatoid arthritis, psoriatic arthritis, axial spondyloarthritis, atopic dermatitis, Crohn's disease, and ulcerative colitis; however, teratogenicity was observed in animal studies. Given the potential for human fetal risk, pregnancy avoidance measures were required during clinical trials. This analysis describes pregnancy outcomes in patients exposed to upadacitinib during pregnancy. METHODS Clinical trial and postmarketing cases of in utero exposure to upadacitinib were identified in AbbVie's safety database through 25 April, 2023. Analysis of clinical trial cases and postmarketing reports are presented separately; prospective and retrospectively reported pregnancy outcomes are integrated for each. Descriptive rates are presented to summarize outcomes. RESULTS There were 128 maternal upadacitinib-exposed pregnancies with known outcomes identified; 80 and 48 pregnancies were reported in clinical trials and the postmarketing setting, respectively. In clinical trials (mean in utero exposure of 5 weeks, 3 days), live births (54%), spontaneous abortions (24%), elective terminations (21%), and ectopic pregnancy (1%) were reported. There was one report of a congenital malformation: a 35-week infant with an atrial septal defect. In postmarketing cases, live births (46%), spontaneous abortions (38%), elective terminations (15%), and ectopic pregnancy (2%) were reported. CONCLUSIONS As the data are limited for in utero exposure to upadacitinib, definitive conclusions cannot be drawn regarding the effect of upadacitinib on pregnancy outcomes. Rates of adverse pregnancy outcomes with upadacitinib exposure were comparable to rates observed in the general population or patients with autoimmune inflammatory diseases. To date, no apparent evidence of teratogenicity exists in the analyses of human pregnancies exposed to upadacitinib during the first trimester.
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Affiliation(s)
- Uma Mahadevan
- Division of Gastroenterology and Hepatology, University of California San Francisco, 1701 Divisadero Street #120, San Francisco, CA, 94010, USA.
| | | | - Lianne Gensler
- Division of Rheumatology, University of California San Francisco, San Francisco, CA, USA
| | | | | | | | | | - Tina Bhutani-Jacques
- Division of Rheumatology, University of California San Francisco, San Francisco, CA, USA
| | - Millie Long
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Megan E B Clowse
- Division of Rheumatology and Immunology, Duke University, Durham, NC, USA
| | - Alexa B Kimball
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Christina Chambers
- Department of Pediatrics, University of California, San Diego, La Jolla, CA, USA
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Rebić N, De Vera MA, Gupta A, Amiri N. Perinatal Use and Discontinuation of Disease-Modifying Antirheumatic Drugs: Outcomes of Patients Seen at a Pregnancy and Rheumatic Diseases Clinic. J Clin Rheumatol 2024; 30:188-192. [PMID: 38753224 DOI: 10.1097/rhu.0000000000002090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2024]
Abstract
BACKGROUND Managing rheumatic disease activity using pregnancy-compatible medications is essential for reducing adverse maternal and fetal outcomes. We characterized medication use and discontinuation before, during, and after pregnancy, among female patients with rheumatic diseases attending a targeted pregnancy and rheumatic diseases clinic. METHODS We conducted a cross-sectional medical record review of female patients with rheumatic diseases at a Canadian clinic between January 2017 and July 2020. Patients were categorized by pregnancy stage at their latest clinic visit: (1) preconception; (2) pregnant; (3) postpartum. We assessed use of conventional, biologic, and targeted synthetic disease-modifying antirheumatic drugs (DMARDs), prednisone, and nonsteroidal anti-inflammatory drugs across 6 perinatal windows: 24 and 12 months preconception, each pregnancy trimester, and 3 months postpartum. We reported adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for medication discontinuation in the first trimester and subsequent disease flare. RESULTS Of 230 included patients, 85 (37.0%), 12 (5.2%), and 133 (57.8%) were preconception, pregnant, and postpartum, respectively. Approximately half experienced at least 1 disease flare during each pregnancy stage (56.4% preconception, 58.1% during pregnancy, and 53.7% postpartum). Most used at least 1 DMARD throughout the perinatal period (82.6% preconception, 55.6% during pregnancy, and 45.1% postpartum). Overall, 25.5% discontinued at least 1 DMARD in the first trimester. DMARD discontinuation was associated with disease flare during pregnancy (aOR, 1.49; 95% CI, 0.55-4.03; p = 0.87) and postpartum (aOR, 3.09; 95% CI, 0.83-11.47; p = 0.09). CONCLUSIONS Patients receiving care at a pregnancy and rheumatic disease clinic show perinatal medication use patterns consistent with recent recommendations and clinical guidelines.
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Gholizadeh Ghozloujeh Z, Singh T, Jhaveri KD, Shah S, Lerma E, Abdipour A, Norouzi S. Lupus nephritis: management challenges during pregnancy. FRONTIERS IN NEPHROLOGY 2024; 4:1390783. [PMID: 38895665 PMCID: PMC11183321 DOI: 10.3389/fneph.2024.1390783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 05/15/2024] [Indexed: 06/21/2024]
Abstract
Lupus nephritis (LN), a severe complication of systemic lupus erythematosus (SLE), leads to significant kidney inflammation and damage and drastically increases mortality risk. Predominantly impacting women in their reproductive years, LN poses specific risks during pregnancy, including pre-eclampsia, growth restrictions, stillbirth, and preterm delivery, exacerbated by lupus activity, specific antibodies, and pre-existing conditions like hypertension. Effective management of LN during pregnancy is crucial and involves carefully balancing disease control with the safety of the fetus. This includes pre-conception counseling and a multidisciplinary approach among specialists to navigate the complexities LN patients face during pregnancy, such as distinguishing LN flare-ups from pregnancy-induced conditions. This review focuses on exploring the complex dynamics between pregnancy and LN, emphasizing the management difficulties and the heightened risks pregnant women with LN encounter.
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Affiliation(s)
- Zohreh Gholizadeh Ghozloujeh
- Department of Medicine, Division of Nephrology, Loma Linda University School of Medicine, Loma Linda, CA, United States
| | - Tripti Singh
- Department of Medicine, Division of Nephrology, University of Wisconsin, Madison, WI, United States
| | - Kenar D. Jhaveri
- Department of Medicine, Division of Kidney Diseases and Hypertension, Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Great Neck, NY, United States
| | - Silvi Shah
- Department of Medicine, Division of Nephrology, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Edgar Lerma
- Department of Medicine, Division of Nephrology, Advocate Christ Medical Center, University of Illinois at Chicago, Oak Lawn, IL, United States
| | - Amir Abdipour
- Department of Medicine, Division of Nephrology, Loma Linda University School of Medicine, Loma Linda, CA, United States
| | - Sayna Norouzi
- Department of Medicine, Division of Nephrology, Loma Linda University School of Medicine, Loma Linda, CA, United States
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Huang J, Wu T, Li Y, Zhang Y, Yu X, Xu D, Wang H. Toxic effect window of ovarian development in female offspring mice induced by prenatal prednisone exposure with different doses and time. J Ovarian Res 2023; 16:71. [PMID: 37038227 PMCID: PMC10088227 DOI: 10.1186/s13048-023-01148-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 03/29/2023] [Indexed: 04/12/2023] Open
Abstract
BACKGROUND Prednisone is one of the most used synthetic glucocorticoids during pregnancy. Epidemiological investigations suggested that prenatal prednisone therapy could affect fetal development, but systematic studies on its effects on ovarian development and the "toxic effect window" remained scarce. METHODS In this study, by simulating clinical application characteristics, Kunming mice were given prednisone by oral gavage with different doses (0.25 or 1.0 mg/kg·d) or at different time gestational days (GD) (GD0-9, GD10-18, or GD0-18). Blood and ovaries of fetal mice were collected on GD18, and the serum estradiol level and the related function indexes of ovarian granulosa cells and oocytes were detected. RESULTS Compared with the control group, prenatal prednisone exposure (PPE) induced pathological injury and enhanced cell proliferation in fetal mice ovary. Furthermore, the expression of steroid synthesis functional genes in pre-granulosa cells, the oocyte function markers, and developmentally related genes was enhanced with different doses or at different time of PPE. The Hippo signaling was activated in the fetal ovary of PPE groups. The above changes were most significant in the low or high-dose and full-term PPE groups. CONCLUSION PPE caused various cell developmental toxicity in the fetal ovary, especially in the low or high-dose, full-term exposure groups. The potential mechanism might be related to the activation of the Hippo signaling pathway.
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Affiliation(s)
- Jing Huang
- Department of Obstetrics and Gynecology, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
- Department of Otorhinolaryngology Head and Neck Surgery, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
- Hubei Provincial Key Laboratory of Developmentally Originated Disease, Wuhan, 430071, China
| | - Tiancheng Wu
- Department of Obstetrics and Gynecology, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
- Hubei Provincial Key Laboratory of Developmentally Originated Disease, Wuhan, 430071, China
| | - Yating Li
- Department of Obstetrics and Gynecology, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
- Hubei Provincial Key Laboratory of Developmentally Originated Disease, Wuhan, 430071, China
| | - Yuanzhen Zhang
- Department of Obstetrics and Gynecology, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
- Hubei Provincial Key Laboratory of Developmentally Originated Disease, Wuhan, 430071, China
| | - Xingjiang Yu
- Department of Histology and Embryology, School of Basic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
| | - Dan Xu
- Department of Pharmacy, School of Pharmaceutical Sciences, Zhongnan Hospital of Wuhan University, Wuhan University, Wuhan, 430071, China.
- Hubei Provincial Key Laboratory of Developmentally Originated Disease, Wuhan, 430071, China.
| | - Hui Wang
- Department of Obstetrics and Gynecology, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China.
