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Sand KMK, Gruber MM, Sandlie I, Mathiesen L, Andersen JT, Wadsack C. Contribution of the ex vivo placental perfusion model in understanding transplacental immunoglobulin G transfer. Placenta 2022; 127:77-87. [PMID: 35981406 DOI: 10.1016/j.placenta.2022.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 07/07/2022] [Accepted: 07/28/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION The acquisition of humoral immunity in utero is essential for the fetus. The crucial protein, which is responsible for this part of immunity, is immunoglobulin-G (IgG). Immune functions of IgGs are mediated via the interaction of the crystallizable fragment (Fc) region of IgG with specific Fc γ receptors (FcγRs). However, an atypical FcγR, the neonatal Fc receptor (FcRn), is a key regulator of IgG transfer across the human placenta. During the last four decades ex vivo placental perfusion studies have contributed significantly to the study of mechanisms of IgG transfer across the multicellular placental barrier. METHOD A PubMed search was conducted by using specific keywords: placenta, perfusion and IgG to review manuscripts using human placental perfusion to study the transplacental transfer of IgG. Relevant studies found in reference lists of these manuscripts were also added to the review, and references were included that supported or gave nuance to the discussion of the mechanisms of IgG kinetics in the placenta. RESULTS AND DISCUSSION We found twenty publications on the study of transplacental transfer of IgG using human ex vivo placental perfusion, by research groups with partly different settings. This review summarizes knowledge about placental IgG transfer, with a strong focus on the contributions from ex vivo placental perfusion studies.
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Affiliation(s)
- Kine Marita Knudsen Sand
- Department of Biosciences, University of Oslo, 0371, Oslo, Norway; Department of Immunology, Oslo University Hospital Rikshospitalet and University of Oslo, 0424, Oslo, Norway; Department of Pharmacology, Institute of Clinical Medicine, University of Oslo and Oslo University Hospital, 0424, Oslo, Norway
| | - Michael M Gruber
- Department of Obstetrics and Gynaecology, Medical University of Graz, 8036, Graz, Austria
| | - Inger Sandlie
- Department of Biosciences, University of Oslo, 0371, Oslo, Norway; Department of Immunology, Oslo University Hospital Rikshospitalet and University of Oslo, 0424, Oslo, Norway; Department of Pharmacology, Institute of Clinical Medicine, University of Oslo and Oslo University Hospital, 0424, Oslo, Norway
| | - Line Mathiesen
- Section of Environmental Health, Department of Public Health, University of Copenhagen, Copenhagen, Denmark.
| | - Jan Terje Andersen
- Department of Immunology, Oslo University Hospital Rikshospitalet and University of Oslo, 0424, Oslo, Norway; Department of Pharmacology, Institute of Clinical Medicine, University of Oslo and Oslo University Hospital, 0424, Oslo, Norway
| | - Christian Wadsack
- Department of Obstetrics and Gynaecology, Medical University of Graz, 8036, Graz, Austria; BioTechMed-Graz, Austria
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Galstyan GM, Maschan AA, Klebanova EE, Kalinina II. [Treatment of thrombotic thrombocytopenic purpura]. TERAPEVT ARKH 2021; 93:736-745. [PMID: 36286842 DOI: 10.26442/00403660.2021.06.200894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 07/10/2021] [Indexed: 11/22/2022]
Abstract
The review discusses approaches to treatment of acquired thrombotic thrombocytopenic purpuгa (aTTP). In patients with aTTP plasma exchanges, glucocorticosteroids allow to stop an acute attack of TTP, and use of rituximab allows to achieve remission. In recent years, caplacizumab has been used. Treatment options such as cyclosporin A, bortezomib, splenectomy, N-acetylcysteine, recombinant ADAMTS13 are also described. Separately discussed issues of management of patients with TTP during pregnancy, and pediatric patients with TTP.
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Affiliation(s)
| | - A A Maschan
- Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology
| | | | - I I Kalinina
- Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology
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3
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Molinelli E, Sapigni C, Campanati A, Brisigotti V, Offidani A. Metabolic, pharmacokinetic, and toxicological issues of biologic therapies currently used in the treatment of hidradenitis suppurativa. Expert Opin Drug Metab Toxicol 2020; 16:1019-1037. [PMID: 32896186 DOI: 10.1080/17425255.2020.1810233] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Hidradenitis suppurativa is a chronic, relapsing, debilitating inflammatory dermatologic disease of the terminal hair follicles at intertriginous sites clinically characterized by painful inflammatory nodules, abscesses, draining sinus tracts, and dermal fibrosis. The management of hidradenitis suppurativa is a challenge and usually consists of both medical and surgical approaches, which must often be combined for best outcome. The introduction of biological therapies, specifically TNFα-inhibitors such as adalimumab, has profoundly changed the therapeutic armamentarium of the disease. AREAS COVERED The PubMed database was searched using combinations of the following keywords: hidradentis suppurativa, biologic therapy, TNF-α inhibitors, adalimumab, etanercept, infliximab, certolizumab pegol, golimumab, adverse effects, pharmacodynamics, pharmacology, adverse events, pharmacokinetics, drug interaction. This article reviews and updates the chemistry, pharmacokinetics, mechanism of action, adverse effects, drug interactions of on-label and off-label use of TNF-α inhibitors in HS. EXPERT OPINION Biologic agents, particularly adalimumab, exhibit clinical efficacy in patients with hidradenitis suppurativa. Careful patient selection and close monitoring during treatment are mandatory to provide safe and effective use of the TNF-α inhibitor. Familiarity with biologic agents is crucial because these agents could become a consolidated treatment option in the clinician's therapeutic approaches.
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Affiliation(s)
- Elisa Molinelli
- Dermatological Unit, Department of Clinical and Molecular Sciences, Polytechnic Marche University , Ancona, Italy
| | - Claudia Sapigni
- Dermatological Unit, Department of Clinical and Molecular Sciences, Polytechnic Marche University , Ancona, Italy
| | - Anna Campanati
- Dermatological Unit, Department of Clinical and Molecular Sciences, Polytechnic Marche University , Ancona, Italy
| | - Valerio Brisigotti
- Dermatological Unit, Department of Clinical and Molecular Sciences, Polytechnic Marche University , Ancona, Italy
| | - Annamaria Offidani
- Dermatological Unit, Department of Clinical and Molecular Sciences, Polytechnic Marche University , Ancona, Italy
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Nesbitt E, Clements S, Driscoll M. A concise clinician's guide to therapy for hidradenitis suppurativa. Int J Womens Dermatol 2020; 6:80-84. [PMID: 32258336 PMCID: PMC7105662 DOI: 10.1016/j.ijwd.2019.11.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 11/11/2019] [Accepted: 11/14/2019] [Indexed: 12/26/2022] Open
Abstract
Hidradenitis suppurativa (HS) is a chronic, often debilitating, skin condition that historically does not respond well to treatment. Although there is no cure for HS, symptoms can be managed if the appropriate diagnosis is made. HS most commonly develops in postpubertal women and manifests as painful, deep-seated, inflamed lesions, including nodules, sinus tracts, and abscesses. HS flares are marked by increased pain and suppuration at varying intervals and can occur in women before menstruation. HS is commonly misdiagnosed; physicians might mistake a lesion for an infection, abscess, or sexually transmitted infection. Incision and drainage of these lesions often leads to recurrence. Given that management of this chronic disease is often difficult, we sought to outline current diagnosis and management strategies for HS.
