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Ting MYL, Vega-Tapia F, Anguita R, Cuitino L, Valenzuela RA, Salgado F, Valenzuela O, Ibañez S, Marchant R, Urzua CA. Non-Infectious Uveitis and Pregnancy, is There an Optimal Treatment? Uveitis Course and Safety of Uveitis Treatment in Pregnancy. Ocul Immunol Inflamm 2024; 32:1819-1831. [PMID: 38194442 DOI: 10.1080/09273948.2023.2296030] [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: 04/03/2023] [Revised: 11/23/2023] [Accepted: 12/11/2023] [Indexed: 01/11/2024]
Abstract
In pregnancy, a plethora of factors causes changes in maternal immunity. Uveitis flare-ups are more frequent in the first trimester and in undertreated patients. Management of non-infectious uveitis during pregnancy remains understudied. A bibliographic review to consolidate existing evidence was performed by a multidisciplinary group of Ophthalmologists, Gynaecologists and Rheumatologists. Our group recommends initial management with minimum-required doses of corticosteroids, preferably locally, to treat intraocular inflammation whilst ensuring good neonatal outcomes. If ineffective, clinicians should consider addition of Cyclosporine, Azathioprine or Certolizumab pegol, which are seemingly safe in pregnancy. Other therapies (such as Methotrexate, Mycophenolate Mofetil and alkylating agents) are teratogenic or have a detrimental effect on the foetus. Furthermore, careful multidisciplinary preconception discussions and close follow-up are recommended, monitoring for flare-ups and actively tapering medication doses, with a primary endpoint focused on protecting ocular tissues from inflammation, whilst giving minimal risk of poor pregnancy and foetal outcomes.
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Affiliation(s)
| | - Fabian Vega-Tapia
- Laboratory of Ocular and Systemic Autoimmune Diseases, Department of Ophthalmology, Faculty of Medicine, Universidad de Chile, Santiago, Chile
| | - Rodrigo Anguita
- Moorfields Eye Hospital NHS Foundation Trust, London, UK
- Laboratory of Ocular and Systemic Autoimmune Diseases, Department of Ophthalmology, Faculty of Medicine, Universidad de Chile, Santiago, Chile
- Department of Ophthalmology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Loreto Cuitino
- Laboratory of Ocular and Systemic Autoimmune Diseases, Department of Ophthalmology, Faculty of Medicine, Universidad de Chile, Santiago, Chile
- Servicio de Oftalmología, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Rodrigo A Valenzuela
- Department of Health Science, Universidad de Aysén, Coyhaique, Chile
- Department of Chemical and Biological Sciences, Faculty of Health, Universidad Bernardo O'Higgins, Santiago, Chile
| | - Felipe Salgado
- Laboratory of Ocular and Systemic Autoimmune Diseases, Department of Ophthalmology, Faculty of Medicine, Universidad de Chile, Santiago, Chile
| | - Omar Valenzuela
- Faculty of Medicine, Clinica Alemana-Universidad del Desarrollo, Santiago, Chile
| | - Sebastian Ibañez
- Faculty of Medicine, Clinica Alemana-Universidad del Desarrollo, Santiago, Chile
| | - Ruben Marchant
- Faculty of Medicine, Clinica Alemana-Universidad del Desarrollo, Santiago, Chile
| | - Cristhian A Urzua
- Laboratory of Ocular and Systemic Autoimmune Diseases, Department of Ophthalmology, Faculty of Medicine, Universidad de Chile, Santiago, Chile
- Faculty of Medicine, Clinica Alemana-Universidad del Desarrollo, Santiago, Chile
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Kittleson MM, DeFilippis EM, Bhagra CJ, Casale JP, Cauldwell M, Coscia LA, D'Souza R, Gaffney N, Gerovasili V, Ging P, Horsley K, Macera F, Mastrobattista JM, Paraskeva MA, Punnoose LR, Rasmusson KD, Reynaud Q, Ross HJ, Thakrar MV, Walsh MN. Reproductive health after thoracic transplantation: An ISHLT expert consensus statement. J Heart Lung Transplant 2023; 42:e1-e42. [PMID: 36528467 DOI: 10.1016/j.healun.2022.10.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 10/10/2022] [Indexed: 11/16/2022] Open
Abstract
Pregnancy after thoracic organ transplantation is feasible for select individuals but requires multidisciplinary subspecialty care. Key components for a successful pregnancy after lung or heart transplantation include preconception and contraceptive planning, thorough risk stratification, optimization of maternal comorbidities and fetal health through careful monitoring, and open communication with shared decision-making. The goal of this consensus statement is to summarize the current evidence and provide guidance surrounding preconception counseling, patient risk assessment, medical management, maternal and fetal outcomes, obstetric management, and pharmacologic considerations.
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Affiliation(s)
- Michelle M Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
| | - Ersilia M DeFilippis
- Division of Cardiology, New York Presbyterian-Columbia University Irving Medical Center, New York, New York
| | - Catriona J Bhagra
- Department of Cardiology, Cambridge University and Royal Papworth NHS Foundation Trusts, Cambridge, UK
| | - Jillian P Casale
- Department of Pharmacy Services, University of Maryland Medical Center, Baltimore, Maryland
| | - Matthew Cauldwell
- Department of Obstetrics, Maternal Medicine Service, St George's Hospital, London, UK
| | - Lisa A Coscia
- Transplant Pregnancy Registry International, Gift of Life Institute, Philadelphia, Pennsylvania
| | - Rohan D'Souza
- Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
| | - Nicole Gaffney
- Lung Transplant Service, Alfred Hospital, Melbourne, Australia; Department of Medicine, Central Clinical School, Monash University, Melbourne, Australia
| | | | - Patricia Ging
- Department of Pharmacy, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Kristin Horsley
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
| | - Francesca Macera
- De Gasperis Cardio Center and Transplant Center, Niguarda Hospital, Milan, Italy; Dept of Cardiology, Cliniques Universitaires de Bruxelles - Hôpital Erasme, Brussels, Belgium
| | - Joan M Mastrobattista
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine Houston, Texas
| | - Miranda A Paraskeva
- Lung Transplant Service, Alfred Hospital, Melbourne, Australia; Department of Medicine, Central Clinical School, Monash University, Melbourne, Australia
| | - Lynn R Punnoose
- Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Quitterie Reynaud
- Cystic Fibrosis Adult Referral Care Centre, Department of Internal Medicine, Hospices civils de Lyon, Pierre Bénite, France
| | - Heather J Ross
- Peter Munk Cardiac Centre of the University Health Network, Toronto, Ontario, Canada; Ted Rogers Centre for Heart Research, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - Mitesh V Thakrar
- Department of Medicine, Division of Respirology, University of Calgary, Calgary, Alberta, Canada
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3
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The positive effect of pregnancy in rheumatoid arthritis and the use of medications for the management of rheumatoid arthritis during pregnancy. Inflammopharmacology 2021; 29:987-1000. [PMID: 33844107 DOI: 10.1007/s10787-021-00808-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 03/30/2021] [Indexed: 01/30/2023]
Abstract
Rheumatoid arthritis (RA) is an autoimmune systemic inflammatory disorder that is mostly characterised by progressive symmetrical joint destruction, particularly in the wrist and fingers, while it may also affect additional joints and several organs, such as the skin, heart, blood vessels, and lungs. It is identified by raised anti-rheumatoid factor and anti-cyclic citrullinated peptide antibodies. The chemical mediators involved in the activity of RA are IL-1β, TNF-α, and IL-6. Pregnancy exerts a positive effect on RA that helps to modulate the disease condition. Different hypotheses are recommended to explain the ameliorating effect of pregnancy in RA. RA cannot be completely cured. The treatment goal is the attrition of pain and inflammation and the further progression of the disease. Long-term management of RA is carried out using disease-modifying antirheumatic drugs (DMARDs). Therapy of acute flares can be done with Non-steroidal anti-inflammatory drugs (NSAIDs) accompanied by ad interim usage of glucocorticoids. Biologic response modifiers are also available; they act by abolishing the activity of T- cells. However, it is necessary to select the correct treatment regimen when it comes to the management of RA in pregnancy.