- Department of Pharmacology, Wuhan University School of Basic Medical Sciences, Wuhan, 430071, China.
- Hubei Provincial Key Laboratory of Developmentally Originated Disease, Wuhan, 430071, China.
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Shridharmurthy D, Lapane KL, Baek J, Nunes A, Kay J, Liu SH. Comanagement with rheumatology and prescription biologics filled during pregnancy in women with rheumatic diseases: a retrospective analysis of US administrative claims data. BMJ Open 2022; 12:e065189. [PMID: 36549721 PMCID: PMC9791456 DOI: 10.1136/bmjopen-2022-065189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES To evaluate comanagement with rheumatology and biological prescriptions filled during pregnancy among women with axial spondyloarthritis (axSpA), rheumatoid arthritis (RA) or psoriatic arthritis (PsA) and to examine factors associated with receiving comanagement with rheumatology during pregnancy. DESIGN A retrospective analysis of US claims data. SETTING Commercially insured enrollees using data from the 2013-2018 IBM MarketScan Commercial Claims and Encounters Database. PARTICIPANTS We identified 4131 pregnant women aged ≤55 years from the 2013-2018 IBM MarketScan Commercial Claims and Encounters Database with an International Classification of Disease, 9th Revision/10th Revision codes for RA, axSpA or PsA, with continuous enrolment at ≥3 months before the date of the last menstrual period (LMP) (index date) and throughout pregnancy. PRIMARY OUTCOMES Filled biologics (prescriptions and infusions) claims were categorised by 90 days before the LMP and trimester, as were primary care, obstetrician and rheumatological claims. RESULTS The prevalence of axSpA, RA and PsA was 0.7%, 0.2% and 0.04% among reproductive age women. The average maternal age was 32.7 years (SD 5.7). During pregnancy, 9.1% of those with axSpA (n=2,410) and 56.4% of those with RA/PsA (n=1,721) had a rheumatological claim. Biologics claims were less common among those with axSpA (90 days before LMP: 1.6%, during pregnancy: 1.1%) than those with RA/PsA (90 days before LMP: 11.9%, during pregnancy: 6.9%). Medications during pregnancy included corticosteroids (axSpA: 0.3%, RA/PsA: 2.2%), non-biological disease-modifying antirheumatic drugs (axSpA: 0.2%, RA/PsA: 1.7%), non-steroidal anti-inflammatory drugs (axSpA: 0.2%, RA/PsA: 1.3%) and opioids (axSpA: 0.2%, RA/PsA: 0.6%). Established rheumatological care and biologics claims during the 90 days before LMP showed good prediction accuracy for receiving comanagement with rheumatology during pregnancy (axSpA: area under the receiver operator curve (AUC) 0.73, RA/PsA: AUC 0.70). CONCLUSION Comanagement with rheumatology during pregnancy occurs infrequently, especially for women with axSpA. Biologics claims during pregnancy may not align with published guidelines. Future research is warranted to improve comanagement with rheumatology during pregnancy.
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Affiliation(s)
- Divya Shridharmurthy
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester, Massachusetts, USA
- Clinical and Population Health Research Program, Graduate School of Biomedical Sciences, UMass Chan Medical School, Worcester, Massachusetts, USA
| | - Kate L Lapane
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester, Massachusetts, USA
| | - Jonggyu Baek
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester, Massachusetts, USA
| | - Anthony Nunes
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester, Massachusetts, USA
| | - Jonathan Kay
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester, Massachusetts, USA
- Division of Rheumatology, UMass Memorial Medical Center, Worcester, Massachusetts, USA
- Division of Rheumatology, Department of Medicine, UMass Chan Medical School, Worcester, Massachusetts, USA
| | - Shao-Hsien Liu
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester, Massachusetts, USA
- Division of Rheumatology, Department of Medicine, UMass Chan Medical School, Worcester, Massachusetts, USA
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Zanetti A, Zambon A, Scirè CA, Bortoluzzi A. Impact of rheumatoid arthritis and methotrexate on pregnancy outcomes: retrospective cohort study of the Italian Society for Rheumatology. RMD Open 2022; 8:rmdopen-2022-002412. [PMID: 36597979 DOI: 10.1136/rmdopen-2022-002412] [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: 05/03/2022] [Accepted: 11/02/2022] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE To evaluate the impact of rheumatoid arthritis (RA) and methotrexate (MTX) on the probability of becoming pregnant, pregnancy losses, elective termination of pregnancy (TOP) and congenital malformations. METHODS A retrospective cohort study on administrative healthcare databases was conducted. Three patients' cohorts were enrolled among childbearing-age women. The first cohort included patients with RA starting MTX between July 2004 and December 2011. The second cohort included patients with RA without MTX treatment randomly selected from the same population (ratio 1:1). Finally, a cohort of subjects without RA was identified (ratio 1:4). Multivariate logistic regression models were implemented, ORs and 95% CI were reported. RESULTS The two matched RA cohorts included 3564 patients with MTX and without MTX. The cohort without RA included 14 256 subjects. In the three cohorts, the proportion of women achieving pregnancy during follow-up was 6.3%, 9.1% and 11.9%, respectively. Congenital malformations were very rare in all cohorts. RA women treated with MTX at any time before conception showed significantly higher risks of pregnancy losses than non-RA women (OR (95% CI) 2.22 (1.40 to 3.45)). We observed a significant positive relationship between the exposure to MTX in the 3 months window before conception and increased risk of elective TOP (OR (95% CI) 4.77 (1.08 to 19.40)). CONCLUSION MTX-treated patients appeared to be the cohort with the highest risk of pregnancy losses. The positive association with elective TOP and exposure to MTX in the three months window before conception in patients with RA reinforces the need for adequate preconception counselling to avoid unplanned pregnancies.
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Affiliation(s)
- Anna Zanetti
- Epidemiology Unit, Italian Society of Rheumatology, Milano, Italy.,Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - Antonella Zambon
- Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy.,IRCCS Istituto Auxologico Italiano, Biostatistics Unit, Milan, Italy
| | - Carlo Alberto Scirè
- Epidemiology Unit, Italian Society of Rheumatology, Milano, Italy .,School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Alessandra Bortoluzzi
- Section of Rheumatology, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
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Russell MD, Dey M, Flint J, Davie P, Allen A, Crossley A, Frishman M, Gayed M, Hodson K, Khamashta M, Moore L, Panchal S, Piper M, Reid C, Saxby K, Schreiber K, Senvar N, Tosounidou S, van de Venne M, Warburton L, Williams D, Yee CS, Gordon C, Giles I, Roddy E, Armon K, Astell L, Cotton C, Davidson A, Fordham S, Jones C, Joyce C, Kuttikat A, McLaren Z, Merrison K, Mewar D, Mootoo A, Williams E. British Society for Rheumatology guideline on prescribing drugs in pregnancy and breastfeeding: immunomodulatory anti-rheumatic drugs and corticosteroids. Rheumatology (Oxford) 2022; 62:e48-e88. [PMID: 36318966 PMCID: PMC10070073 DOI: 10.1093/rheumatology/keac551] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 09/15/2022] [Indexed: 11/07/2022] Open
Affiliation(s)
- Mark D Russell
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Mrinalini Dey
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Julia Flint
- Department of Rheumatology, Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Shropshire, UK
| | - Philippa Davie
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Alexander Allen
- Clinical Affairs, British Society for Rheumatology, London, UK
| | | | - Margreta Frishman
- Rheumatology, North Middlesex University Hospital NHS Trust, London, UK
| | - Mary Gayed
- Rheumatology, Sandwell and West Birmingham Hospitals, Birmingham, UK
| | | | - Munther Khamashta
- Lupus Research Unit, Division of Women's Health, King's College London, London, UK
| | - Louise Moore
- Rheumatic and Musculoskeletal Disease Unit, Our Lady's Hospice and Care Service, Dublin, Ireland
| | - Sonia Panchal
- Department of Rheumatology, South Warwickshire NHS Foundation Trust, Warwickshire, UK
| | - Madeleine Piper
- Royal National Hospital for Rheumatic Diseases, Royal United Hospital, Bath, UK
| | | | - Katherine Saxby
- Pharmacy, University College London Hospitals NHS Foundation Trust, London, UK
| | - Karen Schreiber
- Thrombosis and Haemostasis, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Department of Rheumatology, Danish Hospital for Rheumatic Diseases, Sonderborg, Denmark.,Department of Regional Health Research (IRS), University of Southern Denmark, Odense, Denmark
| | - Naz Senvar
- Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Sofia Tosounidou
- Lupus UK Centre of Excellence, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | | | | | - David Williams
- Obstetrics, University College London Hospitals NHS Foundation Trust, London, UK
| | - Chee-Seng Yee
- Department of Rheumatology, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, Doncaster, UK
| | - Caroline Gordon
- Rheumatology Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Ian Giles
- Centre for Rheumatology, Division of Medicine, University College London, London, UK
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Rebić N, Munro S, Garg R, Hazlewood G, Amiri N, Baldwin C, Ensworth S, Proulx L, De Vera MA. “The medications are the decision-makers…” Making reproductive and medication use decisions among female patients with rheumatoid arthritis: a constructivist grounded theory. Arthritis Res Ther 2022; 24:31. [PMID: 35065668 PMCID: PMC8783434 DOI: 10.1186/s13075-021-02704-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 12/11/2021] [Indexed: 11/10/2022] Open
Abstract
Abstract
Objective
To examine how female patients with RA form decisions about having children, pregnancy, and medication use.
