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Andreoli L, Andersen J, Avcin T, Chambers CD, Fazzi EM, Marlow N, Wulffraat NM, Tincani A. The outcomes of children born to mothers with autoimmune rheumatic diseases. THE LANCET. RHEUMATOLOGY 2024; 6:e573-e586. [PMID: 38876127 DOI: 10.1016/s2665-9913(24)00096-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Revised: 04/03/2024] [Accepted: 04/10/2024] [Indexed: 06/16/2024]
Abstract
Maternal autoimmune rheumatic diseases can influence the outcomes of children through several life stages. During pregnancy, maternal inflammation and autoantibodies can hinder fetal development and lead to growth restriction, preterm birth, and low birth weight; prematurity, especially at extreme gestational ages, can in turn impair future child health. Treatment with compatible immunomodulatory drugs and preventive medications aims to keep maternal disease under control and minimise the risk of adverse pregnancy outcomes. However, concerns have been raised about the effects of immunomodulatory drugs on neonatal conditions (ie, the risk of serious infections, inadequate responses to vaccinations, and organ toxicity) and long-term outcomes (metabolic and cardiovascular problems and neurodevelopmental disorders). Among the unmet needs of parents with autoimmune rheumatic diseases, there is the estimation of risk for the children to develop autoimmune disorders and the need for reassurance about parenting capacity while living with a chronic condition. This Series paper provides a comprehensive overview of the literature and guidance on discussing these topics with patients.
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Affiliation(s)
- Laura Andreoli
- Rheumatology and Clinical Immunology Unit, ERN ReCONNET, ASST Spedali Civili, Brescia, Italy; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy; Danish Centre for Expertise in Rheumatology, Danish Hospital for Rheumatic Diseases, Sonderborg, Denmark; Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | | | - Tadej Avcin
- Department of Allergology, Rheumatology and Clinical Immunology, ERN RITA, ERN ReCONNET, University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia; Department of Pediatrics, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | | | - Elisa M Fazzi
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy; Child Neurology and Psychiatry Unit, ASST Spedali Civili, Brescia, Italy
| | - Neil Marlow
- UCL Elizabeth Garret Anderson Institute for Women's Health, University College London, London, UK
| | - Nico M Wulffraat
- Department of Pediatric Rheumatology and Immunology, ERN RITA, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Angela Tincani
- Rheumatology and Clinical Immunology Unit, ERN ReCONNET, ASST Spedali Civili, Brescia, Italy; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.
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2
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Giles I, Thorne I, Schmidt NS, Reid C, Crossley A, Panca M, Freemantle N, Tower C, Dass S, Sharma SK, Williams D, O'Neill S, Dolhain RJEM, Toplak N, Hodson K, Nelson-Piercy C, Clowse MEB. The time of equipoise on the use of biological DMARDs in for inflammatory arthritis during pregnancy is finally over: a reappraisal of evidence to optimise pregnancy management. THE LANCET. RHEUMATOLOGY 2024; 6:e546-e559. [PMID: 38876126 DOI: 10.1016/s2665-9913(24)00097-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 11/22/2023] [Accepted: 04/10/2024] [Indexed: 06/16/2024]
Abstract
Active inflammatory arthritis in pregnancy is associated with an increased risk of adverse pregnancy outcomes. Treatment of active inflammation and maintenance of low disease activity with medication reduces these risks. Therapeutic decisions on disease-modifying antirheumatic drugs (DMARDs) in pregnancy are complicated by safety concerns, which have led to inappropriate withdrawal of treatment and consequential harm to mother and fetus. Studies of inflammatory arthritis in pregnancy have consistently shown minimal safety concerns with the use of biological DMARDs and an increased risk of disease flare with discontinuation of biological DMARDs. It is our opinion that during pregnancy, the benefits of disease control with biological DMARDs, when required in addition to conventional synthetic DMARDs, outweigh the risks. In this Series paper, we review the reasons for reconsideration of equipoise and propose an agenda for future research to optimise the use of biological DMARDs in inflammatory arthritis during pregnancy.