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Belizna C, Meroni PL, Shoenfeld Y, Devreese K, Alijotas-Reig J, Esteve-Valverde E, Chighizola C, Pregnolato F, Cohen H, Fassot C, Mattera PM, Peretti P, Levy A, Bernard L, Saiet M, Lagarce L, Briet M, Rivière M, Pellier I, Gascoin G, Rakotonjanahary J, Borghi MO, Stojanovich L, Djokovic A, Stanisavljevic N, Bromley R, Elefant-Amoura E, Bahi Buisson N, Pindi Sala T, Kelchtermans H, Makatsariya A, Bidsatze V, Khizroeva J, Latino JO, Udry S, Henrion D, Loufrani L, Guihot AL, Muchardt C, Hasan M, Ungeheuer MN, Voswinkel J, Damian L, Pabinger I, Gebhart J, Lopez Pedrera R, Cohen Tervaert JW, Tincani A, Andreoli L. In utero exposure to Azathioprine in autoimmune disease. Where do we stand? Autoimmun Rev 2020; 19:102525. [PMID: 32240856 DOI: 10.1016/j.autrev.2020.102525] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 01/23/2020] [Indexed: 12/19/2022]
Abstract
Azathioprine (AZA), an oral immunosuppressant, is safe during pregnancy. Some reports suggested different impairments in the offspring of mothers with autoimmune diseases (AI) exposed in utero to AZA. These observations are available from retrospective studies or case reports. However, data with respect to the long-term safety in the antenatally exposed child are still lacking. The aim of this study is to summarize the current knowledge in this field and to focus on the need for a prospective study on this population. We performed a PubMed search using several search terms. The actual data show that although the risk of congenital anomalies in offspring, as well as the infertility risk, are similar to those found in general population, there is a higher incidence of prematurity, of lower weight at birth and an intra-uterine delay of development. There is also an increased risk of materno- fetal infections, especially cytomegalovirus infection. Some authors raise the interrogations about neurocognitive impairment. Even though the adverse outcomes might well be a consequence of maternal illness and disease activity, interest has been raised about a contribution of this drug. However, the interferences between the external agent (in utero exposure to AZA), with the host (child genetic susceptibility, immune system anomalies, emotional status), environment (public health, social context, availability of health care), economic, social, and behavioral conditions, cultural patterns, are complex and represent confounding factors. In conclusion, it is necessary to perform studies on the medium and long-term outcome of children born by mothers with autoimmune diseases, treated with AZA, in order to show the safety of AZA exposure. Only large-scale population studies with long-term follow-up will allow to formally conclude in this field. TAKE HOME MESSAGES.
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Affiliation(s)
- Cristina Belizna
- Vascular and Coagulation Department, University Hospital Angers, Angers, France; MITOVASC institute and CARFI facility, University of Angers, UMR CNRS 6015, INSERM U1083, Angers, France; Internal Medicine Department, Clinique de l'Anjou, Angers, France; UMR CNRS 6015, Angers, France; INSERM U1083, Angers, France.
| | - Pier Luigi Meroni
- Clinical Immunology and Rheumatology Research Department Auxologico Institute, Milan, Italy
| | - Yehuda Shoenfeld
- The Zabludowicz Center for Autoimmune Diseases, Affiliated to Sackler Faculty of Medicine, Tel-Aviv University, Israel; I.M. Sechenow First Moscow State Medical University, Moscow, Russia
| | - Katrien Devreese
- Coagulation Laboratory, Department of Clinical Biology, Immunology and Microbiology, Ghent University Hospital, Ghent, Belgium
| | - Jaume Alijotas-Reig
- Systemic Autoimmune Disease Unit, Department of Internal Medicine, Vall d'Hebron University Hospital, Barcelona, Spain; Department of Medicine, Universitat Autonòma, Barcelona, Spain
| | | | - Cecilia Chighizola
- Clinical Immunology and Rheumatology Research Department Auxologico Institute, Milan, Italy
| | - Francesca Pregnolato
- Clinical Immunology and Rheumatology Research Department Auxologico Institute, Milan, Italy
| | - Hannah Cohen
- Haematology Department, University College Hospital, London, UK
| | - Celine Fassot
- Internal Medicine Department, Clinique de l'Anjou, Angers, France
| | - Patrick Martin Mattera
- Faculty of Human and Social Sciences, Laboratory of Research in Psychopathology, 3 place André Leroy, 49008 Angers, France
| | - Pascale Peretti
- Faculty of Human and Social Sciences, Laboratory of Research in Psychopathology, 3 place André Leroy, 49008 Angers, France
| | - Alexandre Levy
- Faculty of Human and Social Sciences, Laboratory of Research in Psychopathology, 3 place André Leroy, 49008 Angers, France
| | - Laurence Bernard
- Faculty of Human and Social Sciences, Laboratory of Research in Psychopathology, 3 place André Leroy, 49008 Angers, France
| | - Mathilde Saiet
- Faculty of Human and Social Sciences, Laboratory of Research in Psychopathology, 3 place André Leroy, 49008 Angers, France
| | - Laurence Lagarce
- Departement of Pharmacovigilance, University Hospital Angers, Angers, France
| | - Marie Briet
- Departement of Pharmacovigilance, University Hospital Angers, Angers, France
| | - Marianne Rivière
- French Lupus and Other Autoimmune Disease Patients Association, AFL+, Cuvry, France
| | - Isabelle Pellier
- Department of Pediatrics, University Hospital Angers, Angers, France
| | - Géraldine Gascoin
- Department of Neonatology, University Hospital Angers, Angers, France
| | | | - Maria Orietta Borghi
- Clinical Immunology and Rheumatology Research Department Auxologico Institute, Milan, Italy
| | - Ljudmila Stojanovich
- Scientific Research Department, Internal Medicine-Rheumatology Bezhanijska Kosa, University Medical Center, Belgrade University, Serbia
| | - Aleksandra Djokovic
- Scientific Research Department, Internal Medicine-Rheumatology Bezhanijska Kosa, University Medical Center, Belgrade University, Serbia
| | - Natasa Stanisavljevic
- Scientific Research Department, Internal Medicine-Rheumatology Bezhanijska Kosa, University Medical Center, Belgrade University, Serbia
| | - Rebecca Bromley
- Manchester University Hospitals NHS Trust, Manchester, UK; Division of Evolution and Genomic Science, School of Biological Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Elisabeth Elefant-Amoura
- Genetical and Medical Embriology, CRAT Reference Center on Teratogenic Agents, Paris Est - Hôpital d'Enfants Armand-Trousseau, 26 avenue du Docteur Arnold Netter, 75571 Paris, France
| | - Nadia Bahi Buisson
- Neurology & Neurodevelopmental disorders Department Necker Enfants Malades University Hospital, APHP, Paris 149 Rue de Sèvres, 75015 Paris; INSERM U1163, Hôpital Necker Enfants Malades, 149 rue de Sèvres, 75015 Paris, France; INSERM U1163, Hôpital Necker Enfants Malades, 149 rue de Sèvres, 75015 Paris, France
| | - Taylor Pindi Sala
- EA 7334, Patient Centered Outcomes Research, University Paris Diderot, Paris, France
| | - Hilde Kelchtermans
- Synapse Research Institute, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Alexander Makatsariya
- Department of Obstetrics and Gynecology, I.M. Sechenow First Moscow State Medical University, Moscow, Russia
| | - Viktoria Bidsatze
- Department of Obstetrics and Gynecology, I.M. Sechenow First Moscow State Medical University, Moscow, Russia
| | - Jamilya Khizroeva
- Department of Obstetrics and Gynecology, I.M. Sechenow First Moscow State Medical University, Moscow, Russia
| | - Jose Omar Latino
- Autoimmune and thrombophilic disorders Department, Hospital Carlos G. Durand, Buenos Aires, Argentina
| | - Sebastian Udry
- Autoimmune and thrombophilic disorders Department, Hospital Carlos G. Durand, Buenos Aires, Argentina
| | - Daniel Henrion
- Internal Medicine Department, Clinique de l'Anjou, Angers, France
| | - Laurent Loufrani
- Internal Medicine Department, Clinique de l'Anjou, Angers, France
| | | | - Christian Muchardt
- Unit of Epigenetic Regulation, Department of Developmental and Stem Cell Biology, UMR3738 CNRS, Institut Pasteur, Paris, France
| | - Milena Hasan
- Cytometry and Biomarkers Unit of Technology and Service, Center for Translational Science, Institut Pasteur, 28, Rue Doct Roux, 75015 Paris, France
| | - Marie Noelle Ungeheuer
- Clinical Investigation and Acces to Bioresources Department, Institut Pasteur, 28, Rue Doct Roux, 75015 Paris, France
| | - Jan Voswinkel
- Department of Internal Medicine I, Saarland Medical School, University of Saarland, Homburg, Saarland, Germany
| | - Laura Damian
- Department of Rheumatology, County Emergency Hospital Cluj-Napoca, Cluj-Napoca, Romania
| | - Ingrid Pabinger
- Department of Medicine, Division of Hematology and Haemostasis, University Hospital of Vienna, Austria
| | - Johanna Gebhart
- Department of Medicine, Division of Hematology and Haemostasis, University Hospital of Vienna, Austria
| | - Rosario Lopez Pedrera
- Institute Maimónides of Biomedical Investigations, University Hospital Reina Sofía, Cordoba, Spain
| | | | - Angela Tincani
- Rheumatology and Clinical Immunology Unit, University of Brescia, Brescia, Italy; I.M. Sechenow First Moscow State Medical University, Moscow, Russia
| | - Laura Andreoli
- Rheumatology and Clinical Immunology Unit, University of Brescia, Brescia, Italy
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Borisow N, Hellwig K, Paul F. Neuromyelitis optica spectrum disorders and pregnancy: relapse-preventive measures and personalized treatment strategies. EPMA J 2018; 9:249-256. [PMID: 30174761 PMCID: PMC6107451 DOI: 10.1007/s13167-018-0143-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 07/11/2018] [Indexed: 12/19/2022]
Abstract
Neuromyelitis optica spectrum disorders (NMOSD) are autoimmune inflammatory diseases of the central nervous system that predominately affect women. Some of these patients are of childbearing age at NMOSD onset. This study reviews, on the one hand, the role NMOSD play in fertility, pregnancy complications and pregnancy outcome, and on the other, the effect of pregnancy on NMOSD disease course and treatment options available during pregnancy. Animal studies show lower fertility rates in NMOSD; however, investigations into fertility in NMOSD patients are lacking. Pregnancies in NMOSD patients are associated with increased disease activity and more severe disability postpartum. Some studies found higher risks of pregnancy complications, e.g., miscarriages and preeclampsia. Acute relapses during pregnancy can be treated with methylprednisolone and/or plasma exchange/immunoadsorption. A decision to either stop or continue immunosuppressive therapy with azathioprine or rituximab during pregnancy should be evaluated carefully and factor in the patient's history of disease activity. To this end, involving neuroimmunological specialist centers in the treatment and care of pregnant NMOSD patients is recommended, particularly in specific situations like pregnancy.