Methods
We employed a constructivist grounded theory design and recruited female participants who are 18 years or older, have a rheumatologist-confirmed RA diagnosis, live in Canada, and are able to communicate in English or French. We collected data through semi-structured individual and focus group interviews using telephone or video conferencing technology. Data collection and analysis were iterative, employed theoretical sampling, reflexive journaling, and peer debriefing, and culminated in a theoretical model.
Results
We recruited 21 participants with a mean age of 34 years and median 10 years since RA diagnosis. Overall, 33% had never been pregnant, 57% had previously been pregnant, and 10% were pregnant at the time of interview. Of those who had experienced pregnancy, 64% had at least one pregnancy while diagnosed with RA and of those, 56% used DMARD(s) during a pregnancy. We constructed a patient-centred framework depicting the dynamic relationships between 4 decision-making processes—(1) using medications, (2) having children, (3) planning pregnancy, and (4) parenting—and the substantial impact of healthcare providers on patients’ experiences making these decisions. These processes were further influenced by participants’ intersecting identities and contextual factors, particularly attitudes towards health and medications, disease onset and severity, familial support system, and experiences interacting with the healthcare system.
Conclusion
Our framework provides insight into how patients make reproductive decisions in the context of managing RA and the opportunities for providers to support them at each decision-making process. A patient-centred care approach is suggested to support female patients with RA in making reproductive and medication choices aligning with their individual desires, needs, and values.
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Treatment Patterns and Resource Utilization of Pregnant Women with Inflammatory Rheumatic Diseases or Psoriasis in Germany: A Claims Database Analysis. Rheumatol Ther 2021; 8:1565-1584. [PMID: 34427895 PMCID: PMC8572290 DOI: 10.1007/s40744-021-00347-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 07/05/2021] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Uncontrolled inflammatory disease activity can impact pregnancy outcomes and the health of the mother and child. This retrospective claims database analysis assessed treatment patterns before, during, and after pregnancy among women with inflammatory rheumatic disease (IRD; axial spondyloarthritis [axSpA], psoriatic arthritis [PsA], and rheumatoid arthritis [RA]) or psoriasis (PSO) in Germany. METHODS Data were extracted from the BARMER sickness fund (2013-2017). Pregnant women (18-45 years) with documented IRD or PSO diagnoses were compared with age-matched controls from the same database for the analysis of patient characteristics, healthcare resource utilization, and pharmacological treatment during pregnancy. Reported measures included the proportion of women with pharmacological prescriptions or hospitalization/new prescription of corticosteroids or biologics in the 180 days before pregnancy, during pregnancy, and 180 days after delivery. Pre-specified prescription categories (such as disease-specific drugs [not including biologics]) were identified by anatomical therapeutic chemical classification codes. Extrapolated values to the German statutory health insurance population are reported. RESULTS Overall, 2702 pregnant women with IRD (axSpA: 1063; PsA: 660; RA: 979) and 6527 with PSO were identified. The proportion of women with IRD receiving prescriptions for disease-specific drugs reduced during pregnancy and remained stable after delivery (before: 15.0%; during: 9.0%; after: 9.7%). The proportion of women with PSO receiving prescriptions for disease-specific drugs was low (before: 0.6%; during: 0.3%; after: 0.1%). The proportion of women with hospitalization/new prescription of corticosteroids or biologics decreased during pregnancy, compared with pre-pregnancy, and increased after delivery in women with IRD (before: 9.0%; during: 5.1%; after: 11.1%) and PSO (before: 3.5%; during: 1.9%; after: 2.7%). CONCLUSIONS A reduction in pharmacological treatment during pregnancy was observed for women with IRD in Germany. Many women with IRD did not return to pre-pregnancy treatments after delivery, despite signs of disease exacerbation, such as hospitalization and initiation of treatment with corticosteroids/biologics, in this period.
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10
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Wolgemuth T, Stransky OM, Chodoff A, Kazmerski TM, Clowse MEB, Birru Talabi M. Exploring the Preferences of Women Regarding Sexual and Reproductive Health Care in the Context of Rheumatology: A Qualitative Study. Arthritis Care Res (Hoboken) 2021; 73:1194-1200. [PMID: 32374928 DOI: 10.1002/acr.24249] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 04/28/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To explore the sexual and reproductive health (SRH) care and counseling needs of young women with rheumatic diseases in the context of their rheumatology care. METHODS Semistructured qualitative telephone interviews were conducted with female patients with rheumatic diseases ages 18-45 years (n = 30). Women were recruited from outpatient rheumatology clinics in western Pennsylvania. Interviews were audiorecorded and transcribed verbatim. A codebook was inductively developed based on the interview transcripts, and the finalized coding was used to conduct a thematic analysis. RESULTS Four themes emerged from interviews: 1) women want rheumatologists to initiate conversations about SRH and to revisit the conversation over time; 2) women desire clear and complete information regarding fetal, pregnancy, and infertility risks associated with their diseases and disease-modifying antirheumatic drugs (DMARDs); 3) women want to be treated holistically, with SRH addressed in the context of their life circumstances and personal values in addition to their rheumatic diseases; 4) women generally feel that they are intermediaries between their rheumatologists and obstetrician-gynecologists (OB/GYNs), but preferred for providers to communicate directly with one another about their SRH. CONCLUSION Patients strongly desired rheumatologists to play an active role in their SRH, by initiating family planning conversations, providing SRH education in the context of their diseases and DMARDs, and directly coordinating SRH care with OB/GYNs. To meet patients' SRH needs, further work is needed to clarify the specific role of rheumatologists in providing SRH care and to identify ways to better facilitate communication between rheumatologists and reproductive health care providers.
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Affiliation(s)
- Tierney Wolgemuth
- Center for Women's Health Research and Innovation and University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Olivia M Stransky
- Center for Women's Health Research and Innovation, Pittsburgh, Pennsylvania
| | | | - Traci M Kazmerski
- Center for Women's Health Research and Innovation and University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Mehret Birru Talabi
- Center for Women's Health Research and Innovation and University of Pittsburgh, Pittsburgh, Pennsylvania
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Birru Talabi M, Eudy AM, Jayasundara M, Haroun T, Nowell WB, Curtis JR, Crow-Hercher R, White W, Ginsberg S, Clowse MEB. Tough Choices: Exploring Medication Decision-Making During Pregnancy and Lactation Among Women With Inflammatory Arthritis. ACR Open Rheumatol 2021; 3:475-483. [PMID: 34114738 PMCID: PMC8281053 DOI: 10.1002/acr2.11240] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 01/27/2021] [Indexed: 01/04/2023] Open
Abstract
Objective This study explored how women’s beliefs about drug safety and interactions with their health care providers influenced their decisions to continue arthritis medications during pregnancy and lactation. Methods We collaborated with ArthritisPower, a patient‐powered research network, and CreakyJoints, its partner online community, to develop and disseminate a survey among members with inflammatory arthritis who had at least one pregnancy after diagnosis. Participants’ free‐text responses were evaluated by using thematic analysis. Results Women in the sample were 40 years old on average (N = 66). Nineteen of their pregnancies had ended in fetal loss. Fifteen percent of all pregnancies were exposed to methotrexate. Among women who used safe arthritis medications, up to 80% discontinued treatment either in preparation for pregnancy or during pregnancy or lactation. Women’s decisions to continue medications during pregnancy were influenced by their perceptions of safety and advisement from health care providers, although they often described that advice about medication safety was inconsistent between providers. Conclusion Women often chose to endure active inflammatory arthritis rather than to use disease‐modifying antirheumatic drugs because of concerns about medication safety during pregnancy and lactation. Conflicting medical advice from health care providers undermined patients’ trust in their providers and in the safety of their medications. The high rate of peripartum exposure to methotrexate, a fetotoxic drug, underscores the need for better family planning care for women with childbearing potential.
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Affiliation(s)
| | - Amanda M Eudy
- Duke University Medical Center, Durham, North Carolina
| | | | | | - W Benjamin Nowell
- Global Healthy Living Foundation, CreakyJoints, Upper Nyack, New York
| | | | | | - Whitney White
- Global Healthy Living Foundation, CreakyJoints, Upper Nyack, New York
| | - Seth Ginsberg
- Global Healthy Living Foundation, CreakyJoints, Upper Nyack, New York
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12
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Beltagy A, Aghamajidi A, Trespidi L, Ossola W, Meroni PL. Biologics During Pregnancy and Breastfeeding Among Women With Rheumatic Diseases: Safety Clinical Evidence on the Road. Front Pharmacol 2021; 12:621247. [PMID: 34122062 PMCID: PMC8189556 DOI: 10.3389/fphar.2021.621247] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 01/04/2021] [Indexed: 12/31/2022] Open
Abstract
Females are generally more affected by autoimmune diseases, a fact that underlines the relationship with pregnancy and the safety of anti-rheumatic drugs in pregnancy and lactation. Biologic therapies are increasingly prescribed to treat and maintain remission in a significant number of systemic autoimmune rheumatic diseases. The experience with the use of biologics during gestation is extremely lacking because of the observational nature of the available studies and the difficulty in designing proper clinical trials in pregnancy. Among the studied biologics, more information was published on TNFα inhibitors and, in particular, on their potential passage through the placenta and impact on the fetus. Currently, a fragment of anti-TNFα monoclonal IgG, certolizumab pegol, is considered safe with almost no placental transfer. Subsequent observations are suggesting a comparable safety for the soluble TNFα receptor etanercept. Another biologic, eculizumab, the anti-C5a antibody used to treat complement-mediated microangiopathies, is also considered safe due to the unique engineered IgG2/4κ formulation that limits its passage through the placental barrier. Still, long-term data about children born to women treated with biologics in pregnancy are not attainable. Data on breastfeeding are currently available for several biologics. This article reviews the literature available about which drugs are considered safe during pregnancy and lactation, which are not, and on future prospects.