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Affiliation(s)
- Emily Nesbitt
- University of Maryland School of Medicine, United States
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5
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Tsao NW, Lynd LD, Sayre EC, Sadatsafavi M, Hanley G, De Vera MA. Use of biologics during pregnancy and risk of serious infections in the mother and baby: a Canadian population-based cohort study. BMJ Open 2019; 9:e023714. [PMID: 30787081 PMCID: PMC6398640 DOI: 10.1136/bmjopen-2018-023714] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVES To investigate the association between exposure to biologics during pregnancy and serious infections in mothers and infants. DESIGN Retrospective cohort study. SETTING Population-based. PARTICIPANTS Women with one or more autoimmune diseases identified by International Classification of Diseases 9th/10th revision codes in healthcare administrative databases in British Columbia, Canada, who had pregnancies ending in a live or stillbirth between 1 January 2002 and 31 December 2012. Women were defined as exposed if they had at least one biologic prescription during pregnancy, and infants born to these women were considered exposed in utero. Disease-matched women with no biologics prescriptions during pregnancy, and their infants, comprised the unexposed groups. PRIMARY OUTCOME MEASURES Serious infections requiring hospitalisation. RESULTS Over the 10-year study period, there were 6218 women (8607 pregnancies) who had an autoimmune disease diagnosis, of which 90 women were exposed to biologics during pregnancy, with 100 babies born to these women. Among women exposed to biologics during pregnancy, occurrence of serious postpartum infections were low, ranging from 0% to 5%, depending on concomitant exposures to immunosuppressants. In multivariable models using logistic regression, the OR for the association of biologics exposure with serious maternal postpartum infections was 0.79 (95% CI 0.24 to 2.54). In infants exposed to biologics in utero, occurrence of serious infections during the first year of life ranged from 0% to 7%, depending on concomitant exposures to immunosuppressants in utero. Multivariable models showed no association between biologics exposure in utero and serious infant infections (OR 0.56, 95% CI 0.17 to 1.81). CONCLUSIONS These population-based data suggest that the use of biologics by women with autoimmune diseases during pregnancy is not associated with an increased risk of serious infections in mothers, during post partum or in infants during the first year of life.
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Affiliation(s)
- Nicole W Tsao
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Larry D Lynd
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Health Evaluation and Outcomes Sciences, Vancouver, British Columbia, Canada
| | - Eric C Sayre
- Arthritis Research Canada, Richmond, British Columbia, Canada
| | - Mohsen Sadatsafavi
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Gillian Hanley
- Department of Obstetrics & Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mary A De Vera
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
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Pefanis A, Williams DS, Skrzypek H, Fung A, Paizis K. A case of ANCA-associated vasculitis presenting de novo in pregnancy, successfully treated with rituximab. Obstet Med 2018; 13:41-44. [PMID: 32284732 DOI: 10.1177/1753495x18780853] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 04/26/2018] [Indexed: 12/16/2022] Open
Abstract
Antineutrophil cytoplasm antibody (ANCA)-associated vasculitides are rare small vessel vasculitides of unknown cause. The pathogenic role of MPO-ANCA in the vasculitides has been supported using various animal models, with B-cells playing a role in the disease pathogenesis. Pregnancy in the presence of an autoimmune disease such as vasculitis is often associated with significant morbidity. Little is known about the outcomes when women present with de novo vasculitis during pregnancy, and the appropriate management of such presentations is unclear. We describe a case of a 33-year-old female presenting in her second pregnancy with new onset ANCA vasculitis at 12 weeks' gestation. She was successfully treated with prednisolone and rituximab, and delivered a healthy 2.8 kg boy at 36 weeks' gestation with no clinical manifestations of vasculitis or neutropenia in the neonate.
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Affiliation(s)
- A Pefanis
- Department of Nephrology, Austin Health, Melbourne, Australia
| | - D S Williams
- Department of Nephrology, Austin Health, Melbourne, Australia
| | - H Skrzypek
- Department of Obstetric, Medicine, Mercy Health, Melbourne, Australia
| | - A Fung
- Department of Obstetric, Medicine, Mercy Health, Melbourne, Australia
| | - K Paizis
- Department of Nephrology, Austin Health, Melbourne, Australia.,Department of Obstetric, Medicine, Mercy Health, Melbourne, Australia
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Harris C, Marin J, Beaulieu MC. Rituximab induction therapy for de novo ANCA associated vasculitis in pregnancy: a case report. BMC Nephrol 2018; 19:152. [PMID: 29954345 PMCID: PMC6022350 DOI: 10.1186/s12882-018-0949-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 06/17/2018] [Indexed: 12/16/2022] Open
Abstract
Background The diagnosis of antineutrophil cytoplasmic antibody (ANCA) associated vasculitis (AAV) is rare in pregnancy but potentially life threatening. There are no randomized controlled trials to guide the management of AAV in pregnancy and fetal safety data remains limited. Rituximab administration, a treatment for AAV, has been reported in pregnant women with reassuring fetal outcomes in the oncology and rheumatology literature; however, no published reports describe its use in AAV. Case presentation We present a case of de novo myeloperoxidase positive (MPO) AAV diagnosed at 22 weeks gestation. Clinical presentation included elevated serum creatinine at 177 μmol/L, hematuria and nephrotic range proteinuria along with high-titre MPO. Diagnosis was confirmed by renal biopsy. Patient was treated with methylprednisolone IV followed by oral prednisone 70 mg daily and Rituximab 650 mg IV weekly for four weeks followed by azathioprine maintenance therapy and prednisone taper. Delivery occurred at 29 weeks gestation via cesarean section for maternal neurologic symptoms concerning for preeclampsia. Maternal and fetal CD + 19 cells were depleted at time of delivery with associated fetal lymphopenia in the absence of infection or other complications related to Rituximab use. The patient experienced a reduction in proteinuria and inflammatory markers following Rituximab therapy; however, serum creatinine increased to 375 μmol/L by 11 weeks post-partum. Conclusion We report the first use, to our knowledge, of Rituximab with corticosteroids for induction therapy of AAV in pregnancy.
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Affiliation(s)
- Claire Harris
- Division of Nephrology, University of British Columbia, Vancouver, BC, Canada
| | - Judith Marin
- St. Paul's Hospital, 1081 Burrard St. Vancouver BC, Vancouver, Canada
| | - Monica C Beaulieu
- Division of Nephrology, University of British Columbia, Vancouver, BC, Canada. .,St. Paul's Hospital, 1081 Burrard St. Vancouver BC, Vancouver, Canada. .,BC Provincial Renal Agency, Vancouver, BC, Canada.
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Clowse MEB, Feldman SR, Isaacs JD, Kimball AB, Strand V, Warren RB, Xibillé D, Chen Y, Frazier D, Geier J, Proulx J, Marren A. Pregnancy Outcomes in the Tofacitinib Safety Databases for Rheumatoid Arthritis and Psoriasis. Drug Saf 2017; 39:755-62. [PMID: 27282428 PMCID: PMC4933738 DOI: 10.1007/s40264-016-0431-z] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Tofacitinib is an oral Janus kinase inhibitor for the treatment of rheumatoid arthritis (RA), and is being investigated for the treatment of psoriasis. Both conditions can present in women of child-bearing potential, but pregnancy was an exclusion and discontinuation criterion in tofacitinib randomized controlled trials (RCTs) because of the unknown effects of tofacitinib on mother and child. Tofacitinib is a small molecule that has the potential to cross the placenta. OBJECTIVE The objective was to report outcomes of pregnancy cases identified through April 2014 from tofacitinib RA/psoriasis RCTs, RA post-approval non-interventional studies, and spontaneous adverse-event reporting. METHODS Pregnancy outcomes were categorized as follows: healthy newborn, medical termination, fetal death, congenital malformation, spontaneous abortion, or pending/lost to follow-up. RESULTS Out of 9815 patients, 1821 female patients of child-bearing age were enrolled in the RA/psoriasis RCTs; 47 women became pregnant, including 33 who received tofacitinib monotherapy, 13 who received combination therapy with methotrexate (RA patients only), and one patient whose therapy was still blinded. No fetal deaths were reported. One congenital pulmonary valve stenosis (monotherapy, n = 1), seven spontaneous abortions (monotherapy, n = 4; combination therapy, n = 3), and eight medical terminations (monotherapy, n = 4; combination therapy, n = 3; blinded therapy, n = 1) were identified. Remaining cases reported healthy newborns (n = 25) or were pending/lost to follow-up (n = 6). Forty-four cases of paternal exposure to tofacitinib were reported (monotherapy, n = 43; combination therapy, n = 1), including five spontaneous abortions (monotherapy, n = 4; combination therapy, n = 1), 23 healthy newborns, and 16 pending/lost to follow-up. CONCLUSIONS The pregnancy outcomes reported in this small number of RA/psoriasis patients appear similar to those observed in the general population and in patients treated with biologic therapies for inflammatory diseases. However, definitive conclusions cannot be drawn, and pregnancy outcomes in patients receiving tofacitinib will continue to be monitored.