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Affiliation(s)
- Nadja Borisow
- NeuroCure Clinical Research Center, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117 Berlin, Germany
| | - Kerstin Hellwig
- Clinic for Neurology, St. Josef Hospital, Ruhr Universität Bochum, Bochum, Germany
| | - Friedemann Paul
- NeuroCure Clinical Research Center, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117 Berlin, Germany
- Experimental and Clinical Research Center, Max Delbrueck Center for Molecular Medicine and Charité – Universitätsmedizin Berlin, Berlin, Germany
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6
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Bermas BL, Tassinari M, Clowse M, Chakravarty E. The new FDA labeling rule: impact on prescribing rheumatological medications during pregnancy. Rheumatology (Oxford) 2018; 57:v2-v8. [PMID: 30137587 PMCID: PMC6099131 DOI: 10.1093/rheumatology/key010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 01/11/2018] [Indexed: 12/30/2022] Open
Abstract
After several decades of deliberation, the US Food and Drug Administration updated the Pregnancy and Lactation Labeling Rule in 2015, eliminating the prior A, B, C, D, X grading system for medication use in pregnancy. Although physicians and patients liked the relative ease of use of this system, it was often misconstrued and not updated to include new data suggesting greater compatibility of medications with pregnancy. The new label is designed to include more clinically relevant data, including data from human studies and registries, and fewer animal data. A key goal of the new label is to assist physicians and patients as they weigh the risks and benefits of medications vs the risks of pregnancy in a woman with a chronic, untreated illness. As such, each label now includes a section outlining the pregnancy risks of the diseases that the medication treats. This review includes a historical perspective on the label change and a guide to the interpretation of the new label. It also includes an assessment of the baseline risk of pregnancy in women with SLE and RA, to help balance the consideration of medication risks and benefits in pregnancy.
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Affiliation(s)
- Bonnie L Bermas
- Division of Rheumatic Diseases, University of Texas Southwestern Medical Center, Dallas, TX
| | | | - Megan Clowse
- Division of Rheumatology and Immunology, Duke University Medical Center, Durham, NC
| | - Eliza Chakravarty
- Division of Arthritis and Clinical Immunology, Oklahoma Medical Research Foundation, Oklahoma City, OK, USA
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7
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Borisow N, Hellwig K, Paul F. [Neuromyelitis optica spectrum disorder and pregnancy]. DER NERVENARZT 2018; 89:666-673. [PMID: 29383411 DOI: 10.1007/s00115-018-0486-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Neuromyelitis optica spectrum disorders (NMOSD) are autoimmune inflammatory diseases of the central nervous system that mainly affect women. In some of these patients NMOSD occurs during fertile age. For this reason, treating physicians may be confronted with questions concerning family planning, pregnancy and birth. OBJECTIVE This study provides an overview on the influence of NMOSD on fertility, pregnancy complications and pregnancy outcome. The effect of pregnancy on NMOSD course and therapy options during pregnancy are discussed. MATERIAL AND METHODS A search of the current literature was carried out using the PubMed database. RESULTS AND CONCLUSION Animal studies have shown lower fertility rates in NMOSD; however, studies investigating fertility in NMOSD patients are lacking. Pregnancy in NMOSD patients are associated with an increase in postpartum disease activity and a higher grade of disability after pregnancy. Some studies showed higher risks of pregnancy complications e. g. spontaneous abortions and preeclampsia. With a few limitations, acute relapses during pregnancy can be treated with methylprednisolone and/or plasma exchange/immunoadsorption. Stopping or continuing immunosuppressive therapy with azathioprine or rituximab during pregnancy should be critically weighed considering previous and current disease activity. Therefore, a joint supervision by a specialized center is recommended, particularly in specific situations such as pregnancy.
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Affiliation(s)
- N Borisow
- NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Deutschland.
| | - K Hellwig
- Klinik für Neurologie, St. Josef Hospital, Ruhr Universität Bochum, Bochum, Deutschland
| | - F Paul
- NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Deutschland
- Experimental and Clinical Research Center, Max Delbrueck Center for Molecular Medicine and Charité - Universitätsmedizin Berlin, Berlin, Deutschland
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8
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Thomas C, Monteil-Ganiere C, Mirallié S, Hémont C, Dert C, Léger A, Joyau C, Caldari D, Audrain M. A Severe Neonatal Lymphopenia Associated With Administration of Azathioprine to the Mother in a Context of Crohn's Disease. J Crohns Colitis 2018; 12:258-261. [PMID: 28961694 DOI: 10.1093/ecco-jcc/jjx123] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 08/30/2017] [Indexed: 12/12/2022]
Abstract
Azathioprine is commonly used in Crohn's disease. It has been administered to many pregnant women over many years without significant side effects. However, pancytopenia and severe combined immune deficiency-like disease have been reported in infants whose mothers received azathioprine throughout pregnancy. Moreover, myelotoxicity has been described in patients being treated with azathioprine and having a low or absent thiopurine S-methyl transferase [TPMT] activity.Here, we describe the case of a newborn girl found to be highly lymphopenic [< 300 CD3+ T cells] after a positive newborn screening for severe combined immuno deficiency. The clinical examination was normal. The mother was treated with azathioprine throughout her pregnancy, without any reduction of the dose. It was shown that the mother was heterozygous for the 3A [TPMT] activity mutation and that the baby was homozygous for the same mutation; 6-thioguanine nucleotides were high (744 pmol/8.108 red blood cells [RBC]) in the mother and detectable in the infant [177 pmol/8.108 RBC].Although rare, this case illustrates the potential grave consequences of unsuspected TPMT homozygosity in a newborn of a mother receiving thiopurines during pregnancy. Because of the severity of the risk for the newborn, consideration should be given to performing maternal genetic testing and newborn routine blood count in cases of thiopurine treatment during pregnancy.
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Affiliation(s)
- Caroline Thomas
- Service d'hématologie et d'immunologie pédiatrique, Hôpital Mère-Enfants, CHU de Nantes, Nantes, France
| | | | | | | | - Cecile Dert
- Direction de la recherche, cellule Innovation, CHU de Nantes, Nantes, France
| | - Alexandra Léger
- Service d'hématologie et d'immunologie pédiatrique, Hôpital Mère-Enfants, CHU de Nantes, Nantes, France.,Service d'immunologie, CHU de Nantes, Nantes, France
| | - Caroline Joyau
- Service de pharmacologie Clinique, CHU de Nantes, Nantes, France
| | - Dominique Caldari
- Service de pédiatrie, Hôpital Mère-Enfants, CHU de NANTES, Nantes, France
| | - Marie Audrain
- Service d'immunologie, CHU de Nantes, Nantes, France
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9
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Palosse-Cantaloube L, Hurault-Delarue C, Beau AB, Montastruc JL, Lacroix I, Damase-Michel C. Risk of infections during the first year of life after in utero exposure to drugs acting on immunity: A population-based cohort study. Pharmacol Res 2016; 113:557-562. [PMID: 27697641 DOI: 10.1016/j.phrs.2016.09.028] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 09/21/2016] [Accepted: 09/23/2016] [Indexed: 10/20/2022]
Abstract
The aim of the study was to evaluate the association between in utero exposure to drugs that potentially exhibit immunosuppressive activity and occurrence of infections during the first year of life. We conducted a cohort study on the prescription data of pregnant women and their children registered in EFEMERIS cohort (France), during a one-year period. We classified in utero child exposure according to the number of reimbursements for immunosuppressive drugs during pregnancy. The number of infectious episodes during the first year of life was estimated through the number of anti-infective drugs dispensed. The association was estimated by a quasi-Poisson regression with adjustment for confounders. The study population consisted of 9614 children, 3141 of whom had been exposed to immunosuppressive drugs during pregnancy. The most frequently immunosuppressive drugs prescribed were corticosteroids. The mean number of infectious episodes during the first year after birth gradually increased with the number of immunosuppressive drugs dispensed during pregnancy (from 2.38 in controls to 3.88 in the most exposed group). After adjustment for potential confounders, in utero exposure to immunosuppressive drugs was significantly associated with the number of infectious episodes during the first year of life (RR 3ormoreexposuresVS0=1.35, 95% CI 1.24-1.46). Intrauterine exposure to potentially immunosuppressive drugs could be associated with an increased susceptibility to infections in early childhood.