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Affiliation(s)
- Asmaa Beltagy
- Istituto Auxologico Italiano, IRCCS, Immunorheumatology Research Laboratory, Milan, Italy.,Rheumatology and Clinical Immunology Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Azin Aghamajidi
- Department of Immunology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Laura Trespidi
- Department of Obstetrics and Gynaecology, Fondazione Ca Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Wally Ossola
- Department of Obstetrics and Gynaecology, Fondazione Ca Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Pier Luigi Meroni
- Istituto Auxologico Italiano, IRCCS, Immunorheumatology Research Laboratory, Milan, Italy
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13
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Abstract
PURPOSE OF REVIEW As active rheumatic and musculoskeletal disease during pregnancy increases the risk for pregnancy loss, preterm birth, and maternal illness, ongoing management with pregnancy-compatible medications can improve these outcomes. Selecting and taking these medications can be challenging for rheumatologists and patients due to limited knowledge about potential risks and benefits. RECENT FINDINGS Fortunately, the American College of Rheumatology, American College of Obstetrics and Gynecology, British Rheumatology Society, and the European League Against Rheumatism have each published recommendations to guide the use of antirheumatic medications in pregnancy and lactation. Each of these groups endorsed the use of hydroxychloroquine, azathioprine, sulfasalazine, corticosteroids, NSAIDs, and tumor necrosis factor inhibitors in pregnancy. They also agreed that methotrexate, mycophenolate, cyclophosphamide, and leflunomide should be avoided in pregnancy. New medications, including small-molecules and biologics, have limited data to support safety in pregnancy and are not currently recommended during this period. Most antirheumatic medications are compatible with lactation. SUMMARY Because many patients are hesitant to use antirheumatic medications during pregnancy, honest and accurate discussions about pregnancy planning and management are important to help women make decisions that are in their and their offspring's best interest.
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14
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Nathan NO, Mørch LS, Wu CS, Olsen J, Hetland ML, Li J, Rom AL. Rheumatoid arthritis and risk of spontaneous abortion: a Danish nationwide cohort study. Rheumatology (Oxford) 2021; 59:1984-1991. [PMID: 31776579 DOI: 10.1093/rheumatology/kez565] [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: 08/21/2019] [Revised: 10/22/2019] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES To investigate the influence of RA or preclinical RA on the risk of spontaneous abortion (SA) while taking age and duration of RA into consideration. METHODS By linkage of data from Danish national registries, we established a nationwide cohort of pregnancies in Denmark from 1 January 1977 to 31 December 2014. We used multiple logistic regression to estimate; odds ratios (OR) for SA in women with RA or preclinical RA, compared with women without, and OR for SA by maternal age in women with RA or preclinical RA. RESULTS A total of 2 612 529 pregnancies were included. Women aged <35 years diagnosed with RA <5 years before pregnancy had an increased risk of SA (OR = 1.25 95% CI: 1.07, 1.48), compared with women without RA aged <35. Women at the same age diagnosed with RA ≥5 years before pregnancy had an OR of 1.14 (0.96-1.34), compared with women without. Among women with RA aged ≥35 years and women with preclinical RA at time of pregnancy, no increased risk of SA was found. The risk of SA increased by maternal age in both women with RA, preclinical RA and in women without. CONCLUSION Among women aged <35 years, the risk of SA was higher in women with RA compared with women without. After the age of 35 years, the risk of SA was no different from that among women without RA, even though the risk of SA increased with increasing age.
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Affiliation(s)
- Nina O Nathan
- Department of Obstetrics, The Juliane Marie Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen.,Research Unit Women's and Children's Health, The Juliane Marie Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen
| | - Lina S Mørch
- Research Unit Women's and Children's Health, The Juliane Marie Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen
| | - Chun S Wu
- Research Unit of Gynecology and Obstetrics, Institute of Clinical Research, University of Southern Denmark.,Department of Obstetrics and Gynecology, Odense University Hospital, Odense
| | - Jørn Olsen
- Department of Clinical Epidemiology, University of Aarhus, Aarhus, Denmark.,Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, CA, USA
| | - Merete L Hetland
- Center for Rheumatology and Spine Diseases, Copenhagen Center for Arthritis Research, Rigshospitalet, Glostrup.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jiong Li
- Department of Clinical Epidemiology, University of Aarhus, Aarhus, Denmark
| | - Ane L Rom
- Department of Obstetrics, The Juliane Marie Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen.,Research Unit Women's and Children's Health, The Juliane Marie Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen
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15
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Abstract
Chronic rheumatic diseases often occur in women of reproductive age, and the effect rheumatic disease has on pregnancy varies depending on the condition. Medical management of rheumatic diseases during pregnancy may prevent joint or organ damage and minimize the adverse effects of the disease itself on pregnancy outcomes. Each patient requires individual assessment to control disease activity while minimizing or avoiding medications with potential maternal or fetal toxicity. An open discussion with shared decision making between patients, obstetricians, rheumatologists, and pharmacists is imperative to create an individualized treatment plan that meets patients' goals. This article will review the current literature for use of disease modifying antirheumatic drugs and biologics during pregnancy and lactation, providing health care professionals with the most up-to-date information available.
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16
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Natividade da Silva F, Brunetta HS, Bruxel MA, Gomes FA, Rafacho A. Impact of glucocorticoid treatment before pregnancy on glucose homeostasis of offspring exposed to glucocorticoid in adult life. Life Sci 2019; 237:116913. [DOI: 10.1016/j.lfs.2019.116913] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 09/24/2019] [Accepted: 09/24/2019] [Indexed: 12/31/2022]
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17
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Rebić N, Sayre EC, Zusman EZ, Amiri N, Baldwin C, De Vera MA. Perinatal use and discontinuation of disease-modifying anti-rheumatic drugs and biologics in women with rheumatoid arthritis: a cohort study. Rheumatology (Oxford) 2019; 59:1514-1521. [DOI: 10.1093/rheumatology/kez478] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 09/10/2019] [Indexed: 01/06/2023] Open
Abstract
AbstractObjectivesTo characterize the utilization and discontinuation of medications before, during and after pregnancy among women with RA.MethodsWe used population-based administrative data to identify women with RA who had a singleton pregnancy ending in delivery between 1 January 2002 and 31 December 2012. We assessed the utilization of RA medications, namely, conventional synthetic DMARDs, biologics, glucocorticosteroids and NSAIDs, across six windows spanning 24 and 12 months before the start of pregnancy, each trimester of pregnancy and 12 months post-pregnancy. We defined medication discontinuation as no prescription in a given window following a prescription in the preceding window and evaluated predictors using logistic regression models, calculating adjusted odds ratios (ORs) and 95% CIs.ResultsWe studied 1730 pregnancies in 1301 women with RA (mean age at delivery 31.4 ± 5.4 years). We observed substantial medication discontinuation, particularly in the first trimester, with discontinuation of antimalarials in 57.3% of patients, azathioprine 59.1%, sulfasalazine 69.5% and biologics 50.8%. Factors inversely associated with discontinuation of antimalarials in the first trimester were maternal age [OR 0.90 (95% CI 0.86, 0.95)] and number of rheumatology visits [OR 0.86 (95% CI 0.75, 0.97)] and for biologics, prior adverse birth outcome [OR 0.22 (95% CI 0.05, 0.95)].ConclusionOur population-based study shows frequent discontinuation of medications for RA, particularly in the first trimester. Findings indicate a need to educate women with RA who are planning pregnancy on the benefits and risks of medications during pregnancy.
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Affiliation(s)
- Nevena Rebić
- University of British Columbia, Faculty of Pharmaceutical Sciences, Vancouver, BC, Canada
- Collaboration for Outcomes Research and Evaluation, Vancouver, BC, Canada
- Arthritis Research Canada, Richmond, BC, Canada
| | | | - Enav Z Zusman
- University of British Columbia, Faculty of Pharmaceutical Sciences, Vancouver, BC, Canada
- Collaboration for Outcomes Research and Evaluation, Vancouver, BC, Canada
- Arthritis Research Canada, Richmond, BC, Canada
| | - Neda Amiri
- Division of Rheumatology, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Corisande Baldwin
- Division of Rheumatology, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Mary A De Vera
- University of British Columbia, Faculty of Pharmaceutical Sciences, Vancouver, BC, Canada
- Collaboration for Outcomes Research and Evaluation, Vancouver, BC, Canada
- Arthritis Research Canada, Richmond, BC, Canada
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18
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MacDonald SC, Cohen JM, Panchaud A, McElrath TF, Huybrechts KF, Hernández-Díaz S. Identifying pregnancies in insurance claims data: Methods and application to retinoid teratogenic surveillance. Pharmacoepidemiol Drug Saf 2019; 28:1211-1221. [PMID: 31328328 PMCID: PMC6830505 DOI: 10.1002/pds.4794] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 04/05/2019] [Accepted: 04/09/2019] [Indexed: 11/11/2022]
Abstract
PURPOSE The purpose of the study is to develop an algorithm to identify pregnancies in administrative databases and apply it to assess pregnancy rates and outcomes in women prescribed isotretinoin or tretinoin. METHODS Using the 2011 to 2015 Truven Health MarketScan Database, we identified pregnancies, including losses and terminations. In a cohort design, nonpregnant women filling a prescription for isotretinoin or tretinoin were matched to five women without either prescription. Women were followed for 365 days or until conception, medication discontinuation, or enrollment discontinuation ("prescription episode"). Rates of pregnancy, risks of pregnancy losses, and prevalence of infant malformations at birth were assessed by exposure. RESULTS We identified 2 179 192 livebirths, 8434 stillbirths, 2521 mixed births, 415 110 spontaneous abortions, 124 556 elective terminations, and 8974 unspecified abortions. There were 86 834 isotretinoin and 973 587 tretinoin episodes, matched to 5 302 105 unexposed women. Pregnancy rates were 3 (isotretinoin), 19 (tretinoin), and 34 (unexposed) per 1000 person-years. Risk of spontaneous pregnancy losses were similar; however, terminations were more common in the isotretinoin-exposed (28% [95% CI: 21%-36%]) than the tretinoin-exposed (10% [95% CI: 9%-11%]) or unexposed pregnancies (6%). Malformations occurred in 4.5% (95% CI: 3.5%-5.6%) of the tretinoin-exposed pregnancies and 4.2% of the unexposed pregnancies (adjusted odds ratio: 1.16 [95% CI: 0.85-1.58]); isotretinoin-exposed births were too few to assess malformations. CONCLUSIONS Administrative databases can complement risk evaluation and mitigation strategies (REMS) for known teratogens and contribute to safety surveillance for other medications. Here, isotretinoin-exposed pregnancy rates were low, but existent, and many pregnancies were terminated. Tretinoin exposure was not associated with a meaningfully elevated risk of losses or malformations as compared with unexposed pregnancies.