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Affiliation(s)
| | - Steven R Feldman
- Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - John D Isaacs
- The NIHR Newcastle Biomedical Research Centre, Newcastle University and Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Alexandra B Kimball
- Department of Dermatology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Vibeke Strand
- Division of Immunology/Rheumatology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Richard B Warren
- Dermatology Centre, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Daniel Xibillé
- Hospital General de Cuernavaca, Cuernavaca, Morelos, Mexico
| | - Yan Chen
- Pfizer Inc, 500 Arcola Rd, Collegeville, PA, 19426, USA
| | | | | | | | - Amy Marren
- Pfizer Inc, 500 Arcola Rd, Collegeville, PA, 19426, USA.
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Perng P, Zampella JG, Okoye GA. Management of hidradenitis suppurativa in pregnancy. J Am Acad Dermatol 2017; 76:979-989. [DOI: 10.1016/j.jaad.2016.10.032] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 10/21/2016] [Accepted: 10/24/2016] [Indexed: 12/16/2022]
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Ngian GS, Briggs AM, Ackerman IN, Van Doornum S. Safety of anti-rheumatic drugs for rheumatoid arthritis in pregnancy and lactation. Int J Rheum Dis 2016; 19:834-43. [PMID: 27125255 DOI: 10.1111/1756-185x.12860] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Women with rheumatoid arthritis (RA) are often of childbearing age and therefore questions regarding reproductive health and the use of medications, including disease-modifying anti-rheumatic drugs (DMARDs) may arise during the clinical consultation. Each patient requires individual assessment in order to effectively manage the disease while minimizing any treatment-associated risks to the fetus. Although good-quality controlled trials are lacking, there is an increasing volume of evidence surrounding the use of immunosuppressive therapies in pregnancy and lactation. This review summarizes the currently available information which can be of benefit to clinicians guiding patients and their families through the risks and benefits of continuing RA therapy during pregnancy and lactation. Further studies and ongoing surveillance of drug safety in pregnancy are required to resolve the uncertainties that remain regarding synthetic and biologic DMARDs.
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Affiliation(s)
- Gene-Siew Ngian
- Department of Medicine (RMH), The University of Melbourne, Melbourne, Victoria, Australia
| | - Andrew M Briggs
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia, Australia.,Arthritis and Osteoporosis Victoria, Melbourne, Victoria, Australia
| | - Ilana N Ackerman
- Department of Medicine (RMH), The University of Melbourne, Melbourne, Victoria, Australia.,Melbourne EpiCentre, Melbourne Health, Melbourne, Victoria, Australia
| | - Sharon Van Doornum
- Department of Medicine (RMH), The University of Melbourne, Melbourne, Victoria, Australia. .,Melbourne EpiCentre, Melbourne Health, Melbourne, Victoria, Australia.
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Dalmau-Carolà J. Childbirth in a woman with antisynthetase syndrome and severe lung disease on long-term rituximab therapy. INDIAN JOURNAL OF RHEUMATOLOGY 2016. [DOI: 10.1016/j.injr.2016.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Affiliation(s)
- May Ching Soh
- High Risk Maternity Services; Oxford University Hospitals NHS Trust; John Radcliffe Hospital; Headley Way Headington Oxford OX3 9DU UK
- de Swiet Obstetric Medicine Unit; Imperial College Healthcare NHS Trust; Queen Charlotte's and Chelsea Hospital; Du Cane Road London W12 0HS UK
| | - Lucy MacKillop
- High Risk Maternity Services; Oxford University Hospitals NHS Trust; John Radcliffe Hospital; Headley Way Headington Oxford OX3 9DU UK
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Saavedra Salinas MÁ, Barrera Cruz A, Cabral Castañeda AR, Jara Quezada LJ, Arce-Salinas CA, Álvarez Nemegyei J, Fraga Mouret A, Orozco Alcalá J, Salazar Páramo M, Cruz Reyes CV, Andrade Ortega L, Vera Lastra OL, Mendoza Pinto C, Sánchez González A, Cruz Cruz PDR, Morales Hernández S, Portela Hernández M, Pérez Cristóbal M, Medina García G, Hernández Romero N, Velarde Ochoa MDC, Navarro Zarza JE, Portillo Díaz V, Vargas Guerrero A, Goycochea Robles MV, García Figueroa JL, Barreira Mercado E, Amigo Castañeda MC. Guías de práctica clínica para la atención del embarazo en mujeres con enfermedades reumáticas autoinmunes del Colegio Mexicano de Reumatología. Parte II. ACTA ACUST UNITED AC 2015; 11:305-15. [DOI: 10.1016/j.reuma.2014.12.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Accepted: 12/12/2014] [Indexed: 12/14/2022]
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Khan N, Asim H, Lichtenstein GR. Safety of anti-TNF therapy in inflammatory bowel disease during pregnancy. Expert Opin Drug Saf 2015; 13:1699-708. [PMID: 25406728 DOI: 10.1517/14740338.2014.973399] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION The highest incidence of inflammatory bowel disease (IBD) is seen between the second and fourth decades of life, which is the most fertile age for women. Increased disease activity has been shown to effect female fertility and pregnancy outcomes, stressing the need for drugs that can safely induce and maintain clinical remission without harming either the mother or fetus. AREAS COVERED Anti-TNF-α agents have been shown to be effective in both inducing and maintaining remission among IBD patients. This review highlights the results of previous studies conducted on pregnant women who were exposed to anti-TNF-α agents during the course of their pregnancy. The drugs reviewed include infliximab (IFX), adalimumab (ADA), certolizumab pegol (CZP) and golimumab (GMB). Of > 200 articles reviewed, 105 were included in the manuscript based on relevance. The keywords used were anti-TNF, infliximab, adalimumab, certolizumab, golimumab, biologics, pregnancy and inflammatory bowel disease. EXPERT OPINION Anti-TNF agents have been studied extensively during pregnancy from the early case reports to the more recent prospective Pregnancy in IBD and Neonatal Outcomes study. A comprehensive review of the literature has shown that biologics can be safely used during pregnancy. In view of this safety data, it is recommended to maintain therapy during pregnancy.