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Affiliation(s)
- Lucie Palosse-Cantaloube
- Pharmacologie Médicale et Clinique, UMR INSERM 1027, Centre Hospitalier Universitaire de Toulouse, Faculté de Médecine, Université Toulouse III, 37 Allées Jules Guesde, 31000 Toulouse, France
| | - Caroline Hurault-Delarue
- Pharmacologie Médicale et Clinique, UMR INSERM 1027, Centre Hospitalier Universitaire de Toulouse, Faculté de Médecine, Université Toulouse III, 37 Allées Jules Guesde, 31000 Toulouse, France
| | - Anna-Belle Beau
- Pharmacologie Médicale et Clinique, UMR INSERM 1027, Centre Hospitalier Universitaire de Toulouse, Faculté de Médecine, Université Toulouse III, 37 Allées Jules Guesde, 31000 Toulouse, France
| | - Jean-Louis Montastruc
- Pharmacologie Médicale et Clinique, UMR INSERM 1027, Centre Hospitalier Universitaire de Toulouse, Faculté de Médecine, Université Toulouse III, 37 Allées Jules Guesde, 31000 Toulouse, France
| | - Isabelle Lacroix
- Pharmacologie Médicale et Clinique, UMR INSERM 1027, Centre Hospitalier Universitaire de Toulouse, Faculté de Médecine, Université Toulouse III, 37 Allées Jules Guesde, 31000 Toulouse, France
| | - Christine Damase-Michel
- Pharmacologie Médicale et Clinique, UMR INSERM 1027, Centre Hospitalier Universitaire de Toulouse, Faculté de Médecine, Université Toulouse III, 37 Allées Jules Guesde, 31000 Toulouse, France.
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10
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Perrone G, Brunelli R, Marcoccia E, Zannini I, Candelieri M, Gozzer M, Stefanutti C. Therapeutic Apheresis in Pregnancy: Three Differential Indications With Positive Maternal and Fetal Outcome. Ther Apher Dial 2016; 20:677-685. [DOI: 10.1111/1744-9987.12422] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 01/14/2016] [Accepted: 03/01/2016] [Indexed: 12/15/2022]
Affiliation(s)
- Giuseppina Perrone
- Department of Obstetrical and Gynecological Sciences and Urological Sciences
| | - Roberto Brunelli
- Department of Obstetrical and Gynecological Sciences and Urological Sciences
| | - Eleonora Marcoccia
- Department of Obstetrical and Gynecological Sciences and Urological Sciences
| | - Ilaria Zannini
- Department of Obstetrical and Gynecological Sciences and Urological Sciences
| | - Miriam Candelieri
- Department of Obstetrical and Gynecological Sciences and Urological Sciences
| | | | - Claudia Stefanutti
- Extracorporeal Therapeutic Techniques Unit, Immunohematology and Transfusion Medicine, Lipid Clinic and Atherosclerosis Prevention Centre, Department of Molecular Medicine; ‘Umberto I’ Hospital, ‘Sapienza’ University of Rome; Rome Italy
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11
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Biggioggero M, Borghi MO, Gerosa M, Trespidi L, Cimaz R, Meroni PI. Immune function in children born to mothers with autoimmune diseases and exposed in utero to immunosuppressants. Lupus 2016; 16:651-6. [PMID: 17711903 DOI: 10.1177/0961203307079569] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The administration of immunosuppressive drugs during pregnancy is often necessary in women with autoimmune diseases. Teratogenicity of immunosuppressives during pregnancy has been evaluated, only few data exist about the effects on immune systems. We therefore performed a pilot study on the influence of foetal exposure to immunosuppressives on immune function of babies born to mothers with autoimmune disorders. We investigated serological and cellular parameters as indicators of immune system status. We included in the study 14 babies (mean age 11 months, range 1—24) born to mothers with autoimmune diseases and exposed in utero to different immunosuppressants and, as controls, 14 babies whose mothers had autoimmune manifestations but did not receive immunosuppressive therapy. We evaluated: (i) complete blood count, (ii) immunoglobulin levels and IgG subclasses, (iii) antibody response to hepatitis B vaccine, (iv) leukocyte subpopulations and (v) interleukin-2 and interferon γ in vitro production by resting or activated peripheral blood mononuclear cells. We did not find statistically significant differences between exposed and not exposed babies or among treatments for the tested parameters. Immunosuppressive regimens currently in use for controlling maternal autoimmune disorders do not significantly affect the immune status of the offspring. Lupus (2007) 16, 651—656.
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Affiliation(s)
- M Biggioggero
- Department of Internal Medicine, University of Milan, IRCCS Istituto Auxologico Italiano, Milan, Italy
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12
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Cimaz R, Meregalli E, Biggioggero M, Airò P, Danieli E, Antonioli CM, Motta M, Chirico G, Columbrita D, Frassi M, Meroni PL, Tincani A. Response to tetanus vaccination in infants exposed in utero to immunosuppressants for maternal autoimmune disorders. Lupus 2016; 16:129-32. [PMID: 17402369 DOI: 10.1177/0961203306075738] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Immunosuppressive drugs given during pregnancy to mothers suffering from a systemic autoimmune disease (AID) can cross the placenta, thus being potentially able to affect the offspring immune system. Aim of our study was to evaluate the in vivo immune function of a series of these newborns. Twenty-two babies born from mothers suffering from autoimmune diseases (AID) who had been taking immunosuppressive drugs during pregnancy were evaluated for their response to vaccination with C. Tetani toxoid. Six babies born from mothers receiving low-dose aspirin only were used as controls. The immune response to C. Tetani vaccination was evaluated with an ELISA to detect circulating antibodies. Five children out of 28 (17%) did not achieve a protective titer of anti C. Tetanitoxoid IgG. No clear relationship was found between specific drug exposure and antibody response. Our findings suggest that maternal immunosuppressive treatment given for a systemic AID can affect the response to an active immunization, without specificities for drug types used.
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Affiliation(s)
- R Cimaz
- Hospices Civils de Lyon- Universitè Lyon 1, Lyon, France.
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13
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Pregnancy and autoimmune connective tissue diseases. Best Pract Res Clin Rheumatol 2016; 30:63-80. [PMID: 27421217 DOI: 10.1016/j.berh.2016.05.002] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 05/24/2016] [Accepted: 05/29/2016] [Indexed: 12/28/2022]
Abstract
Autoimmune connective tissue diseases predominantly affect women and often occur during the reproductive years. Thus, specialized issues in pregnancy planning and management are commonly encountered in this patient population. This chapter provides a current overview of pregnancy as a risk factor for onset of autoimmune disease, considerations related to the course of pregnancy in several autoimmune connective tissue diseases, and disease management and medication issues before pregnancy, during pregnancy, and in the postpartum period. A major theme that has emerged across these inflammatory diseases is that active maternal disease during pregnancy is associated with adverse pregnancy outcomes, and that maternal and fetal health can be optimized when conception is planned during times of inactive disease and through maintaining treatment regimens compatible with pregnancy.
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14
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Bermas BL. Drugs and pregnancy. Rheumatology (Oxford) 2015. [DOI: 10.1016/b978-0-323-09138-1.00068-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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15
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Non-steroidal anti inflammatory drugs, glucocorticoids and disease modifying anti-rheumatic drugs for the management of rheumatoid arthritis before and during pregnancy. Curr Opin Rheumatol 2014; 26:334-40. [DOI: 10.1097/bor.0000000000000054] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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16
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Mockova A, Dortova E, Dort J, Nahlovsky J, Korecko V, Ulcova-Gallova Z. Extremely hypotrophic newborn of mother with systemic lupus erythematosus and antiphospholipid syndrome. Lupus 2013; 23:313-8. [PMID: 24356613 DOI: 10.1177/0961203313517406] [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
The case presented describes a high-risk pregnancy of a woman with systemic lupus erythematosus (SLE) with multiple lesions of central nervous system (CNS), vasculitis, secondary epilepsy and antiphospholipid syndrome (APS). At gestational age 28 weeks and 3 days the pregnancy was urgently terminated via caesarean section and an extremely hypotrophic immature newborn with a birth weight of 580 g was born. The high disease activity in the mother at the time of conception and the histologically proven chronic placental insufficiency due to APS are presumably the causes for the extensive hypotrophy of the neonate. The significant comorbidity of the newborn, including respiratory distress syndrome, bronchopulmonary dysplasia, necrotizing enterocolitis, osteopathy of prematurity, transient hypothyroidism and hypocortisolism, vesicoureteral reflux, and hypertonic-hyperexcitation syndrome complicated his three-month stay in NICU. A positive titre of transplacentally transferred anticardiolipin and anti-β2 glycoprotein antibody was detected in the child and persisted through the following 30 months. During the three-year follow-up, significantly delayed neuropsychological development with microcephaly (-4 SD) and short stature of the child was observed. Finally, the authors discuss possible causes of neuropsychological consequences in children of mothers with SLE and APS and emphasize the need for long-term monitoring and specialized care to improve development of these children.