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Affiliation(s)
- Sarah C MacDonald
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Jacqueline M Cohen
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Alice Panchaud
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Thomas F McElrath
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Krista F Huybrechts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Sonia Hernández-Díaz
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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19
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Ray-Griffith SL, Wendel MP, Stowe ZN, Magann EF. Chronic pain during pregnancy: a review of the literature. Int J Womens Health 2018; 10:153-164. [PMID: 29692634 PMCID: PMC5901203 DOI: 10.2147/ijwh.s151845] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND PURPOSE The majority of the reviews and studies on chronic pain in pregnancy have primarily focused on the pharmacological and non-pharmacological treatment options. The purpose of our review was to identify evidence-based clinical research for the evaluation and management of preexisting chronic pain in pregnancy, chronic pain associated with pregnancy, and chronic pain in relation to mode of delivery. METHODS A literature search was undertaken using the search engines PubMed, CINAHL, EBSCOhost, and Web of Science. Search terms used included "chronic pain" AND "pregnant OR pregnancy" OR "pregnancy complications" from inception through August 2016. RESULTS The basis of this review was the 144 articles that met inclusion criteria for this review. Based on our review of the current literature, we recommend 7 guidelines for chronic pain management during and after pregnancy: 1) complete history and physical examination; 2) monitor patients for alcohol, nicotine, and substance use; 3) collaborate with patient to set treatment goals; 4) develop a management plan; 5) for opioids, use lowest effective dose; 6) formulate a pain management plan for labor and delivery; and 7) discuss reproductive health with women with chronic pain. CONCLUSION The management of chronic pain associated with pregnancy is understudied. Obstetrical providers primarily manage chronic pain during pregnancy. Some general guidelines are provided for those health care providers until more information is available.
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Affiliation(s)
- Shona L Ray-Griffith
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Michael P Wendel
- Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Zachary N Stowe
- Department of Psychiatry, University of Wisconsin-Madison, Madison, WI, USA
| | - Everett F Magann
- Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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20
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Palmsten K, Rolland M, Hebert MF, Clowse MEB, Schatz M, Xu R, Chambers CD. Patterns of prednisone use during pregnancy in women with rheumatoid arthritis: Daily and cumulative dose. Pharmacoepidemiol Drug Saf 2018; 27:430-438. [PMID: 29488292 DOI: 10.1002/pds.4410] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2017] [Revised: 12/08/2017] [Accepted: 01/28/2018] [Indexed: 12/19/2022]
Abstract
PURPOSE To characterize prednisone use in pregnant women with rheumatoid arthritis using individual-level heat-maps and clustering individual trajectories of prednisone dose, and to evaluate the association between prednisone dose trajectory groups and gestational length. METHODS This study included pregnant women with rheumatoid arthritis who enrolled in the MotherToBaby Autoimmune Diseases in Pregnancy Study (2003-2014) before gestational week 20 and reported prednisone use without another oral glucocorticoid during pregnancy (n = 254). Information on medication use and pregnancy outcomes was collected by telephone interview plus by medical record review. Prednisone daily dose and cumulative dose were plotted by gestational day using a heat map for each individual. K-means clustering was used to cluster individual trajectories of prednisone dose into groups. The associations between trajectory group and demographics, disease severity measured by the Health Assessment Questionnaire at enrollment, and gestational length were evaluated. RESULTS Women used prednisone 3 to 292 days during pregnancy, with daily doses ranging from <1 to 60 mg. Total cumulative dose ranged from 8 to 6225 mg. Disease severity, non-biologic disease modifying anti-rheumatic drug use, and gestational length varied significantly by trajectory group. After adjusting for disease severity, non-biologic disease modifying anti-rheumatic drug use, and other covariates, the highest vs lowest daily dose trajectory group was associated with reduced gestational age at delivery (β: -2.3 weeks (95%: -3.4, -1.3)), as was the highest vs lowest cumulative dose trajectory group (β: -2.6 weeks (95%: -3.6, -1.5)). CONCLUSIONS In pregnant women with rheumatoid arthritis, patterns of higher prednisone dose were associated with shorter gestational length compared with lower dose.
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Affiliation(s)
- Kristin Palmsten
- HealthPartners Institute, Minneapolis, MN, USA.,Department of Pediatrics, University of California, San Diego, La Jolla, CA, USA
| | - Matthieu Rolland
- INSERM U1219-Centre Inserm Bordeaux Population Health, Université de Bordeaux, Bordeaux, France
| | - Mary F Hebert
- Departments of Pharmacy and Obstetrics and Gynecology, University of Washington, Seattle, WA, USA
| | - Megan E B Clowse
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Michael Schatz
- Department of Allergy, Kaiser Permanente Medical Center, San Diego, CA, USA
| | - Ronghui Xu
- Department of Mathematics, University of California, San Diego, La Jolla, CA, USA.,Department of Family Medicine and Public Health, University of California, San Diego, La Jolla, CA, USA
| | - Christina D Chambers
- Department of Pediatrics, University of California, San Diego, La Jolla, CA, USA.,Department of Family Medicine and Public Health, University of California, San Diego, La Jolla, CA, USA
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21
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Desai RJ, Huybrechts KF, Bateman BT, Hernandez-Diaz S, Mogun H, Gopalakrishnan C, Patorno E, Kim SC. Brief Report: Patterns and Secular Trends in Use of Immunomodulatory Agents During Pregnancy in Women With Rheumatic Conditions. Arthritis Rheumatol 2017; 68:1183-9. [PMID: 26606742 DOI: 10.1002/art.39521] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 11/17/2015] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To describe patterns and secular trends in the use of immunomodulatory agents in pregnant women with systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), psoriatic arthritis (PsA), or ankylosing spondylitis (AS). METHODS We identified a cohort of women with SLE, RA, PsA, or AS enrolled in public (Medicaid, 2001-2010) or private (Optum Clinformatics, 2004-2012) health insurance, and we included women filling prescriptions for immunomodulatory agents (including steroids, nonbiologic disease-modifying agents, and biologic agents) in the 3-month period immediately prior to their pregnancies. The proportion of women continuing or discontinuing individual agents during pregnancy was reported. Annual prescription fill rates, estimated after accounting for patient characteristics and random variability from year to year in mixed-effects regression models, were used to conduct time trends analysis. RESULTS We included 2,645 women being treated with immunomodulatory agents prior to pregnancy. More women with PsA or AS stopped filling prescriptions for immunomodulatory agents during pregnancy (61%) than women with SLE (26%) or women with RA (34.5%). From the first to the third trimester, the proportions of women filling prescriptions for immunomodulatory agents decreased across all indications. Overall, steroids and hydroxychloroquine were the most frequently used agents in pregnancy (48.4% and 27.1%, respectively). The rates (reported per 100 deliveries in our cohort) for steroid prescription fills during pregnancy decreased significantly from 54.4 in 2001 to 42.4 in 2012, while rates for biologic agents increased from 5.1 in 2001 to 16.6 in 2012 (P < 0.001 for both trends). CONCLUSION Steroids and hydroxychloroquine remain the most widely prescribed treatment options in pregnancy, but the use of biologic agents is becoming increasingly common.
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Affiliation(s)
- Rishi J Desai
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Krista F Huybrechts
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Brian T Bateman
- Brigham and Women's Hospital, Massachusetts General Hospital, and Harvard Medical School, Boston, Massachusetts
| | | | - Helen Mogun
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | | | - Elisabetta Patorno
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Seoyoung C Kim
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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22
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Shesternya PA, Petrova MM, Vasilyeva AO. [New horizons in the use of biological agents during pregnancy in patients with rheumatic disease]. TERAPEVT ARKH 2017. [PMID: 28631708 DOI: 10.17116/terarkh2017895105-112] [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: 11/17/2022]
Abstract
Pregnancy in the presence of rheumatic diseases (RD) and adequate therapy before planned conception, during gestation, and after delivery during lactation is challenging. Advances in the treatment of RD are largely due to the clinical introduction of a new class of biological agents (BAs). There are less than two decades of experience in using BAs in rheumatology and to date there are no unified standards and accepted rules governing their use during pregnancy. According to the current requirements, information on a medicine should be given in three sections: 1) pregnancy; 2) lactation, and 3) use in men and women who are planning concept (the latter section has appeared for the first time). The present article summarizes data on the possible use of BAs in patients with RD during pregnancy planning, pregnancy, and breastfeeding.