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Affiliation(s)
- Nabeel Khan
- University of Pennsylvania Perelman School of Medicine, Department of Gastroenterology , Philadelphia, PA , USA
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Cordero-Coma M, Salazar-Méndez R, Yilmaz T. Treatment of severe non-infectious uveitis in high-risk conditions (Part I): pregnancy and malignancies, management and safety issues. Expert Opin Drug Saf 2015; 14:1071-86. [DOI: 10.1517/14740338.2015.1044969] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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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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Khan N, Asim H, Lichtenstein GR. Safety of anti-TNF therapy in inflammatory bowel disease during pregnancy. Expert Opin Drug Saf 2014. [DOI: 10.1517/14740338.2015.973399] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Anti-TNFα therapies are safe during pregnancy in women with inflammatory bowel disease: a systematic review and meta-analysis. Inflamm Bowel Dis 2014; 20:1862-9. [PMID: 24983985 DOI: 10.1097/mib.0000000000000092] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The use of TNFα antagonists is well described for inflammatory bowel disease (IBD), but their safety profile during pregnancy is yet to be fully elucidated. A systematic review and meta-analysis were performed to identify studies that explored the safety of anti-TNFα therapy during pregnancy in patients with IBD. METHODS A systematic literature search was conducted to identify studies that investigated the pregnancy outcomes among women with IBD on anti-TNFα therapy. The primary outcome was the overall rate of unfavourable pregnancy-related outcomes among women with IBD on anti-TNFα therapy. Secondary outcomes included rates of abortions (spontaneous or elective), preterm delivery, low birth weight, and congenital malformations. Odds ratios (OR) with 95% confidence interval (CI) are reported. Eligible studies used an observational or interventional design, enrolled subjects with IBD on anti-TNFα therapy for at least 1 trimester and compared outcomes with appropriately matched controls. RESULTS Overall, 5 studies with a total of 1216 participants were eligible for inclusion in the meta-analysis. There was no significant difference in the rates of total unfavourable pregnancy outcomes between pregnant women with IBD who were on anti-TNFα therapy and controls not on anti-TNFα therapy (OR, 1.00 [95% CI, 0.72-1.41]). Similarly, there were no statistically significant differences in the rates of abortion (OR, 1.53 [95% CI, 0.97-2.41]), preterm birth (OR, 1.00 [95% CI, 0.62-1.62]), low birth weight (OR, 1.05 [95% CI, 0.62-1.78]), or congenital malformation (OR, 1.10 [95% CI, 0.58-2.09]). CONCLUSIONS The use of anti-TNFα therapy does not seem to increase the risk of unfavorable pregnancy outcomes among women with IBD, although the optimal timing of therapy through pregnancy and the postpartum period was not assessed in this analysis. These data can help counsel patients around family planning and perinatal management.
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Abstract
Pregnancy poses an important challenge for doctors looking after women with systemic lupus erythematosus. Knowledge about safety of medications, the effect of pregnancy on such disease, and vice versa, together with multidisciplinary team care, are basic cornerstones needed to provide the best obstetric and medical care to these women. Pre-conceptional counselling constitutes the ideal scenario where a patient's previous obstetric history, organ damage, disease activity, serological profile and additional medical history can be summarized. Important issues regarding medication adjustment, planned scans and visits, and main risks discussion should also be raised at this stage. Planned pregnancies lead to better outcomes for both mothers and babies. Close surveillance throughout pregnancy and the puerperium, and tailored management approach guarantee the highest rates of successful pregnancies in these women.
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Affiliation(s)
- O Ateka-Barrutia
- Lupus Research Unit, Women's Health Division, King's College London, UK
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Soh MC, Nelson-Piercy C. Update of the management of rheumatoid arthritis in pregnancy. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/eog.11.77] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Abstract
Biologic therapies have revolutionized treatment outcomes for patients with inflammatory arthritis. However, there remains a concern regarding their safety during conception, pregnancy and breastfeeding. Data on the safety of these treatments are largely limited to uncontrolled case reports. Collective evidence from many hundreds of pregnancies in inflammatory arthritis and IBD have suggested that exposure to anti-TNF therapies at the time of conception or during the first trimester does not result in an increased risk of adverse pregnancy and fetal outcomes. Monoclonal antibodies, and to a lesser extent recombinant fusion proteins, do cross the placenta during the second and third trimester and are functional in the fetus, as evidence by lymphopaenia reported at birth in children exposed to rituximab in utero. In addition, live vaccines should be avoided in children with in utero exposure to biologics for at least the first 6 months of life. The longer-term effects of in utero exposure remain unknown. Studies suggest that many of these drugs do enter breast milk in small amounts, but the extent to which they are absorbed by the infant is less clear. Limited reports have not suggested adverse pregnancy outcomes in women whose partners were exposed to anti-TNF therapies or rituximab at the time of conception. Data on other biologic therapies, including anakinra, abatacept and tocilizumab, in both men and women remain extremely limited.
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Affiliation(s)
- Kimme L Hyrich
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Institute of Inflammation and Repair, University of Manchester, Manchester, UK.
| | - Suzanne M M Verstappen
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Institute of Inflammation and Repair, University of Manchester, Manchester, UK
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Safety of anti-TNF agents during pregnancy and breastfeeding in women with inflammatory bowel disease. Am J Gastroenterol 2013; 108:1426-38. [PMID: 23752881 DOI: 10.1038/ajg.2013.171] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2013] [Accepted: 04/30/2013] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Anti-tumor necrosis factor (TNF) drugs are an effective therapeutic option in patients with inflammatory bowel disease (IBD). However, data regarding their safety during pregnancy and breastfeeding are scarce. The aim of this study was to critically review available data on the safety of anti-TNF therapy during pregnancy and breastfeeding in women with IBD. METHODS Bibliographical searches (MEDLINE) up to January 2013. RESULTS The studies included provided data from 462 women with IBD exposed to anti-TNF agents during pregnancy. Although these drugs cross the placenta from the end of the second trimester, they are low-risk in the short term. The use of anti-TNF agents after the second trimester leads to intra-uterine exposure. An increase in infections has recently been observed in infants exposed to immunomodulators plus anti-TNF drugs in utero, thus raising concerns about the consequences for the development of the immune system. Accordingly, it has recently been suggested that anti-TNF drugs should be stopped during the second trimester. Certolizumab is a Fab fragment of an anti-TNF monoclonal antibody, and, therefore, it may not be necessary to stop it during pregnancy. Anti-TNF drugs have been detected in breast milk, although in miniscule amounts. Case reports do not suggest toxicity; however, the effects of exposure on the neonate merit further investigation. CONCLUSIONS Anti-TNF drugs can cross the placenta from the latter part of the second trimester of gestation, although they seem to be safe, at least in the short term. Miniscule amounts of anti-TNF drugs are transferred in breast milk; therefore, a deleterious effect of this exposure on the neonate, although unlikely, cannot be excluded.
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Nielsen OH, Loftus Jr EV, Jess T. Safety of TNF-α inhibitors during IBD pregnancy: a systematic review. BMC Med 2013; 11:174. [PMID: 23902720 PMCID: PMC3734216 DOI: 10.1186/1741-7015-11-174] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2012] [Accepted: 07/01/2013] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Tumor necrosis factor (TNF)-α inhibitors are increasingly being used in inflammatory bowel disease (IBD). Because this chronic intestinal disorder often affects women of fertile age, it is essential to assess the effect of biologics on pregnancy outcome. METHODS We performed a systematic review of the English-language literature to investigate if treatment with TNF-α blockers during pregnancy in women with IBD increases the risk of spontaneous abortions, preterm delivery, stillbirth, low birth weight, congenital malformations, or risk of infections in the offspring. Of 552 articles and abstracts reviewed, 58 articles or abstracts with unique content were identified and included in this systematic review. However, most presentations were case reports or case series supplied by a limited number of observational studies. No randomized controlled studies were available. RESULTS TNF-α inhibitors do not seem to affect either outcome of pregnancy in mothers with IBD, or the outcome in the offspring (congenital malformations and immunosuppression). Further, recent data have not identified any increased risk of infections in the first year of life in the offspring of mothers who received biologics, even in combination with immunomodulators (thiopurines). CONCLUSIONS From the present systematic review, no association was found between administration of TNF inhibitors for IBD during pregnancy and adverse pregnancy outcome or congenital abnormalities. Further, no increased relative risk of infections has been reported in the first year of life in offspring of mothers who received biologics. Biologics should be discontinued during pregnancy solely if the IBD is in remission using the same stopping criteria as for patients with IBD in general, as uncontrolled activity of IBD may expose the mother and child to a risk greater than those only potentially coming from the use of TNF-α inhibitors. In such cases, inoculation of the offspring with live vaccines is contraindicated until the biologic agent is no longer detectable in the child's circulation.