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Affiliation(s)
- A Mockova
- 1Department of Neonatology, Faculty of Medicine in Pilsen and University Hospital, Charles University in Prague, Czech Republic
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17
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de Boer NKH, de Meij T, van Bodegraven AA. Thiopurines during pregnancy in inflammatory bowel disease: is there a risk for the (unborn) child? Expert Rev Gastroenterol Hepatol 2013; 7:669-71. [PMID: 24134152 DOI: 10.1586/17474124.2013.841541] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Nanne K H de Boer
- Department of Gastroenterology and Hepatology, VU University Medical Centre, PO Box 7057, 1007 MB, Amsterdam, The Netherlands
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18
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de Meij TGJ, Jharap B, Kneepkens CMF, van Bodegraven AA, de Boer NKH. Long-term follow-up of children exposed intrauterine to maternal thiopurine therapy during pregnancy in females with inflammatory bowel disease. Aliment Pharmacol Ther 2013; 38:38-43. [PMID: 23675854 DOI: 10.1111/apt.12334] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2013] [Revised: 04/03/2013] [Accepted: 04/24/2013] [Indexed: 12/23/2022]
Abstract
BACKGROUND Inflammatory bowel disease (IBD) affects a substantial number of female patients in their reproductive years. Therefore, many physicians face the dilemma whether thiopurines, prescribed to maintain remission, can be taken safely during pregnancy. Data on long-term development outcome of children exposed to maternal thiopurine therapy are very limited. AIM To assess the long-term effects of in utero exposure to thiopurines during pregnancy on infant health status. METHODS A prospective multicentre follow-up study was performed in children exposed intrauterine to maternal thiopurine therapy. Physical, cognitive and social aspects of infant health status were assessed with the 43-item TNO-AZL Preschool Children Quality of Life Questionnaire (TAPQOL). Furthermore, information on visits to general practitioner and medical specialists, and physician's advice regarding lactation was evaluated. Data were compared with normative data from a control group consisting of 340 children. RESULTS Thirty children were included in this study [median 3.8 years (IQR 2.9-4.7)]. No differences on global medical and psychosocial health status were found between children exposed to intrauterine thiopurines and the reference group. Exposure to intrauterine thiopurines was not associated with increased susceptibility to infection or immunodeficiency in childhood. Twenty-one of 30 children were exclusively formula-fed based on a negative advice of medical specialists directed at thiopurine use during lactation. CONCLUSIONS Thiopurine use during pregnancy did not affect long-term development or immune function of children up to 6 years of age. Our results underscore the present notion that mothers, even those using thiopurines, should be encouraged to breastfeed their infants.
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Affiliation(s)
- T G J de Meij
- Department of Pediatric Gastroenterology, VU University Medical Center, 1081 HV Amsterdam, The Netherlands.
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19
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Maruyama H, Tada K, Fujiwara T, Ota K, Kageyama M. Utility of maternal 6-thioguanine nucleotide levels in predicting neonatal pancytopenia. AJP Rep 2013; 3:25-8. [PMID: 23943705 PMCID: PMC3699157 DOI: 10.1055/s-0032-1329683] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2012] [Accepted: 07/27/2012] [Indexed: 10/27/2022] Open
Abstract
An infant with pancytopenia was born to a mother who used the common immunosuppressant azathioprine (AZA). Maternal and neonatal blood levels of 6-thioguanine nucleotides (6TGN; metabolite of AZA) were 1890 and 1480 pmol/8 × 10(8) red blood cells, respectively. Maternal 6TGN levels could be useful in predicting neonatal pancytopenia.
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Affiliation(s)
- Hidehiko Maruyama
- Department of Neonatology, National Hospital Organization, Okayama Medical Center, Okayama, Japan
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20
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Marder W, Ganser MA, Romero V, Hyzy MA, Gordon C, McCune WJ, Somers EC. In utero azathioprine exposure and increased utilization of special educational services in children born to mothers with systemic lupus erythematosus. Arthritis Care Res (Hoboken) 2013; 65:759-66. [PMID: 23139238 PMCID: PMC3572294 DOI: 10.1002/acr.21888] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2012] [Accepted: 10/14/2012] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Azathioprine (AZA) is recognized among immunosuppressive medications as relatively safe during pregnancy for women with systemic lupus erythematosus (SLE) requiring aggressive treatment. This pilot study aimed to determine whether SLE therapy during pregnancy was associated with developmental delays in offspring. METHODS This cohort study included SLE patients with at least one live birth postdiagnosis. Medical histories were obtained via interviews and chart review. Multiple logistic regression was used to examine associations between SLE therapy during pregnancy and maternal report of special educational (SE) requirements (as proxy for developmental delays) among offspring. Propensity scoring (incorporating corticosteroid use, lupus flare, and lupus nephritis) was used to account for disease severity. RESULTS Of 60 eligible offspring from 38 mothers, 15 required SE services, the most common indication for which was speech delay. Seven (54%) of the 13 children with in utero AZA exposure utilized SE services versus 8 (17%) of 47 nonexposed children (P < 0.01). After adjustment for pregnancy duration, small for gestational age, propensity score, maternal education level, and antiphospholipid antibody syndrome, AZA was significantly associated with SE utilization occurring from age 2 years onward (odds ratio 6.6, 95% confidence interval 1.0-43.3), and bordered on significance for utilization at any age or age <2 years. CONCLUSION AZA exposure during SLE pregnancy was independently associated with increased SE utilization in offspring, after controlling for confounders. Further research is indicated to fully characterize developmental outcomes among offspring with in utero AZA exposure. Vigilance and early interventions for suspected developmental delays among exposed offspring may be warranted.
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Affiliation(s)
- Wendy Marder
- Department of Internal Medicine, Division of Rheumatology, University of Michigan, Ann Arbor, MI, USA
| | - Martha A Ganser
- Department of Internal Medicine, Division of Rheumatology, University of Michigan, Ann Arbor, MI, USA
| | - Vivian Romero
- Department of Obstetrics and Gynecology, Division of Maternal and Fetal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Margaret A Hyzy
- Department of Internal Medicine, Division of Rheumatology, University of Michigan, Ann Arbor, MI, USA
| | - Caroline Gordon
- Rheumatology Research Group, School of Immunity and Infection, College of Medical and Dental Sciences, University of Birmingham, UK
| | - WJ McCune
- Department of Internal Medicine, Division of Rheumatology, University of Michigan, Ann Arbor, MI, USA
| | - Emily C Somers
- Department of Internal Medicine, Division of Rheumatology, University of Michigan, Ann Arbor, MI, USA
- Department of Environmental Health Sciences, University of Michigan School of Public Health, Ann Arbor, MI, USA
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21
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Akbari M, Shah S, Velayos FS, Mahadevan U, Cheifetz AS. Systematic review and meta-analysis on the effects of thiopurines on birth outcomes from female and male patients with inflammatory bowel disease. Inflamm Bowel Dis 2013; 19:15-22. [PMID: 22434610 DOI: 10.1002/ibd.22948] [Citation(s) in RCA: 160] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Inflammatory bowel disease (IBD) affects people during their prime reproductive years. The thiopurines (6-mercaptopurine and azathioprine), commonly used for induction and maintenance of remission, are U.S. Food and Drug Administration (FDA) pregnancy category D, raising concern for fetal risk. We performed a systematic review and meta-analysis to evaluate the effects of thiopurine exposure during pregnancy or at the time of conception on three measures of fetal risk in women and men with IBD. METHODS A systematic search of PubMed and Web of Science using a combination of Mesh and text terms was performed to identify studies reporting birth outcomes from IBD women and men exposed to thiopurines within 3 months of conception and/or during pregnancy. A meta-analysis was performed using the random effects model to pool estimates and report odds ratio (OR) for three outcomes in women: low birth weight (LBW), preterm birth, and congenital abnormalities and one in men: congenital abnormalities. RESULTS In women with IBD exposed to thiopurines, the pooled ORs for LBW, preterm birth, and congenital abnormalities were 1.01 (95% confidence interval [CI] 0.96, 1.06), 1.67 (95% CI 1.26, 2.20), and 1.45 (95% CI 0.99, 2.13), respectively. In men, the pooled OR for congenital abnormality was 1.87 (95% CI 0.67, 5.25). CONCLUSIONS Thiopurine exposure in women with IBD was not associated with LBW or congenital abnormalities, but was associated with preterm birth. Exposure in men at the time of conception was not associated with congenital abnormalities.
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Affiliation(s)
- Mona Akbari
- Department of Internal Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts 02215, USA
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22
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O'Connor A, Qasim A, O'Moráin CA. The long-term risk of continuous immunosuppression using thioguanides in inflammatory bowel disease. Ther Adv Chronic Dis 2012; 1:7-16. [PMID: 23251725 DOI: 10.1177/2040622310368736] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The efficacy of thiopurine treatment in the induction, and especially maintenance, of remission in inflammatory bowel disease is well proven; however, it is associated with side effects in both medium and long-term use. The potential harmful effects may be anticipated and minimised by due diligence prior to commencing these drugs followed by close monitoring of haematological and biochemical parameters once started. Careful clinical examination and history taking are also essential. Affected patients are expected to lead lives that include travel, employment and pregnancy - the implications of continued thiopurine therapy in such patients are discussed.
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Affiliation(s)
- Anthony O'Connor
- Dr Asghar Qasim Prof. Colm A. O'Moráin Department of Gastroenterology, Adelaide and Meath Hospital incorporating the National Children's Hospital/Trinity College Dublin, Belgard Road, Tallaght, Dublin 24, Ireland
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23
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Optimum Use of Disease-Modifying and Immunosuppressive Antirheumatic Agents During Pregnancy and Lactation. ACTA ACUST UNITED AC 2012. [DOI: 10.1007/bf03259314] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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24
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Myasthenia gravis in pregnancy: a case report. Case Rep Obstet Gynecol 2012; 2012:736024. [PMID: 22567528 PMCID: PMC3335651 DOI: 10.1155/2012/736024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2011] [Accepted: 12/06/2011] [Indexed: 11/17/2022] Open
Abstract
Objective. To present a case of maternal myasthenia gravis in pregnancy and give a systematic review of the literature. Case. We report the case of a 38-year-old parturient with a life-threatening complication of immune-mediated myasthenia gravis shortly after an elective cesarean section on patient's request under spinal anesthesia at 35 + 3 weeks of gestation. The newborn was transferred to the pediatric unit for surveillance and did not show any signs of muscular weakness in the course of time. The mother developed a respiratory insufficiency on the second day postpartum. The myasthenic crisis led to a progressive dyspnoea within minutes, which exacerbated in a secondary generalized seizure with cardiac-circulatory arrest. After successful cardiopulmonary resuscitation, the patient was transferred to intensive care. The interdisciplinary therapeutic approach included ventilatory assistance via endotracheal intubation, parenteral pyridostigmine, azathioprine, and steroids. By interdisciplinary measures, a stable state was regained. Conclusion. Myasthenia gravis especially when associated with pregnancy is a high-risk disease. As this disease predominantly occurs in women of reproductive age, it is important to be aware of this condition in obstetrics and its interdisciplinary diagnostic and therapeutic management.