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Affiliation(s)
- P A Shesternya
- Prof. V.F. Voino-Yasenetsky Krasnoyarsk State Medical University, Ministry of Health of Russia, Krasnoyarsk, Russia
| | - M M Petrova
- Prof. V.F. Voino-Yasenetsky Krasnoyarsk State Medical University, Ministry of Health of Russia, Krasnoyarsk, Russia
| | - A O Vasilyeva
- Prof. V.F. Voino-Yasenetsky Krasnoyarsk State Medical University, Ministry of Health of Russia, Krasnoyarsk, Russia
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23
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Krause ML, Makol A. Management of rheumatoid arthritis during pregnancy: challenges and solutions. Open Access Rheumatol 2016; 8:23-36. [PMID: 27843367 PMCID: PMC5098768 DOI: 10.2147/oarrr.s85340] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Rheumatoid arthritis, a chronic inflammatory autoimmune disease with significant physical disability, affects women three times more frequently than men, often in their childbearing years. Parenthood decisions can be challenging, often affected by perceptions of their disease state, health care needs, and complex pharmacological treatments. Many women struggle to find adequate information to guide them on pregnancy planning, lactation, and early parenting in relation to their chronic condition. The expanded availability and choice of pharmacotherapies have supported optimal disease control prior to conception and enhanced physical capabilities for women to successfully overcome the challenges of raising children but require a detailed understanding of their risks and safety in the setting of pregnancy and breastfeeding. This review outlines the various situational challenges faced by rheumatologists in providing care to men and women in the reproductive age group interested in starting a family. Up to date evidence-based solutions particularly focusing on the safe use of disease-modifying antirheumatic drugs and biologic response modifiers to assist rheumatologists in the care of pregnant and lactating women with RA are reviewed.
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Affiliation(s)
- Megan L Krause
- Division of Rheumatology, Department of Internal Medicine, Mayo Clinic, MN, USA
| | - Ashima Makol
- Division of Rheumatology, Department of Internal Medicine, Mayo Clinic, MN, USA
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25
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Wallenius M, Salvesen KÅ, Daltveit AK, Skomsvoll JF. Miscarriage and Stillbirth in Women with Rheumatoid Arthritis. J Rheumatol 2015; 42:1570-2. [DOI: 10.3899/jrheum.141553] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/26/2015] [Indexed: 01/01/2023]
Abstract
Objective.To examine the risk of pregnancy loss in women with rheumatoid arthritis (RA).Methods.Cumulative numbers of early miscarriages (before gestational Week 12), late miscarriages (weeks 12–22), and stillbirths reported to the Medical Birth Registry of Norway in the period 1999–2009.Results.There were 1578 women with RA and 411,130 reference women included in the study. Relative risks of early and late miscarriage in women with RA versus references were 1.2 (95% CI 1.1–1.3) and 1.4 (95% CI 1.1–1.7), respectively. There was no difference in stillbirth.Conclusion.The risk of miscarriage was slightly higher among women with RA than in references.
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Kavanaugh A, Cush JJ, Ahmed MS, Bermas BL, Chakravarty E, Chambers C, Clowse M, Curtis JR, Dao K, Hankins GDV, Koren G, Kim SC, Lapteva L, Mahadevan U, Moore T, Nolan M, Ren Z, Sammaritano LR, Seymour S, Weisman MH. Proceedings From the American College of Rheumatology Reproductive Health Summit: The Management of Fertility, Pregnancy, and Lactation in Women With Autoimmune and Systemic Inflammatory Diseases. Arthritis Care Res (Hoboken) 2015; 67:313-25. [DOI: 10.1002/acr.22516] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Accepted: 11/04/2014] [Indexed: 01/31/2023]
Affiliation(s)
| | | | | | | | | | | | - Megan Clowse
- Duke University Medical Center; Durham North Carolina
| | | | | | | | - Gideon Koren
- The Hospital for Sick Children, Toronto; Ontario Canada
| | | | | | | | - Thomas Moore
- School of Medicine, University of California at San Diego
| | - Martha Nolan
- Society for Women's Health Research; Washington DC
| | - Zhaoxia Ren
- National Institute of Child Health and Human Development, National Institutes of Health; Bethesda Maryland
| | - Lisa R. Sammaritano
- Hospital for Special Surgery, Weill Medical College of Cornell University; New York New York
| | - Sally Seymour
- US Food and Drug Administration; Silver Spring Maryland
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Rom AL, Wu CS, Olsen J, Kjaergaard H, Jawaheer D, Hetland ML, Vestergaard M, Mørch LS. Fetal growth and preterm birth in children exposed to maternal or paternal rheumatoid arthritis: a nationwide cohort study. Arthritis Rheumatol 2015; 66:3265-73. [PMID: 25393524 DOI: 10.1002/art.38874] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Accepted: 09/04/2014] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To assess indicators of fetal growth and risk of preterm birth in children of parents with rheumatoid arthritis (RA). METHODS Through linkage of Danish national registries, we identified all children born in Denmark between 1977 and 2008. We used general linear regression models to estimate mean differences in indicators of fetal growth among children with a parent with RA compared to unexposed children. Odds ratios (ORs) and 95% confidence intervals (95% CIs) of preterm birth were calculated using a logistic regression model. RESULTS Of the 1,917,723 children included, a total of 13,556 children were exposed to maternal RA or maternal preclinical RA. Children exposed to maternal RA (n = 2,101) had approximately similar length, head circumference, and abdominal circumference at birth compared with children of mothers without RA. Birth weight was 87 gm lower (mean difference -87.04 gm [95% CI -111.23, -62.84]) and placenta weight was 14 gm lower (-13.45 gm [95% CI -21.46, -5.43]) than those in children of mothers without RA. Rather similar results were found in children exposed to maternal preclinical RA (n = 11,455). Compared with unexposed children, a higher risk of preterm birth was found in children exposed to maternal RA (OR 1.48 [95% CI 1.20, 1.84]) and preclinical RA (OR 1.32 [95% CI 1.07, 1.64]). No associations were found with paternal RA. CONCLUSION Children exposed to either maternal RA or maternal preclinical RA are more often born preterm. However, indicators of fetal growth measured at birth were only slightly lower than those in unexposed children.
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Affiliation(s)
- Ane L Rom
- Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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Considerations in using registry and health plan data for studying pregnancy in rheumatic diseases. Curr Opin Rheumatol 2014; 26:315-20. [PMID: 24667289 DOI: 10.1097/bor.0000000000000056] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to critically evaluate the strengths and limitations of different data sources for pregnancy-related research in patients with rheumatic diseases. We describe challenges in studying adverse pregnancy outcomes in the setting of observational research, with a particular focus on the studies of maternal drug exposures. RECENT FINDINGS We discuss potential threats to validity in the assessment of exposure and outcomes and controlling for confounding; present findings from selected pregnancy-related observational studies conducted using data from registries and health plans; and highlight future research opportunities for pregnancy research. SUMMARY Registry and health plan data contribute complementary information to each other. Used together, linked data sources may allow clinicians, researchers, and patients to obtain a more complete understanding of the risk and benefits associated with maternal drug exposure and of the risk factors associated with adverse birth outcomes in women with rheumatic disease.
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Krause ML, Amin S, Makol A. Use of DMARDs and biologics during pregnancy and lactation in rheumatoid arthritis: what the rheumatologist needs to know. Ther Adv Musculoskelet Dis 2014; 6:169-84. [PMID: 25342996 DOI: 10.1177/1759720x14551568] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Rheumatoid arthritis (RA), a chronic autoimmune inflammatory disease of synovial joints, can lead to chronic pain and structural joint damage, as well as other organ involvement, especially if not adequately controlled. Because it can affect women in their reproductive years, care of pregnant women with RA requires a delicate balance of maintaining disease control while limiting potential toxicity to the fetus and neonate. While most women experience a substantial improvement in disease activity during pregnancy, for some women their RA remains active. It can even manifest itself for the first time during pregnancy or early in the post-partum period. Optimizing disease control prior to conception is key, but utilizing disease-modifying treatments effectively and safely throughout pregnancy and lactation requires open dialogue and shared decision making. This review provides evidence-based recommendations for use of disease-modifying antirheumatic drugs (DMARDs) and biologic response modifiers to guide rheumatologists in their care of pregnant and lactating women with RA and serves as a guide to counsel male patients with RA on family planning decisions.
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Affiliation(s)
- Megan L Krause
- Division of Rheumatology, Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Shreyasee Amin
- Division of Rheumatology, Department of Internal Medicine; and Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Ashima Makol
- Department of Internal Medicine, Division of Rheumatology, Mayo Clinic, College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
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Stone RH, Hong J, Jeong H. Pharmacokinetics of monoclonal antibodies used for inflammatory bowel diseases in pregnant women. ACTA ACUST UNITED AC 2014; 4. [PMID: 26539323 DOI: 10.4172/2161-0495.1000209] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Inflammatory bowel disease (IBD) is a condition of chronic immune response and inflammation of the gastrointestinal tract. Most women with IBD are affected during their reproductive years, and untreated IBD can have detrimental maternal and fetal outcomes. In recent years, many biological therapies including anti-TNF agents (infliximab, adalimumab, and certolizumab) have been developed for the treatment of IBD. An increasing number of IBD patients are treated with these agents during pregnancy. Sporadic reports suggest an absence of negative pregnancy outcomes related to use of anti-TNF agents in women with IBD. However, it is unclear if the physiological changes occurring in pregnancy alter mAb dose requirements for optimal maternal disease management and minimal fetal exposure to therapeutic antibodies. Based on current understanding of the pharmacokinetic profiles for anti-TNF agents in nonpregnant subjects, it appears very likely that physiological changes accompanying pregnancy can alter pharmacokinetics of anti-TNF agents. This review focuses on how such physiological changes may impact disposition of anti-TNF agents during pregnancy. Further improvement in pregnancy outcomes may be achieved in women with IBD by better understanding of pregnancy-mediated changes in the pharmacokinetics of anti-TNF agents.