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Affiliation(s)
- Ole Haagen Nielsen
- Department of Gastroenterology, Medical Section, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Edward V Loftus Jr
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Tine Jess
- Department of Epidemiology Research, Statens Serum Institute, National Health Surveillance and Research, Copenhagen, Denmark
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Barnea ER, Rambaldi M, Paidas MJ, Mecacci F. Reproduction and autoimmune disease: important translational implications from embryo–maternal interaction. Immunotherapy 2013; 5:769-80. [DOI: 10.2217/imt.13.59] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Pregnancy and autoimmune disorders (ADs) coexist in a delicate balance. Whereas women are disproportionately affected by ADs – frequently occurring during reproductive years – the disease often improves during pregnancy, unless severe. However, when ADs are at an advanced stage, both mother and fetus can be severely affected. Maternal AD amelioration reduces fetal morbidity/mortality. AD improvement occurs without compromising immune tolerance for the fetus; however, it is short-lived since postpartum, flare-up frequently occurs. Consequences of pregnancy-related maternal disease can have life-long impact. Pregnancy is not an immune-suppressed state, but rather a controlled inflammatory environment with distinct local and systemic coordination. Pregnancy requires a delicate immune balance; the embryo/allograft does not cause graft-versus-host disease while the mother/host immunity is modulated without suppression. We herein critically examine the synergetic reciprocal relationship between pregnancy and ADs. We review key ADs and their current prognosis and management. Finally, we describe PreImplantation Factor, a peptide secreted by viable embryos that, beyond its essential autotrophic and proimplantation properties, regulates systemic immune response and also proved effective in nonpregnant autoimmune and transplantation models. Hence, PreImplantation Factor may have a key role in improving ADs in pregnancy, and provide a novel drug for treatment of immune disorders in general.
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Affiliation(s)
- Eytan R Barnea
- Society for the Investigation of Early Pregnancy, Cherry Hill, NJ, USA
- BioIncept, LLC, Cherry Hill, NJ, USA
- Department of Obstetrics & Gynecology, University of Medicine and Dentistry of New Jersey – Robert Wood Johnson Medical School, Camden, NJ, USA
| | - Mariana Rambaldi
- Department of Obstetrics and Gynecology University of Firenze, Florence, Italy
| | - Michael J Paidas
- Yale Women and Children’s Center for Blood Disorders, Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA
| | - Federico Mecacci
- Department of Obstetrics and Gynecology University of Firenze, Florence, Italy
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Sangle SR, Lutalo PMK, Davies RJ, Khamashta MA, D'Cruz DP. B-cell depletion therapy and pregnancy outcome in severe, refractory systemic autoimmune diseases. J Autoimmun 2013; 43:55-9. [PMID: 23608146 DOI: 10.1016/j.jaut.2013.03.001] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Revised: 02/26/2013] [Accepted: 03/05/2013] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To study the pregnancy outcome following Rituximab treatment before conception in patients with refractory autoimmune rheumatic diseases. METHODOLOGY Five women with systemic lupus erythematosus (SLE) and 1 woman with ANCA positive vasculitis fulfilling the respective ACR classification criteria were studied retrospectively when they became pregnant following rituximab treatment for refractory disease. Rituximab was given as a 1 g infusion together with 500 mg Methylprednisolone, on day 1 and day 15 after written informed consent. RESULTS The median age was 34 (range 32-39) years and median disease duration was 10 (range 5-16) years. All the patients achieved complete B-cell depletion < 1 cell/μL at 1 month and <5 cells/μL at 6 months with prolonged B-cell depletion. Four women had successful pregnancies with median gestational age of 38 (range 31-40) weeks; median weight of the new born was 3.25 (range1.17-3.3) kg with no documented adverse neonatal events. One patient with lupus nephritis (LN) had a premature delivery and increasing proteinuria in the third trimester. One other patient with LN had a premature delivery and the new born had oesophageal atresia. CONCLUSION We report a child with oesophageal atresia born to a mother with lupus nephritis who had received Rituximab 12 months prior to conception, while four other pregnancies in women with SLE resulted in morphologically normal children. We also describe the first report, to our knowledge, of a successful pregnancy outcome in a woman with granulomatosis with polyangiitis treated with rituximab.
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Affiliation(s)
- Shirish R Sangle
- Graham Hughes Research Laboratory, The Rayne Institute, St Thomas' Hospital, Guy's, St Thomas' Hospital and King's College Medical School, London SE1 7EH, UK
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Ojeda-Uribe M, Afif N, Dahan E, Sparsa L, Haby C, Sibilia J, Ternant D, Ardizzone M. Exposure to abatacept or rituximab in the first trimester of pregnancy in three women with autoimmune diseases. Clin Rheumatol 2013; 32:695-700. [DOI: 10.1007/s10067-012-2156-4] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2012] [Revised: 12/19/2012] [Accepted: 12/19/2012] [Indexed: 12/13/2022]
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Ellinger I, Fuchs R. HFcRn-mediated transplacental immunoglobulin G transport: protection of and threat to the human fetus and newborn. Wien Med Wochenschr 2012; 162:207-13. [PMID: 22717875 DOI: 10.1007/s10354-012-0085-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Accepted: 02/28/2012] [Indexed: 02/07/2023]
Abstract
In human newborns, endogenous levels of plasma immunoglobulin G (IgG) begin to rise slowly after birth following exposure to the environment. For immunoprotection during fetal and early neonatal life, maternal IgG is provided by transplacental transport. While cellular immunoprotective IgG effects are mainly triggered by FcγRI, -RII and -RIII, transplacental IgG transfer is mediated by the MHC class I-like neonatal Fc-receptor, hFcRn. This compact review explains the mechanism of hFcRn-mediated IgG transcytosis across the placental barrier - syncytiotrophoblast and fetal endothelial cells. Restrictions of this IgG transport are summarized. These include IgG subclass discrimination and limited IgG transport before the third trimester that can cause insufficient protection from infections of preterm (≤ 35 th week) delivered babies. As hFcRn does not discriminate beneficial from hazardous IgGs, maternal auto- and alloimmune as well as therapeutic antibodies can reach the fetus. The consequences including severe diseases of the newborn are summarized in this article.
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Affiliation(s)
- Isabella Ellinger
- Department of Pathophysiology and Allergy Research, Center for Pathophysiology, Infectiology and Immunology, Medical University Vienna, Vienna, Austria.
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28
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Ateka-Barrutia O, Nelson-Piercy C. Management of rheumatologic diseases in pregnancy. ACTA ACUST UNITED AC 2012. [DOI: 10.2217/ijr.12.54] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Abstract
METABOLISM Cyclosporin A and leflunomide may increase the blood pressure, whereas administration of prednisolone and tacrolimus may cause hyperglycemia. Azathioprine, chloroquine, methotrexate and mycophenolate mofetil seem to be metabolically neutral. Tocilizumab and tumor necrosis factor (TNF) alpha blockers have a negative effect on the lipid profile. INFECTIONS The overall infection risk for prednisolone is estimated to be 1.3. This risk for methotrexate is also 1.3 compared to other disease modifying antirheumatic drugs (DMARDs). Regarding biologics, the highest risk of serious infections was associated with certolizumab pegol and tocilizumab, in contrast to abatacept and rituximab which showed the lowest risk. CANCER RISK: Azathioprine and cyclosporin A are associated with a markedly increased risk of non-melanoma skin cancer. According to the RABBIT registry no significant increase in tumor rate has been reported for biologics. PREGNANCY: Azathioprine, chloroquine, cyclosporin A, prednisolone, sulfasalazine, tacrolimus and cyclophosphamide (only after the second trimester) may be administered during pregnancy. Biologics should be avoided unless there is a treatment need in cases of uncontrolled disease activity. BREAST FEEDING: Only chloroquine, prednisolone, sulfasalazine and tacrolimus may be taken during breast feeding. There are insufficient data on the safety of biologics.