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25
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Westbrook RH, Yeoman AD, Kriese S, Heneghan MA. Outcomes of pregnancy in women with autoimmune hepatitis. J Autoimmun 2012; 38:J239-44. [PMID: 22261501 DOI: 10.1016/j.jaut.2011.12.002] [Citation(s) in RCA: 102] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2011] [Revised: 12/04/2011] [Accepted: 12/05/2011] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Optimal management during pregnancy of patients with autoimmune hepatitis (AIH) remains undefined. We therefore reviewed all patients with AIH who reported pregnancy at our centre to identify any pre-conception factors that might predict adverse outcomes. RESULTS There were 81 pregnancies in 53 women. Median age at conception was 26 years (range 16-42); with 41% of pregnancies occurring in the context of cirrhosis. At conception, 61 patients (75%) were on therapy for AIH. The live birth rate (LBR) was 73% (59/81). Prematurity, occurred in 12/59 (20%) and 6 (11%) required admission to special care baby unit (SCBU). In mothers who were cirrhotic at the time of conception the LBR was lower (p = 0.02) and need for admission to SCBU was higher. The overall maternal complication rate was 31/81 (38%) conceptions. A flare in disease activity occurred in 26/81 (33%) pregnancies. A serious maternal adverse event (death or need for liver transplant) during or within 12-months of delivery, or hepatic decompensation during or within 3-months of delivery, occurred with 9 pregnancies (11%) and was more common in women with cirrhosis (p = 0.028). Maternal therapy had no significant impact on the LBR (p = 0.24), termination rate (p = 0.72), miscarriage rate (p = 0.19) or gestational period (p = 0.8). Flares in AIH were more likely in patients who were not on therapy (p = 0.048) or who had a disease flare in the year prior to conception (p = 0.03). Patients who had a flare in association with pregnancy were more likely to decompensate from a liver standpoint (p = 0.01). CONCLUSIONS This study demonstrates that poor disease control in the year prior to pregnancy and the absence of drug therapy are associated with poor outcomes whist pregnant. These data should facilitate appropriate pre-conception counselling and appropriate pregnancy management in this cohort.
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Affiliation(s)
- Rachel H Westbrook
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, United Kingdom.
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26
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Bermas BL. Drugs and pregnancy. Rheumatology (Oxford) 2011. [DOI: 10.1016/b978-0-323-06551-1.00065-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Rheumatology drugs and pregnancy. Joint Bone Spine 2010; 77:506-10. [PMID: 20961792 DOI: 10.1016/j.jbspin.2010.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2010] [Indexed: 11/22/2022]
Abstract
Medication exposure during pregnancy, especially in the first trimester, is a common event that causes considerable concern among patients and healthcare professionals alike. Once the pregnancy is known, the response often consists in stopping or substantially diminishing the use of medications. Some medications are teratogenic and/or fetotoxic, requiring effective birth control and prior information of women of childbearing potential. Nevertheless, limiting the use of medications out of a sense of caution is warranted only if no major adverse impact on the mother is expected throughout the 9 months of the pregnancy. Treatment decisions during pregnancy should rest on a careful reappraisal of treatment practices and on an in-depth evaluation of the risk/benefit ratio of each medication. Here, we will discuss the main rheumatology drug classes whose use during pregnancy is most likely to cause concern.
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Gisbert JP. Safety of immunomodulators and biologics for the treatment of inflammatory bowel disease during pregnancy and breast-feeding. Inflamm Bowel Dis 2010; 16:881-95. [PMID: 19885906 DOI: 10.1002/ibd.21154] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The aim of this article is to critically review available data regarding the safety of immunomodulators and biological therapies during pregnancy and breast-feeding in women with inflammatory bowel disease. Methotrexate and thalidomide can cause congenital anomalies and are contraindicated during pregnancy (and breast-feeding). Although thiopurines have a Food and Drug Administration (FDA) rating D, available data suggest that these drugs are safe and well tolerated during pregnancy. Although traditionally women receiving azathioprine or mercaptopurine have been discouraged from breast-feeding because of theoretical potential risks, it seems that these drugs may be safe in this scenario. Treatment with cyclosporine for steroid-refractory ulcerative colitis (UC) during pregnancy can be considered safe and effective, and the use of this drug should be considered in cases of severe UC as a means of avoiding urgent surgery. Breast-feeding is contraindicated for patients receiving cyclosporine. Biological therapies appear to be safe in pregnancy, as no increased risk of malformations has been demonstrated. Therefore, the limited clinical results available suggest that the benefits of infliximab and adalimumab in attaining response and maintaining remission in pregnant patients might outweigh the theoretical risks of drug exposure to the fetus. Stopping therapy in the third trimester may be considered, as it seems that transplacental transfer of infliximab is low prior to this. Certolizumab differs from infliximab and adalimumab in that it is a Fab fragment of an antitumor necrosis factor alpha monoclonal antibody, and therefore it may not be necessary to stop certolizumab in the third trimester. The use of infliximab is probably compatible with breast-feeding.
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Affiliation(s)
- Javier P Gisbert
- Gastroenterology Unit, Hospital Universitario de la Princesa and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Madrid, Spain.
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29
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Rituximab administration in third trimester of pregnancy suppresses neonatal B-cell development. Clin Dev Immunol 2008; 2008:271363. [PMID: 18596903 PMCID: PMC2438602 DOI: 10.1155/2008/271363] [Citation(s) in RCA: 113] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2008] [Accepted: 05/05/2008] [Indexed: 01/19/2023]
Abstract
We describe the effect on the neonate of administration of rituximab to a woman with idiopathic thrombocytopenic purpura (ITP). Rituximab, an anti-CD20 antibody, was given weekly for 4 weeks to a woman with ITP in her third trimester of pregnancy. One month after the last rituximab administration a healthy girl was born. She had normal growth and development during the first six months. At birth, B-lymphocytes were not detectable. Rituximab levels in mother and neonate were 24000 and 6700 ng/mL, respectively. Only 7 cases of rituximab administration during pregnancy were described. No adverse events are described for fetus and neonate. We demonstrate that rituximab passes the placenta and inhibits neonatal B-lymphocyte development. However, after 6 months B-lymphocyte levels normalized and vaccination titres after 10 months were adequate. No infection-related complications occurred. Rituximab administration during pregnancy appears to be safe for the child but further studies are warranted.
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Abstract
Chronic immune thrombocytopenic purpura (ITP) is an autoimmune disease characterized by a low platelet count and mucocutaneous bleeding. Pregnancy does not increase the incidence of ITP nor does it exacerbate a preexisting disease. Although pregnant women with ITP may experience several maternal and fetal complications, in most cases even with a very low platelet count, there is neither maternal nor fetal morbidity or mortality. Corticosteroids are the first line of therapy in pregnant women; intravenous immune globulin is commonly used in steroid resistant patients. Other treatments such as intravenously administered anti-D (Rhogam) and splenectomy during pregnancy have been reported. Antiplatelet IgG antibodies can cross the placenta and can induce fetal thrombocytopenia. In most women there is no indication to assess fetal platelet counts during the pregnancy. The mode of delivery is determined by obstetrical considerations.
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Goldstein LH, Dolinsky G, Greenberg R, Schaefer C, Cohen-Kerem R, Diav-Citrin O, Malm H, Reuvers-Lodewijks ME, Rost van Tonningen-van Driel MM, Arnon J, Ornoy A, Clementi M, Di Gianantonio E, Koren G, Braunstein R, Berkovitch M. Pregnancy outcome of women exposed to azathioprine during pregnancy. ACTA ACUST UNITED AC 2007; 79:696-701. [PMID: 17847119 DOI: 10.1002/bdra.20399] [Citation(s) in RCA: 145] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Azathioprine (AZP) interferes with nucleic acid synthesis and is teratogenic in animals. In view of the paucity of information on the use of AZP during pregnancy we investigated this subject in a prospective, controlled, multicenter study. Our objective was too determine whether exposure to AZP during pregnancy increases the risk for major malformations and to determine the effect on pregnancy outcome. METHODS Pregnant women on AZP who contacted one of seven teratogen information services were compared to a cohort of pregnant women who contacted two of the seven teratogen information services and took nonteratogenic treatments during their pregnancy. RESULTS Follow-up was completed on 189 women in the AZP group and compared to 230 women in the control group. The rate of major malformations did not differ between groups with six neonates in each; the AZP rate was 3.5% and the control group rate was 3.0% (p = .775; OR 1.17; CI: 0.37, 3.69). The mean birth weight and gestational age were lower in the AZP group (2,995 g vs. 3,252 g [p = .001, difference of mean: 257, 95% CI: 106.3, 408.1] and 37.8 weeks vs. 39.1 weeks [p = .001, difference of mean: 1.3, 95% CI: .5, 2.0], respectively). The AZP group had more cases of prematurity (21.4% vs. 5.2% [p < .001; OR 4.0; 95% CI: 2.0, 8.06]) and low birth weight (23% vs. 6.0% [p < .001; OR 3.81; 95% CI: 2.0, 7.2]). CONCLUSIONS These results suggest that AZP (50-100 mg/day) does not triple the rate of birth defects; however, it is associated with lower birth weight, gestational age, and prematurity. Larger studies are needed to confirm these observations.