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Affiliation(s)
- Rebecca H Stone
- Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
| | - James Hong
- Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
| | - Hyunyoung Jeong
- Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA ; Department of Biopharmaceutical Sciences, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
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Chung CP, Rohan P, Krishnaswami S, McPheeters ML. A systematic review of validated methods for identifying patients with rheumatoid arthritis using administrative or claims data. Vaccine 2014; 31 Suppl 10:K41-61. [PMID: 24331074 DOI: 10.1016/j.vaccine.2013.03.075] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Revised: 02/15/2013] [Accepted: 03/26/2013] [Indexed: 11/15/2022]
Abstract
PURPOSE To review the evidence supporting the validity of billing, procedural, or diagnosis code, or pharmacy claim-based algorithms used to identify patients with rheumatoid arthritis (RA) in administrative and claim databases. METHODS We searched the MEDLINE database from 1991 to September 2012 using controlled vocabulary and key terms related to RA and reference lists of included studies were searched. Two investigators independently assessed the full text of studies against pre-determined inclusion criteria and extracted the data. Data collected included participant and algorithm characteristics. RESULTS Nine studies reported validation of computer algorithms based on International Classification of Diseases (ICD) codes with or without free-text, medication use, laboratory data and the need for a diagnosis by a rheumatologist. These studies yielded positive predictive values (PPV) ranging from 34 to 97% to identify patients with RA. Higher PPVs were obtained with the use of at least two ICD and/or procedure codes (ICD-9 code 714 and others), the requirement of a prescription of a medication used to treat RA, or requirement of participation of a rheumatologist in patient care. For example, the PPV increased from 66 to 97% when the use of disease-modifying antirheumatic drugs and the presence of a positive rheumatoid factor were required. CONCLUSIONS There have been substantial efforts to propose and validate algorithms to identify patients with RA in automated databases. Algorithms that include more than one code and incorporate medications or laboratory data and/or required a diagnosis by a rheumatologist may increase the PPV.
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Affiliation(s)
- Cecilia P Chung
- Division of Rheumatology, Vanderbilt University School of Medicine, 1161 21st Avenue South, D-3100, Medical Center North, Nashville, TN 37232-2358, USA.
| | - Patricia Rohan
- Office of Biostatistics and Epidemiology, Center for Biologics Evaluation and Research, Food and Drug Administration, WOC1 Building, Room 454S, 1401 Rockville Pike, Rockville, MD 20852-1428, USA
| | - Shanthi Krishnaswami
- Vanderbilt Evidence-based Practice Center, Vanderbilt University Medical Center, Suite 600, 2525 West End Avenue, Nashville, TN 37203-1738, USA.
| | - Melissa L McPheeters
- Vanderbilt Evidence-based Practice Center and Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Suite 600, 2525 West End Avenue, Nashville, TN 37203-1738, USA.
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Likis FE, Sathe NA, Carnahan R, McPheeters ML. A systematic review of validated methods to capture stillbirth and spontaneous abortion using administrative or claims data. Vaccine 2014; 31 Suppl 10:K74-82. [PMID: 24331077 DOI: 10.1016/j.vaccine.2013.03.076] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2012] [Revised: 02/11/2013] [Accepted: 03/26/2013] [Indexed: 10/25/2022]
Abstract
PURPOSE To identify and assess diagnosis, procedure and pharmacy dispensing codes used to identify stillbirths and spontaneous abortion in administrative and claims databases from the United States or Canada. METHODS We searched the MEDLINE database from 1991 to September 2012 using controlled vocabulary and key terms related to stillbirth or spontaneous abortion. We also searched the reference lists of included studies. Two investigators independently assessed the full text of studies against pre-determined inclusion criteria. Two reviewers independently extracted data regarding participant and algorithm characteristics and assessed each study's methodological rigor using a pre-defined approach. RESULTS Ten publications addressing stillbirth and four addressing spontaneous abortion met our inclusion criteria. The International Classification of Diseases, Ninth Revision (ICD-9) codes most commonly used in algorithms for stillbirth were those for intrauterine death (656.4) and stillborn outcomes of delivery (V27.1, V27.3-V27.4, and V27.6-V27.7). Papers identifying spontaneous abortion used codes for missed abortion and spontaneous abortion: 632, 634.x, as well as V27.0-V27.7. Only two studies identifying stillbirth reported validation of algorithms. The overall positive predictive value of the algorithms was high (99%-100%), and one study reported an algorithm with 86% sensitivity. However, the predictive value of individual codes was not assessed and study populations were limited to specific geographic areas. CONCLUSIONS Additional validation studies with a nationally representative sample are needed to confirm the optimal algorithm to identify stillbirths or spontaneous abortion in administrative and claims databases.'
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Affiliation(s)
- Frances E Likis
- Vanderbilt Evidence-based Practice Center, Vanderbilt University Medical Center, Suite 600, 2525 West End Avenue, Nashville, TN, 37203-1738, USA; Department of Medicine, Vanderbilt University Medical Center, Suite 600, 2525 West End Avenue, Nashville, TN, 37203-1738, USA.
| | - Nila A Sathe
- Vanderbilt Evidence-based Practice Center, Vanderbilt University Medical Center, Suite 600, 2525 West End Avenue, Nashville, TN, 37203-1738, USA.
| | - Ryan Carnahan
- Department of Epidemiology, University of Iowa College of Public Health, S437 CPHB University of Iowa, 105 River Street, Iowa City, IA, 52242, USA.
| | - Melissa L McPheeters
- Vanderbilt Evidence-based Practice Center, Vanderbilt University Medical Center, Suite 600, 2525 West End Avenue, Nashville, TN, 37203-1738, USA; Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Suite 600, 2525 West End Avenue, Nashville, TN, 37203-1738, USA.
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Cardiel MH, Díaz-Borjón A, Vázquez del Mercado Espinosa M, Gámez-Nava JI, Barile Fabris LA, Pacheco Tena C, Silveira Torre LH, Pascual Ramos V, Goycochea Robles MV, Aguilar Arreola JE, González Díaz V, Alvarez Nemegyei J, González-López LDC, Salazar Páramo M, Portela Hernández M, Castro Colín Z, Xibillé Friedman DX, Alvarez Hernández E, Casasola Vargas J, Cortés Hernández M, Flores-Alvarado DE, Martínez Martínez LA, Vega-Morales D, Flores-Suárez LF, Medrano Ramírez G, Barrera Cruz A, García González A, López López SM, Rosete Reyes A, Espinosa Morales R. Update of the Mexican College of Rheumatology guidelines for the pharmacologic treatment of rheumatoid arthritis. ACTA ACUST UNITED AC 2013; 10:227-40. [PMID: 24333119 DOI: 10.1016/j.reuma.2013.10.006] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Revised: 09/30/2013] [Accepted: 10/02/2013] [Indexed: 12/31/2022]
Abstract
BACKGROUND The pharmacologic management of rheumatoid arthritis has progressed substantially over the past years. It is therefore desirable that existing information be periodically updated. There are several published international guidelines for the treatment of rheumatoid arthritis that hardly adapt to the Mexican health system because of its limited healthcare resources. Hence, it is imperative to unify the existing recommendations and to incorporate them to a set of clinical, updated recommendations; the Mexican College of Rheumatology developed these recommendations in order to offer an integral management approach of rheumatoid arthritis according to the resources of the Mexican health system. OBJECTIVE To review, update and improve the available evidence within clinical practice guidelines on the pharmacological management of rheumatoid arthritis and produce a set of recommendations adapted to the Mexican health system, according to evidence available through December 2012. METHODS The working group was composed of 30 trained and experienced rheumatologists with a high quality of clinical knowledge and judgment. Recommendations were based on the highest quality evidence from the previously established treatment guidelines, meta-analysis and controlled clinical trials for the adult population with rheumatoid arthritis. RESULTS During the conformation of this document, each working group settled the existing evidence from the different topics according to their experience. Finally, all the evidence and decisions were unified into a single document, treatment algorithm and drug standardization tables. CONCLUSIONS This update of the Mexican Guidelines for the Pharmacologic Treatment of Rheumatoid Arthritis provides the highest quality information available at the time the working group undertook this review and contextualizes its use for the complex Mexican health system.