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Affiliation(s)
- O Psenak
- Univ. Klinik für Innere Medizin III, mit Hämatologie, Internistischer Onkologie, Hämostaseologie, Infektiologie, Rheumatologie und Onkologisches Zentrum, Österreich.
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Bugelski PJ, Martin PL. Concordance of preclinical and clinical pharmacology and toxicology of therapeutic monoclonal antibodies and fusion proteins: cell surface targets. Br J Pharmacol 2012; 166:823-46. [PMID: 22168282 PMCID: PMC3417412 DOI: 10.1111/j.1476-5381.2011.01811.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2011] [Revised: 10/14/2011] [Accepted: 11/28/2011] [Indexed: 12/20/2022] Open
Abstract
Monoclonal antibodies (mAbs) and fusion proteins directed towards cell surface targets make an important contribution to the treatment of disease. The purpose of this review was to correlate the clinical and preclinical data on the 15 currently approved mAbs and fusion proteins targeted to the cell surface. The principal sources used to gather data were: the peer reviewed Literature; European Medicines Agency 'Scientific Discussions'; and the US Food and Drug Administration 'Pharmacology/Toxicology Reviews' and package inserts (United States Prescribing Information). Data on the 15 approved biopharmaceuticals were included: abatacept; abciximab; alefacept; alemtuzumab; basiliximab; cetuximab; daclizumab; efalizumab; ipilimumab; muromonab; natalizumab; panitumumab; rituximab; tocilizumab; and trastuzumab. For statistical analysis of concordance, data from these 15 were combined with data on the approved mAbs and fusion proteins directed towards soluble targets. Good concordance with human pharmacodynamics was found for mice receiving surrogates or non-human primates (NHPs) receiving the human pharmaceutical. In contrast, there was poor concordance for human pharmacodynamics in genetically deficient mice and for human adverse effects in all three test systems. No evidence that NHPs have superior predictive value was found.
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Affiliation(s)
- Peter J Bugelski
- Biologics Toxicology, Janssen Research & Development, division of Johnson & Johnson Pharmaceutical Research & Development, LLC, Radnor, PA 19087, USA
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Wakefield D, El-Asrar AA, McCluskey P. Treatment of Severe Inflammatory Eye Disease in Patients of Reproductive Age and during Pregnancy. Ocul Immunol Inflamm 2012; 20:277-87. [DOI: 10.3109/09273948.2012.684736] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Ugarte A, Villar I, Ruiz-Irastorza G. [Management of pregnancy in patients with systemic lupus erythematosus]. Rev Clin Esp 2012; 212:491-8. [PMID: 22245369 DOI: 10.1016/j.rce.2011.11.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2011] [Revised: 10/02/2011] [Accepted: 11/07/2011] [Indexed: 11/15/2022]
Abstract
Patients with systemic lupus erythematosus are exposed to a remarkably high number of maternal-fetal complications during pregnancy. Knowledge regarding the reciprocal influence between lupus and pregnancy is the starting point to assure that these patients are correctly monitored. It is also important to carry out comprehensive preconception evaluation to individually evaluate the risk of each patient. The immunological profile, history of nephritis, presence of chronic damage and disease activity are the basic data that will determine the specific individual risk profile. Finally, correct drug management must be assured during this period, based on the safety profile of the different treatments during pregnancy and lactation.
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Affiliation(s)
- A Ugarte
- Unidad de Investigación de Enfermedades Autoinmunes, Servicio de Medicina Interna, Hospital de Cruces, Barakaldo, Bizkaia, Spain
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Berencsi III G. Fetal and Neonatal Illnesses Caused or Influenced by Maternal Transplacental IgG and/or Therapeutic Antibodies Applied During Pregnancy. MATERNAL FETAL TRANSMISSION OF HUMAN VIRUSES AND THEIR INFLUENCE ON TUMORIGENESIS 2012. [PMCID: PMC7121401 DOI: 10.1007/978-94-007-4216-1_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The human fetus is protected by the mother’s antibodies. At the end of the pregnancy, the concentration of maternal antibodies is higher in the cord blood, than in the maternal circulation. Simultaneously, the immune system of the fetus begins to work and from the second trimester, fetal IgM is produced by the fetal immune system specific to microorganisms and antigens passing the maternal-fetal barrier. The same time the fetal immune system has to cope and develop tolerance and TREG cells to the maternal microchimeric cells, latent virus-carrier maternal cells and microorganisms transported through the maternal-fetal barrier. The maternal phenotypic inheritance may hide risks for the newborn, too. Antibody mediated enhancement results in dengue shock syndrome in the first 8 month of age of the baby. A series of pathologic maternal antibodies may elicit neonatal illnesses upon birth usually recovering during the first months of the life of the offspring. Certain antibodies, however, may impair the fetal or neonatal tissues or organs resulting prolonged recovery or initiating prolonged pathological processes of the children. The importance of maternal anti-idiotypic antibodies are believed to prime the fetal immune system with epitopes of etiologic agents infected the mother during her whole life before pregnancy and delivery. The chemotherapeutical and biological substances used for the therapy of the mother will be transcytosed into the fetal body during the last two trimesters of pregnancy. The long series of the therapeutic monoclonal antibodies and conjugates has not been tested systematically yet. The available data are summarised in this chapter. The innate immunity plays an important role in fetal defence. The concentration of interferon is relative high in the placenta. This is probably one reason, why the therapeutic interferon treatment of the mother does not impair the fetal development.
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Affiliation(s)
- György Berencsi III
- , Division of Virology, National Center for Epidemiology, Gyáli Street 2-6, Budapest, 1096 Hungary
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Pham T, Bachelez H, Berthelot JM, Blacher J, Bouhnik Y, Claudepierre P, Constantin A, Fautrel B, Gaudin P, Goëb V, Gossec L, Goupille P, Guillaume-Czitrom S, Hachulla E, Huet I, Jullien D, Launay O, Lemann M, Maillefert JF, Marolleau JP, Martinez V, Masson C, Morel J, Mouthon L, Pol S, Puéchal X, Richette P, Saraux A, Schaeverbeke T, Soubrier M, Sudre A, Tran TA, Viguier M, Vittecoq O, Wendling D, Mariette X, Sibilia J. TNF alpha antagonist therapy and safety monitoring. Joint Bone Spine 2011; 78 Suppl 1:15-185. [PMID: 21703545 DOI: 10.1016/s1297-319x(11)70001-x] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To develop and/or update fact sheets about TNFα antagonists treatments, in order to assist physicians in the management of patients with inflammatory joint disease. METHODS 1. selection by a committee of rheumatology experts of the main topics of interest for which fact sheets were desirable; 2. identification and review of publications relevant to each topic; 3. development and/or update of fact sheets based on three levels of evidence: evidence-based medicine, official recommendations, and expert opinion. The experts were rheumatologists and invited specialists in other fields, and they had extensive experience with the management of chronic inflammatory diseases, such as rheumatoid. They were members of the CRI (Club Rhumatismes et Inflammation), a section of the Société Francaise de Rhumatologie. Each fact sheet was revised by several experts and the overall process was coordinated by three experts. RESULTS Several topics of major interest were selected: contraindications of TNFα antagonists treatments, the management of adverse effects and concomitant diseases that may develop during these therapies, and the management of everyday situations such as pregnancy, surgery, and immunizations. After a review of the literature and discussions among experts, a consensus was developed about the content of the fact sheets presented here. These fact sheets focus on several points: 1. in RA and SpA, initiation and monitoring of TNFα antagonists treatments, management of patients with specific past histories, and specific clinical situations such as pregnancy; 2. diseases other than RA, such as juvenile idiopathic arthritis; 3. models of letters for informing the rheumatologist and general practitioner; 4. and patient information. CONCLUSION These TNFα antagonists treatments fact sheets built on evidence-based medicine and expert opinion will serve as a practical tool for assisting physicians who manage patients on these therapies. They will be available continuously at www.cri-net.com and updated at appropriate intervals.