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Affiliation(s)
- Lee Hilary Goldstein
- Clinical Pharmacology Unit, Teratogen Information Service, Assaf Harofeh Medical Center, Sackler School of Medicine, Tel Aviv University, Israel
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Heetun ZS, Byrnes C, Neary P, O'Morain C. Review article: Reproduction in the patient with inflammatory bowel disease. Aliment Pharmacol Ther 2007; 26:513-33. [PMID: 17661756 DOI: 10.1111/j.1365-2036.2007.03397.x] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Inflammatory bowel disease (IBD) affects mainly the young population. The effect of IBD and its treatment on fertility and pregnancy is therefore an important clinical consideration. AIM To review the best management of IBD in the reproductive and pregnant population. METHODS A MEDLINE and an EMBASE search were performed using mainly the search phrases 'pregnancy AND IBD,''sulphasalazine AND male fertility,''abdominal surgery AND female fertility,''AZA AND placenta' and 'infliximab AND pregnancy.' No language or date restrictions were placed. References of review articles were examined. RESULTS Overall male and female fertility are not affected by IBD. Sulphasalzine reduces male fertility. No other drugs used in IBD affect significantly fertility in humans. The risk of pregnancy-related complications and the disease behaviour during pregnancy depends mainly on disease activity at time of conception. Proactive treatment for maintenance of disease remission during gestation is recommended. Except for methotrexate, drugs used in IBD appear safe in pregnancy. Breast feeding should be encouraged. CONCLUSION The management of IBD in the young and pregnant population remains controversial because the literature comes mostly from retrospective studies. Further studies particularly large prospective trials are needed to guide clinicians in decision making.
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Affiliation(s)
- Z S Heetun
- Department of Gastroenterology, Adelaide and Meath Hospital, Trinity College, Tallaght, Dublin 24, Ireland.
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Patel AA, Swerlick RA, McCall CO. Azathioprine in dermatology: The past, the present, and the future. J Am Acad Dermatol 2006; 55:369-89. [PMID: 16908341 DOI: 10.1016/j.jaad.2005.07.059] [Citation(s) in RCA: 104] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2005] [Revised: 02/25/2005] [Accepted: 07/23/2005] [Indexed: 01/19/2023]
Abstract
For several decades, dermatologists have utilized azathioprine to treat numerous debilitating skin diseases. This synthetic purine analog is derived from 6-mercaptopurine. It is thought to act by disrupting nucleic acid synthesis and has recently been found to interfere with T-cell activation. The most recognized uses of azathioprine in dermatology are for immunobullous diseases, generalized eczematous disorders, and photodermatoses. In this comprehensive review, the authors present recent advancements in the understanding of azathioprine and address aspects not covered in prior reviews. They (1) summarize the history of azathioprine; (2) discuss metabolism, integrating information from recent publications; (3) review the mechanism of action with attention paid to the activities of azathioprine not mediated by its 6-mercaptopurine metabolites and review new data about inhibition by azathioprine of the CD28 signal transduction pathway; (4) thoroughly examine thiopurine s-methyltransferase genetics, its clinical relevance, and interethnic variations; (5) review prior uses of azathioprine in the field of dermatology and grade the level of evidence; (6) discuss the use of azathioprine in pregnancy and pediatrics; review (7) key drug interactions and (8) adverse effects; (9) suggest a dosing and monitoring approach different from prior recommendations; and (10) explore the future of azathioprine, focusing on laboratory considerations and therapeutic application.
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Affiliation(s)
- Akash A Patel
- Department of Dermatology, Emory University School of Medicine, Atlanta, GA 30322-0001, USA
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Ferrero S, Pretta S, Nicoletti A, Petrera P, Ragni N. Myasthenia gravis: management issues during pregnancy. Eur J Obstet Gynecol Reprod Biol 2005; 121:129-38. [PMID: 16054951 DOI: 10.1016/j.ejogrb.2005.01.002] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2004] [Revised: 11/04/2004] [Accepted: 01/10/2005] [Indexed: 01/26/2023]
Abstract
Myasthenia gravis (MG) often affects women in the second and third decades of life, overlapping with the childbearing years. The course of the disease is unpredictable during pregnancy; however, worsening of symptoms occurs more likely during the first trimester and postpartum. MG can be well managed during pregnancy with relatively safe and effective therapies. Anticholinesterase drugs are the mainstay of treatment, when MG symptoms are not satisfactorily controlled, corticosteroids, azathioprine and in some cases cyclosporin A can be used. Until information is available regarding safety, mycophenolate mofetil should be discontinued before pregnancy. Pregnancy should be avoided in women treated with methotrexate because of the risk of causing typical malformations. Plasmapheresis and intravenous immunoglobulins have been successfully used in the treatment of MG crisis during pregnancy. Caesarean section is recommended only for obstetric reasons; forceps delivery and vacuum extraction are sometimes required. Epidural anesthesia is advised to reduce physical and emotional stress. MG during pregnancy can lead to serious life-threatening conditions, including respiratory insufficiency; therefore, intensive checkups by a gynaecologist and a neurologist are necessary. Women with myasthenia gravis should not be discouraged from conceiving; however, they should discuss their plan for pregnancy with their neurologist and their gynaecologist.
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Affiliation(s)
- Simone Ferrero
- Department of Obstetrics and Gynaecology, San Martino Hospital, University of Genoa, Largo R. Benzi 1, 16132 Genoa, Italy.
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Abstract
OBJECTIVE To review the toxicity issues of commonly used antirheumatic drugs in pregnancy and lactation. METHODS A review of the medical literature using Medline database via Ovid was performed to identify the toxicities of antirheumatic drugs in pregnancy and lactation. RESULTS Many rheumatologic diseases in women often first present during the childbearing years. In most cases, antirheumatic therapy is required for their disease control. Glucocorticoids may be used during pregnancy; however, first-trimester use should be avoided if possible and breastfeeding should occur 4 hours after the last dosing. Nonsteroidal antiinflammatory drugs (NSAIDs) and cyclooxygenase-2 (COX-2) inhibitors should be discontinued 6 to 8 weeks before delivery. NSAIDs are compatible with lactation, although there is potential risk of jaundice and kernicterus. There is insufficient data on COX-2 inhibitors and lactation. Hydroxychloroquine and sulfasalazine may be continued throughout pregnancy and lactation. Methotrexate and leflunomide are contraindicated during pregnancy and lactation. Cyclophosphamide and mycophenolate mofetil should be avoided during pregnancy and lactation. Azathioprine and cyclosporine A could be used with caution during pregnancy if felt there is a need to suppress disease activity. They are not compatible with breastfeeding. There are insufficient data regarding tumor necrosis factor-antagonists, anakinra, and rituximab in relation to pregnancy and lactation. Male patients should be made aware of the effects methotrexate, leflunomide, sulfasalazine, and cyclophosphamide may have on their fertility. CONCLUSIONS Health care providers should discuss the risks and benefits of antirheumatic therapy during conception, pregnancy, and lactation with their patients. Better maternal and fetal outcomes can be expected if the pregnancy is planned, the rheumatic disease is stable, and if appropriate medication adjustments can be made ahead of time.
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Affiliation(s)
- Katherine K Temprano
- Division of Rheumatology, Department of Internal Medicine, Saint Louis University, MO 63104, USA
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Abstract
Treatment considerations for women who have MG and are of childbearing age are complicated. When possible, before pregnancy, establishing a plan for therapy is ideal, recognizing the potential concerns for the patient and the fetus. Decisions about treatment during pregnancy must balance the potential complications for the fetus, the patient, and even the integrity of the pregnancy. Most women who have MG are able to complete pregnancy successfully and deliver a healthy baby; however, there always is some risk that NMG may occur. Pregnant patients who have MG are served best at centers capable of providing coordinated expert care from neurologic, obstetric, and pediatric providers.
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Affiliation(s)
- Emma Ciafaloni
- Neuromuscular Section, Department of Neurology, University of Rochester, School of Dentistry and Medicine, Rochester, NY, USA
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Matalon ST, Ornoy A, Lishner M. Review of the potential effects of three commonly used antineoplastic and immunosuppressive drugs (cyclophosphamide, azathioprine, doxorubicin on the embryo and placenta). Reprod Toxicol 2004; 18:219-30. [PMID: 15019720 DOI: 10.1016/j.reprotox.2003.10.014] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2003] [Revised: 10/08/2003] [Accepted: 10/24/2003] [Indexed: 01/10/2023]
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Abstract
6-Mercaptopurine and azathioprine have become important therapeutic options for patients with inflammatory bowel disease (IBD). Although accumulating data in the literature have supported the use of these immunomodulators in the management of IBD, marked variation exists in the pattern of clinical practice regarding azathioprine or 6-mercaptopurine therapy in patients with IBD. This article provides a critical review of the data on the clinical efficacy and toxicities of 6-mercaptopurine and azathioprine in the management of IBD. Emerging literature on the potential application of pharmacogenetic testing and metabolite monitoring are also discussed.