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Affiliation(s)
- Mario H Cardiel
- Jefe de la Unidad de Investigación «Dr. Mario Alvizouri Muñoz», Hospital General «Dr. Miguel Silva», Secretaría de Salud de Michoacán, Morelia, Michoacán, México
| | - Alejandro Díaz-Borjón
- Profesor Titular del Curso de Especialización en Medicina Interna, Hospital Ángeles Lomas/UNAM, Huixquilucan, Estado de México, México
| | - Mónica Vázquez del Mercado Espinosa
- Reumatólogo del Nuevo Hospital Civil de Guadalajara «Dr. Juan I. Menchaca», Profesor del Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara. Jefa del Instituto de Investigación en Reumatología y del Sistema Músculo Esquelético, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, México
| | - Jorge Iván Gámez-Nava
- Investigador de UMAE, Hospital de Especialidades Centro Médico Nacional de Occidente, IMSS. Profesor del Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, México
| | - Leonor A Barile Fabris
- Reumatóloga y Doctora en Ciencias de la Salud, Jefa del departamento de Reumatología HE CMNSXXI IMSS, Profesora titular del curso de especialización en Reumatología, miembro titular del Sistema Nacional de Investigadores, México Distrito Federal, México
| | - César Pacheco Tena
- Reumatólogo, Profesor-investigador de la Facultad de Medicina de la Universidad Autónoma de Chihuahua, Chihuahua, México
| | - Luis H Silveira Torre
- Médico adjunto, Profesor adjunto Curso de Reumatología, Departamento de Reumatología, Instituto Nacional de Cardiología Ignacio Chávez, México Distrito Federal, México
| | - Virginia Pascual Ramos
- Médico adscrito del Departamento de Inmunología y Reumatología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, México Distrito Federal, México
| | - María Victoria Goycochea Robles
- Reumatóloga, investigadora titular A, adscrita a la Unidad de Investigación en Epidemiología Clínica del Hospital General Regional Núm. 1. «Dr. Carlos McGregor Sánchez Navarro», IMSS, México Distrito Federal, México
| | - Jorge Enrique Aguilar Arreola
- Reumatólogo del Nuevo Hospital Civil de Guadalajara «Dr. Juan I. Menchaca», Profesor del Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, México
| | - Verónica González Díaz
- Reumatóloga del Antiguo Hospital Civil de Guadalajara «Fray Antonio Alcalde», Guadalajara, México
| | - José Alvarez Nemegyei
- Profesor Investigador de la escuela de Medicina de la Universidad Anáhuac-Mayab, Mérida, Yucatán, México
| | - Laura del Carmen González-López
- Reumatólogo del Hospital General Regional 110 del IMSS, Profesor del Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, México
| | - Mario Salazar Páramo
- Jefe de la División de Investigación de la UMAE, Hospital de Especialidades Centro Médico Nacional de Occidente, IMSS. Profesor del Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, México
| | - Margarita Portela Hernández
- Adscrita al Departamento de Reumatología del Hospital de Especialidades del CMN SXXI, México Distrito Federal, México
| | - Zully Castro Colín
- Adscrita al Departamento de Reumatología de HGZ 27 IMSS, México Distrito Federal, México
| | | | | | | | - Miguel Cortés Hernández
- Medicina Interna-Reumatología, Profesor de Fisiología Humana, Facultad de Medicina, Universidad Autónoma de Estado de Morelos, Morelos, México
| | - Diana E Flores-Alvarado
- Profesora de Medicina Interna y Reumatología, Hospital Universitario «José E. González», Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - Laura A Martínez Martínez
- Investigadora titular, Departamento de Reumatología, Instituto Nacional de Cardiología Ignacio Chávez, México Distrito Federal, México
| | - David Vega-Morales
- Hospital Universitario «José E. González», Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - Luis Felipe Flores-Suárez
- Reumatólogo, Jefe de la Clínica de Vasculitis Sistémicas Primarias, Instituto Nacional de Enfermedades Respiratorias, Investigador en Ciencias Médicas «D», México Distrito Federal, México
| | - Gabriel Medrano Ramírez
- Médico internista y reumatólogo, Adscrito al Servicio de Reumatología, Hospital General de México. Presidente del Consejo Mexicano de Reumatología, México Distrito Federal, México
| | - Antonio Barrera Cruz
- Reumatólogo, Maestro en Ciencias Médicas, Coordinador de Programas Médicos, adscrito a la División de Excelencia Clínica, área de Desarrollo de Guías de Práctica Clínica de la Coordinación de Unidades Médicas de Alta Especialidad del IMSS , México Distrito Federal, México
| | - Adolfo García González
- Reumatólogo, Doctor en Ciencias Médicas, Hospital General de Zona IMSS, La Paz, Baja California Sur, México
| | | | - Alejandra Rosete Reyes
- Reumatóloga especializada en Fármaco-vigilancia, Jefe de operaciones Centro de Investigación en Farmacología y Biotecnología, Médica Sur, México Distrito Federal, México
| | - Rolando Espinosa Morales
- Profesor titular de Reumatología, UNAM, Jefe del Departamento de Reumatología, Instituto Nacional de Rehabilitación, México Distrito Federal, México.
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Palmsten K, Hernández-Díaz S, Kuriya B, Solomon DH, Setoguchi S. Use of disease-modifying antirheumatic drugs during pregnancy and risk of preeclampsia. Arthritis Care Res (Hoboken) 2013; 64:1730-8. [PMID: 23111855 DOI: 10.1002/acr.21807] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To describe patterns of disease-modifying antirheumatic drug (DMARD) use during pregnancy in a population-based cohort, and to evaluate the association between autoimmune disease, DMARDs, corticosteroids, and nonsteroidal antiinflammatory drugs (NSAIDs) and preeclampsia. METHODS Using health care utilization databases from British Columbia (1997-2006), we compared the risk for preeclampsia among 44,786 women with and without autoimmune disease with study drug dispensings before pregnancy (past users) and before and during the first 20 gestational weeks (continuous users). Relative risks (RRs) and 95% confidence intervals (95% CIs) were estimated. RESULTS Only 414 women (0.1%) had a DMARD dispensing during pregnancy. The incidence of preeclampsia was 2.3% for past DMARD users, 2.7% for past corticosteroid users, and 2.9% for past NSAID users. Compared to past users, the continuous DMARD user RR was 2.29 (95% CI 0.81-6.44), and was 0.89 (95% CI 0.51-1.56) for corticosteroid and 0.84 (95% CI 0.63-1.10) for NSAID users. Compared to women without autoimmune disease, the delivery year-adjusted RR was 2.02 (95% CI 1.11-3.64) for women with systemic lupus erythematosus (SLE). The DMARD results were attenuated when antimalarials were excluded, and the delivery year-adjusted RR was 0.95 (95% CI 0.25-3.55) when the DMARD analysis was restricted to women with autoimmune disease. CONCLUSION Few women were exposed to DMARDs during pregnancy. We observed a 2-fold increased risk of preeclampsia among women with SLE and a nonsignificant increase in risk in DMARD users. The DMARD and preeclampsia association was attenuated when antimalarials were excluded and null when restricted to women with autoimmune disease, which suggests the association is likely due to greater autoimmune disease severity in DMARD users.
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Pace LE, Schwarz EB. Balancing act: safe and evidence-based prescribing for women of reproductive age. ACTA ACUST UNITED AC 2012; 8:415-25. [PMID: 22757732 DOI: 10.2217/whe.12.25] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Teratogenic medications are commonly prescribed to women of reproductive age. Caring for women who may benefit from the use of teratogenic medications requires clinicians to engage patients in shared decision-making on the risks and benefits of medication use in the context of the patient's fertility goals, the implications of the patient's medical condition for a pregnancy and the risks and benefits of various contraceptive methods. Effective communication about all of these issues is essential to avoiding medication-induced birth defects. However, data suggest that such communication remains inadequate, leading some women to face unintentional exposure of a pregnancy to a teratogen, undesired pregnancy or, sometimes, the need for pregnancy termination services. This review outlines key information needed to ensure safe prescribing to women of childbearing age. It includes recommendations for changes in medical education, healthcare delivery and health policy to facilitate thoughtful prescribing and comprehensive care.
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Affiliation(s)
- Lydia E Pace
- Brigham & Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
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Raja H, Matteson EL, Michet CJ, Smith JR, Pulido JS. Safety of Tumor Necrosis Factor Inhibitors during Pregnancy and Breastfeeding. Transl Vis Sci Technol 2012; 1:6. [PMID: 24049706 PMCID: PMC3763882 DOI: 10.1167/tvst.1.2.6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2012] [Accepted: 08/06/2012] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Tumor necrosis factor (TNF) inhibitors are useful in the treatment of numerous inflammatory and immunologic disorders. Since many of these conditions occur in women of childbearing age, safety during pregnancy and breastfeeding is of considerable importance. METHODS This paper is a review of the literature on the safety of TNF inhibitors during pregnancy and breastfeeding published between 2001 and 2011. CONCLUSIONS TNF inhibitors do not appear to be associated with a high risk of teratogenicity or intrauterine death. However, a small magnitude increase in risk cannot be ruled out given the paucity of data on the subject. Although TNF inhibitor use may be associated with a higher rate of preterm delivery, this may in fact be due to an active, underlying disease. Therefore, the decision to use these medications should be made on a case-by-case basis. If the disease cannot be managed with first line agents, TNF inhibitors may be helpful in reducing the number of disease exacerbations. Nevertheless, when using TNF inhibitors, it is prudent to discontinue treatment around the third trimester when transfer across the placenta is greatest and to restart postpartum.
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Affiliation(s)
- Harish Raja
- Mayo School of Graduate Medical Education, Mayo Clinic, Rochester, MN
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Chambers CD, Johnson DL. Emerging data on the use of anti-tumor necrosis factor-alpha medications in pregnancy. ACTA ACUST UNITED AC 2012; 94:607-11. [DOI: 10.1002/bdra.23033] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2012] [Revised: 04/17/2012] [Accepted: 04/24/2012] [Indexed: 01/25/2023]
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Cassina M, Johnson DL, Robinson LK, Braddock SR, Xu R, Jimenez JL, Mirrasoul N, Salas E, Luo YJ, Jones KL, Chambers CD. Pregnancy outcome in women exposed to leflunomide before or during pregnancy. ACTA ACUST UNITED AC 2012; 64:2085-94. [DOI: 10.1002/art.34419] [Citation(s) in RCA: 99] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Gogia M, Furst DE. Rheumatoid arthritis and pregnancy: Disease activity, pregnancy outcomes, and treatment options during pregnancy and lactation. Drug Dev Res 2011. [DOI: 10.1002/ddr.20478] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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