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Affiliation(s)
- Thao Pham
- Rheumatology Department, CHU Sainte-Marguerite, Marseille, France.
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Consensus Statement of the Spanish Society of Rheumatology on Risk Management of Biologic Therapy in Rheumatic Patients. ACTA ACUST UNITED AC 2011. [DOI: 10.1016/j.reumae.2011.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Schnitzler F, Fidder H, Ferrante M, Ballet V, Noman M, Van Assche G, Spitz B, Hoffman I, Van Steen K, Vermeire S, Rutgeerts P. Outcome of pregnancy in women with inflammatory bowel disease treated with antitumor necrosis factor therapy. Inflamm Bowel Dis 2011; 17:1846-54. [PMID: 21830263 DOI: 10.1002/ibd.21583] [Citation(s) in RCA: 121] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2010] [Accepted: 10/22/2010] [Indexed: 12/16/2022]
Abstract
BACKGROUND Infliximab (IFX) and adalimumab (ADA) are attractive treatment options in patients with inflammatory bowel disease (IBD) also during pregnancy but there is still limited data on the benefit/risk profile of IFX and ADA during pregnancy. METHODS This observational study assessed pregnancy outcomes in 212 women with IBD under antitumor necrosis factor alpha (TNF) treatment at our IBD unit. Pregnancy outcomes in 42 pregnancies with direct exposure to anti-TNF treatment (35 IFX, 7 ADA) were compared with that in 23 pregnancies prior to IBD diagnosis, 78 pregnancies before start of IFX, 53 pregnancies with indirect exposure to IFX, and 56 matched pregnancies in healthy women. RESULTS Thirty-two of the 42 pregnancies ended in live births with a median gestational age of 38 weeks (interquartile range [IQR] 37-39). There were seven premature deliveries, six children had low birth weight, and there was one stillbirth. One boy weighed 1640 g delivered at week 33, died at age of 13 days because of necrotizing enterocolitis. A total of eight abortions (one patient wish) occurred in seven women. Trisomy 18 was diagnosed in one fetus of a mother with CD at age 37 under ADA treatment (40 mg weekly) and pregnancy was terminated. Pregnancy outcomes after direct exposure to anti-TNF treatment were not different from those in pregnancies before anti-TNF treatment or with indirect exposure to anti-TNF treatment but outcomes were worse than in pregnancies before IBD diagnosis. CONCLUSIONS Direct exposure to anti-TNF treatment during pregnancy was not related to a higher incidence of adverse pregnancy outcomes than IBD overall.
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Affiliation(s)
- Fabian Schnitzler
- Department of Gastroenterology, University Hospital Gasthuisberg, Leuven, Belgium
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Reino JG, Loza E, Andreu JL, Balsa A, Batlle E, Cañete JD, Collantes Estévez E, Fernández Carballido C, Fernández Sueiro JL, García de Vicuña R, González-Álvaro I, González Fernández C, Juanola X, Linares LF, Marenco JL, Martín Mola E, Moreno Ramos M, Mulero Mendoza J, Muñoz Fernández S, Queiro R, Richi Alberti P, Sanz J, Tornero Molina J, Zarco Montejo P, Carmona L. Consenso SER sobre la gestión de riesgo del tratamiento con terapias biológicas en pacientes con enfermedades reumáticas. ACTA ACUST UNITED AC 2011; 7:284-98. [DOI: 10.1016/j.reuma.2011.05.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2011] [Revised: 05/04/2011] [Accepted: 05/04/2011] [Indexed: 12/16/2022]
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Gall B, Yee A, Berry B, Bircham D, Hayashi A, Dansereau J, Hart J. Rituximab for management of refractory pregnancy-associated immune thrombocytopenic purpura. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2011; 32:1167-1171. [PMID: 21176329 DOI: 10.1016/s1701-2163(16)34741-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Rituximab is a novel therapy for immune thrombocytopenic purpura (ITP); however, information about its safety in pregnancy is limited. This case illustrates the successful use of rituximab to treat pregnancy-associated ITP. CASE A 34-year-old woman presented with severe ITP at 23 weeks' gestation. Standard treatment with corticosteroids, intravenous immune globulin, and splenectomy failed to raise the platelet count. Due to ongoing bleeding, rituximab was given in the 26th week of pregnancy. The platelet count rose to over 100 × 10(9)/L after four weeks. The neonatal B-lymphocyte count normalized at four months after delivery. There were no neonatal complications of rituximab therapy. CONCLUSION Rituximab may be safe for use in treating pregnancy-associated ITP. This case highlights the need to investigate further the safety and efficacy of rituximab in pregnancy.
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Affiliation(s)
- Brent Gall
- Faculty of Medicine, University of British Columbia Vancouver BC
| | - Adrian Yee
- Faculty of Medicine, University of British Columbia Vancouver BC
| | - Brian Berry
- Faculty of Medicine, University of British Columbia Vancouver BC
| | - Deborah Bircham
- Faculty of Medicine, University of British Columbia Vancouver BC
| | - Allen Hayashi
- Faculty of Medicine, University of British Columbia Vancouver BC
| | - Jerome Dansereau
- Faculty of Medicine, University of British Columbia Vancouver BC
| | - Jason Hart
- Faculty of Medicine, University of British Columbia Vancouver BC
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Meriño-Ibarra E, Delgado Beltrán C. [Rheumatoid arthritis: how to use drugs during pregnancy and lactation?]. REUMATOLOGIA CLINICA 2011; 7:262-266. [PMID: 21794829 DOI: 10.1016/j.reuma.2010.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2010] [Revised: 11/17/2010] [Accepted: 11/21/2010] [Indexed: 05/31/2023]
Abstract
Rheumatoid arthritis is a disease that is highly prevalent in women of childbearing age. A review is done about the characteristics of the placental barrier, the passage of drugs through it and the use of drugs during pregnancy: those which are potentially safe drugs, those drugs that can only be used if there is a life threatening condition for the mother, drugs that are contraindicated and those with insufficient data on safety and therefore should be avoided, the latter group comprises biological drugs. Also a review is done about the use of drugs during lactation, a period that a flare of rheumatoid arthritis can occur.
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Papagoras C, Drosos AA. Abatacept: a biologic immune modulator for rheumatoid arthritis. Expert Opin Biol Ther 2011; 11:1113-29. [DOI: 10.1517/14712598.2011.592825] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Abstract
Adequate pregnancy care of women with systemic lupus erythematosus (SLE) rests on three pillars: a coordinated medical-obstetrical care, an agreed and well-defined management protocol and a good neonatal unit. Pregnancy should be planned following a preconceptional visit for counselling. Women with severe active disease or a high degree of irreversible damage, such as those with symptomatic pulmonary hypertension, heart failure, severe restrictive pulmonary disease or severe chronic renal failure should best avoid pregnancy. Treatment is based on hydroxychloroquine, low-dose steroids and azathioprine. Patients with antiphospholipid antibodies/syndrome should receive low-dose aspirin +/- low molecular weight heparin. The addition and the dose of heparin depend on the clinical profile of the patient, i.e. a previous history of miscarriage, foetal loss, placental insufficiency or thrombosis. A close surveillance, with monitoring of blood pressure, proteinuria and placental blood flow by Doppler studies helps the early diagnosis and treatment of complications such as preeclampsia and foetal distress. Postpartum follow-up is important.