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Su C, Lichtenstein GR. Treatment of inflammatory bowel disease with azathioprine and 6-mercaptopurine. Gastroenterol Clin North Am 2004; 33:209-34, viii. [PMID: 15177535 DOI: 10.1016/j.gtc.2004.02.004] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
6-Mercaptopurine and azathioprine have become important therapeutic options for patients with inflammatory bowel disease (IBD). Although accumulating data in the literature have supported the use of these immunomodulators in the management of IBD, marked variation exists in the pattern of clinical practice regarding azathioprine or 6-mercaptopurine therapy in patients with IBD. This article provides a critical review of the data on the clinical efficacy and toxicities of 6-mercaptopurine and azathioprine in the management of IBD. Emerging literature on the potential application of pharmacogenetic testing and metabolite monitoring are also discussed.
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Affiliation(s)
- Chinyu Su
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania School of Medicine, 3rd Floor Ravdin Building, 3400 Spruce Street, Philadelphia, PA 19104-4283, USA
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Moskovitz DN, Bodian C, Chapman ML, Marion JF, Rubin PH, Scherl E, Present DH. The effect on the fetus of medications used to treat pregnant inflammatory bowel-disease patients. Am J Gastroenterol 2004; 99:656-61. [PMID: 15089898 DOI: 10.1111/j.1572-0241.2004.04140.x] [Citation(s) in RCA: 118] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES We reviewed data to investigate the effect of 5-ASA drugs, metronidazole, ciprofloxacin, prednisone, 6-mercaptopurine, azathioprine, and cyclosporine on pregnancy outcomes in patients with inflammatory bowel disease (IBD). METHODS One hundred and thirteen female patients with a total of 207 documented conceptions were studied. Treatment information included: smoking history (patient and spouse), dates of conception and termination, and outcome of pregnancy (spontaneous abortion, therapeutic abortion, maternal or fetal illness resulting in abortion, premature birth, healthy full-term birth, multiple births, ectopic pregnancy, congenital defects), weight of baby, type of delivery (cesarian section, vaginal), medication history during each trimester (mean dose, maximum dose, frequency). We analyzed the effect on pregnancy outcome of medication use during the first trimester or at any time during the pregnancy. RESULTS Thirty-nine patients (34.5%) had ulcerative colitis (UC), 73 (64.5%) had crohn's disease (CD), and 1 patient (1%) had indeterminate colitis. For 100 of the 207 conceptions, the patients were on 5-ASA drugs at some time during the pregnancy, 49 on prednisone, 101 on an immunomodulator (6-MP/azathioprine), 27 on metronidazole, 18 on ciprofloxacin, and 2 on cyclosporine. In 85 (31%) of the conceptions, patients were on none of these medications. No significant differences were found among the groups in each pregnancy with respect to outcome (p values 0.091 to 0.9). In multivariate analyses controlling for age of mother, there was no evidence that 5-ASA type drugs or any type of drug influenced pregnancy outcome. CONCLUSIONS In 113 female patients with 207 conceptions none of the drugs used to treat IBD is associated with poor pregnancy outcomes.
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Erkan D, Sammaritano L. New insights into pregnancy-related complications in systemic lupus erythematosus. Curr Rheumatol Rep 2003; 5:357-63. [PMID: 12967517 DOI: 10.1007/s11926-003-0021-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Pregnancy in patients with systemic lupus erythematosus (SLE) presents an additional risk to an already complex clinical situation--overlap in symptoms between changes of pregnancy and SLE, presence of antiphospholipid antibodies, and need for potentially teratogenic medications can all complicate the management of pregnant patients with SLE. Studies demonstrate that, with careful planning, the majority of patients with lupus can complete pregnancy without serious complications. Recent developments are modified instruments to measure disease activity in pregnancy, increasingly common continuation of hydroxychloroquine during pregnancy, more frequent use of in vitro fertilization, and more aggressive fetal monitoring in patients positive for anti-Sjögren's syndrome (SS)-A/Ro or anti- SS-B/La antibody.
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Affiliation(s)
- Doruk Erkan
- Department of Rheumatology, Hospital for Special Surgery, Weill Medical College of Cornell University, 535 East 70th Street, New York, NY 10021, USA.
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Akhavan A, Rudikoff D. The treatment of atopic dermatitis with systemic immunosuppressive agents. Clin Dermatol 2003; 21:225-40. [PMID: 12781440 DOI: 10.1016/s0738-081x(02)00362-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Arash Akhavan
- Department of Dermatology, Mount Sinai School of Medicine, New York, New York 10029, USA
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43
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Polifka JE, Friedman JM. Teratogen update: azathioprine and 6-mercaptopurine. TERATOLOGY 2002; 65:240-61. [PMID: 11967923 DOI: 10.1002/tera.10043] [Citation(s) in RCA: 131] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Janine E Polifka
- TERIS Project, University of Washington, Seattle 98195-7920, USA.
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44
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Affiliation(s)
- R G Strauss
- Department of Pathology, University of Iowa College of Medicine, Iowa City 52242-1182, USA.
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45
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Su CG, Stein RB, Lewis JD, Lichtenstein GR. Azathioprine or 6-mercaptopurine for inflammatory bowel disease: do risks outweigh benefits? Dig Liver Dis 2000; 32:518-31. [PMID: 11057928 DOI: 10.1016/s1590-8658(00)80010-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The treatment of Crohn's disease and ulcerative colitis has evolved and has improved the quality of life of patients afflicted with these disorders. Immune modulators such as azathioprine and 6-mercaptopurine are an important class of medications used for the treatment of patients with inflammatory bowel disease. Controlled studies have demonstrated their efficacy in both induction and maintenance of remission in Crohn's disease, and similarly, for the induction and maintenance of remission in patients with ulcerative colitis. These agents have had an increasing importance in the management of steroid-resistant, steroid-dependent diseases, and fistulizing Crohn's disease. The primary limitations to these agents have been their slow onset of action and their side effect profile. Despite these limitations, these agents have demonstrated efficacy and have become paramount to the management of patients with these incurable potentially disabling disorders. The precise role of azathioprine/6-mercaptopurine, their limitations and their safety are reviewed in this paper.
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Affiliation(s)
- C G Su
- Department of Medicine, Hospital of the University of Pennsylvania, University of Pennsylvania School of Medicine, Philadelphia 19104-4283, USA
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Abstract
The safety of drug therapy for inflammatory bowel disease during pregnancy is an important clinical concern. Current available information is largely derived from animal studies and clinical experience among patients with inflammatory bowel disease and autoimmune disorders and organ transplant recipients. However, these data are confounded by various factors including difficulty projecting the results of animal studies to humans, methodological deficiencies of some studies, insufficient experience with certain agents, difficulty distinguishing the fetal effects of underlying disease from drug therapy and a need to consider the impact of background rates of adverse fetal outcomes which apply to all pregnancies. In inflammatory bowel disease, the effects of active inflammation on the fetus are believed to be more harmful than those of drug treatment, and therapy is often justified to induce or maintain remission during pregnancy. The choice of appropriate treatment is determined by the severity of the disease and the potential for drug toxicity. No causal relationship has been established between exposure to sulfasalazine or other 5-aminosalicylic acid drugs and the development of congenital malformations. These drugs may be used with relative safety during pregnancy and lactation. Considerable experience with corticosteroids have shown them to pose very small risk to the developing fetus. Current evidence indicates that maternal use of azathioprine is not associated with an increased risk of congenital malformations, though impaired fetal immunity, growth retardation or prematurity is occasionally observed. Preliminary evidence derived from patients with inflammatory bowel disease show no significant fetal toxicity following first trimester exposure to mercaptopurine, though its elective use in pregnancy is controversial. Cyclosporin is not teratogenic, but may be associated with growth retardation and prematurity. Pregnancy should be avoided in women treated with methotrexate because of its known abortifacient effects and risk of causing typical malformations. Although treatment with metronidazole or ciprofloxacin for short durations appear to be devoid of adverse fetal reactions, the effect of prolonged exposure as required in Crohn's disease remains unknown.
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Affiliation(s)
- W Connell
- St Vincent's Hospital, Fitzroy, Victoria, Australia.
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47
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48
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Abstract
The effect of pregnancy on disease activity in systemic lupus erythematosus remains controversial. Studies on lupus flares in pregnancy are discussed, including prospective data on severity of flares and organ involvement from the Hopkins Lupus Pregnancy Center. The major fetal concerns of miscarriage (due to the antiphospholipid antibody syndrome), pre-term birth (largely due to pre-eclampsia or premature rupture of membranes) and neonatal lupus, are reviewed.
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Affiliation(s)
- M Petri
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
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49
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Abstract
Immunosuppressive therapy is a common practice in modern medicine. Typical uses of immunosuppressive drugs during pregnancy include the treatment of rheumatic diseases and transplant recipients. The purpose of this article is to assess and summarize current knowledge regarding the use of immunosuppressive drugs in pregnancy, focusing primarily on their effects on the mother and fetus.
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Affiliation(s)
- M S Esplin
- Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, USA
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50
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Affiliation(s)
- L H Brent
- Albert Einstein Medical Center, Philadelphia, Pennsylvania, Philadelphia, Pennsylvania, USA
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