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Affiliation(s)
- Guillermo Ruiz-Irastorza
- Department Of Internal Medicine, Hospital De Cruces, University Of The Basque Country, Bizkaia, Spain
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43
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Rump JA, Schönborn H. [Conception and course of eight pregnancies in five women on TNF blocker etanercept treatment]. Z Rheumatol 2011; 69:903-9. [PMID: 20532789 DOI: 10.1007/s00393-010-0652-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The introduction of tumor necrosis factor (TNF)-α inhibitors s in the late 1990s considerably broadened the treatment options for, and essentially contributed to the successful management of, rheumatoid arthritis (RA) and other immune-mediated inflammatory diseases. Nevertheless, their use during pregnancy is still controversially discussed since it remains unclear whether the benefits of treatment might be outweighed by potential teratogenicity or adverse effects on the course of pregnancy. In this case series report we describe the course and outcome of eight pregnancies in five women (four with RA and one with ankylosing spondylitis) at our private clinical practice treated with the TNF-α inhibitor etanercept at the time of conception and during pregnancy. The course was inconspicuous in six of the eight pregnancies; in one case a megacolon congenitum was diagnosed 2 weeks after birth, while one spontaneous abortion occurred in the 10th week of pregnancy after a disease flare following treatment discontinuation with etanercept in the 5th week of pregnancy. Based on our experience to date and the currently available literature data, we believe that continuation of treatment with TNF-α blockers is justified in pregnant patients with otherwise high disease activity and disease progression.
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Affiliation(s)
- J-A Rump
- Praxis für Rheumatologie & Klinische Immunologie, Merianstrasse 5, Freiburg, Germany.
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Porres-Aguilar M, Figueroa-Casas JB, Porres-Muñoz M, Elliott CG. A 38-year-old pregnant woman with hemoptysis and acute renal failure. Microscopic polyangiitis. ACTA ACUST UNITED AC 2011; 82:60-4. [PMID: 21555869 DOI: 10.1159/000327174] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2011] [Accepted: 03/02/2011] [Indexed: 12/16/2022]
Affiliation(s)
- Mateo Porres-Aguilar
- Department of Internal Medicine, Division of Respiratory Medicine, Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, Texas 79905, USA.
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Abstract
Over the past years, biological therapies, especially anti-TNF-α antibody therapy has emerged as a treatment approach in patients who have failed to achieve or maintain remission with tradional DMARDs. Women suffering from inflammatory arthritis may need to continue therapy throughout pregnancy and/or in the lactation period, hence the increased concern over the safety of antirheumatic drugs during pregnancy. Anti-TNF agents fall within the US FDA category B concerning fetal risk, indicating that no adequate and well-controlled studies have been conducted in pregnant or lactating women. However, in the last decade, numerous case series and registry data of pregnancies exposed to anti-TNF therapy have accumulated in the literature. According to these data, TNF inhibitor therapies appear to be safe in pregnancy, since no increased risk of malformations has been demonstrated. Ceasing therapy after conception should be considered, but treatment may be continued during pregnancy when indicated.The use of these agents is likely compatible with breast-feeding. The extent of fetal risk is not clarified for exposure to other biologics, such as Rituximab.
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Affiliation(s)
- R E Fischer-Betz
- Klinik für Endokrinolologie, Diabetologie und Rheumatologie, Rheumazentrum Rhein-Ruhr, Moorenstr. 5, 40225, Düsseldorf.
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Seguridad de las terapias biológicas: nuevos datos de BIOBADASER. ACTA ACUST UNITED AC 2011; 6S3:S1-6. [DOI: 10.1016/j.reuma.2010.11.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2010] [Revised: 11/02/2010] [Accepted: 11/03/2010] [Indexed: 12/16/2022]
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Abstract
Historically, pregnancy in women with many inflammatory rheumatic diseases was not considered safe and was discouraged. Combined care allows these pregnancies to be managed optimally, with the majority of outcomes being favorable. Disease activity at the time of conception and anti-phospholipid antibodies are responsible for most complications. Disease flares, pre-eclampsia, and thrombosis are the main maternal complications, whereas fetal loss and intrauterine growth restriction are the main fetal complications. Antirheumatic drugs used during pregnancy and lactation to control disease activity are corticosteroids, hydroxychloroquine, sulphasalzine, and azathioprine. Vaginal delivery is possible in most circumstances, with cesarean section being reserved for complications.
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Andreoli L, Bazzani C, Taraborelli M, Reggia R, Lojacono A, Brucato A, Meroni PL, Tincani A. Pregnancy in autoimmune rheumatic diseases: the importance of counselling for old and new challenges. Autoimmun Rev 2010; 10:51-4. [PMID: 20696283 DOI: 10.1016/j.autrev.2010.08.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2010] [Accepted: 08/03/2010] [Indexed: 12/16/2022]
Abstract
Rheumatic diseases can affect women during their childbearing age. Therefore, physicians should introduce a discussion with the patients about pregnancy and its problems. Lupus pregnancies can be successful, even in patients with renal disease, when planned in remission state; the use of low dose aspirin was shown to be an independent predictor of good outcome, so it can be suggested as a preventive measure. Pregnancies in women with Antiphospholipid Syndrome can fail even if properly treated, especially when associated with a systemic autoimmune disease, a history of both thrombosis and pregnancy morbidity, and a triple positivity of antiphospholipid antibody assays. Women with systemic sclerosis have generally a good obstetric outcome, except for an increase rate of preterm deliveries. Severe disease complications were sometimes reported, but their relationship with gestation is not clear yet. Although data on human pregnancy are still preliminary, anti-TNF agents are classified as non teratogens in contrast to methotrexate and leflunomide. So women affected by aggressive chronic arthritis may be treated with anti-TNF in the pre-conceptional period, discontinuing the drug as soon as pregnancy starts. In order to increase maternal compliance and cope with difficult cases, a multidisciplinary team (rheumatologists/internists, obstetricians and neonatologists) should take care of patients during pregnancy.
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Affiliation(s)
- Laura Andreoli
- Rheumatology and Clinical Immunology, Spedali Civili and University of Brescia, Brescia, Italy
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Martineau M, Haskard DO, Nelson-Piercy C. Behçet's syndrome in pregnancy. Obstet Med 2010; 3:2-7. [PMID: 27582833 PMCID: PMC4989763 DOI: 10.1258/om.2009.090033] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2009] [Indexed: 12/16/2022] Open
Abstract
Behçet's syndrome (BS), a systemic inflammatory disease characterized by oral and genital ulceration, eye inflammation and arthritis, usually presents in the third and fourth decades of life, but is rare in pregnancy. BS is not usually associated with a detrimental effect on pregnancy outcome. In most women BS is reported to improve in pregnancy, although it may not always follow a similar course in successive pregnancies and it is not possible to predict the course of BS in a particular pregnancy. Many of the drug therapies used to treat BS are safe to use in pregnancy and in the breastfeeding mother. These include corticosteroids, azathioprine, calcineurin inhibitors and probably colchicine. Experience with use of biologics in pregnancy is increasing. Drugs used in the management of BS that should be avoided in women planning a pregnancy include methotrexate, mycophenolate mofetil, thalidomide, cyclophosphamide and chlorambucil.
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Affiliation(s)
- Marcus Martineau
- Guy's & St Thomas' Foundation Trust, Westminster Bridge Road, London SE1 7EH
| | | | - Catherine Nelson-Piercy
- Guy's & St Thomas' Foundation Trust, Westminster Bridge Road, London SE1 7EH
- Imperial College Healthcare Trust, Imperial College London, UK
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50
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Tehrani R, Ostrowski RA, Hariman R, Jay WM. Review of Biologic Therapies. Neuroophthalmology 2009. [DOI: 10.3109/01658100903360064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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