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Affiliation(s)
- Ian Giles
- Centre for Rheumatology, Division of Medicine, University College London, London, UK.
| | - Iona Thorne
- Chelsea and Westminster Hospital NHS Trust, London, UK
| | - Nanna Surlemont Schmidt
- Danish Centre for Expertise in Rheumatology (CeViG), Danish Hospital for Rheumatic Diseases, Sønderborg, Denmark; Thrombosis and Haemostasis, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Claire Reid
- Department of Rheumatology, UCLH, London, UK
| | | | - Monica Panca
- Comprehensive Clinical Trials Unit, University College London, London, UK
| | - Nick Freemantle
- Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Clare Tower
- Obstetrics and Maternal and Fetal Medicine, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester, UK
| | - Shouvik Dass
- Department of Rheumatology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Shefali K Sharma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - David Williams
- UCL Elizabeth Garrett Anderson Institute for Women's Health, London, UK
| | - Sean O'Neill
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Department of Rheumatology, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Radboud J E M Dolhain
- Department of Rheumatology, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Nataša Toplak
- Department of Allergology, Rheumatology and Clinical Immunology, University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Kenneth Hodson
- Obstetrics and Maternal Medicine, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK; UK Teratology Information Service, Newcastle, UK
| | | | - Megan E B Clowse
- Division of Rheumatology and Immunology, Duke University School of Medicine, Durham, NC, USA
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3
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Mitrova K, Cerna K, Zdychyncova K, Pipek B, Svikova J, Minarikova P, Adamcova M, David J, Lukas M, Duricova D. Serological responses to vaccination in children exposed in utero to ustekinumab or vedolizumab: cross-sectional analysis of a prospective multicentre cohort. Eur J Pediatr 2024:10.1007/s00431-024-05683-4. [PMID: 39023645 DOI: 10.1007/s00431-024-05683-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 07/02/2024] [Accepted: 07/05/2024] [Indexed: 07/20/2024]
Abstract
Evidence on serological responses to vaccination in children exposed to ustekinumab (UST) or vedolizumab (VDZ) in utero is lacking. This multicentre prospective study aimed to assess the impact of prenatal exposure to UST or VDZ due to maternal inflammatory bowel disease (IBD) on serological responses to vaccination and other immunological parameters in exposed children. Children aged ≥ 1 year who were exposed in utero to UST or VDZ and completed at least 1-year of mandatory vaccination were included. We assessed the serological response to vaccination (non-live: tetanus, diphtheria, and Haemophilus influenzae B; live: mumps, rubella, and measles), whole blood count, and immunoglobulin levels. The control group comprised unexposed children born to mothers without IBD. A total of 23 children (median age, 25 months) exposed to UST (n = 13) or VDZ (n = 10) and 10 controls (median age, 37 months) were included. The serological response to vaccination was comparable between the UST and VDZ groups and controls, with an adequate serological response rate of ≥ 80%. Only children exposed to UST showed a slightly reduced serological response to mumps (67% vs. 86% in controls), whereas all children exposed to VDZ showed an adequate response. The majority of the exposed children had normal levels of individual immunoglobulin classes, similar to the controls. No severe pathology was observed in any of the children.Conclusion: Despite the limited sample size, our findings suggest that in utero exposure to VDZ or UST does not significantly impair the vaccine response or broader immunological parameters in exposed children.
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Affiliation(s)
- Katarina Mitrova
- IBD Clinical and Research Centre, ISCARE a.s., Prague, Czech Republic.
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, V Uvalu 84, 150 06, Prague, Czech Republic.
| | - Karin Cerna
- IBD Clinical and Research Centre, ISCARE a.s., Prague, Czech Republic
- GENNET s.r.o., Prague, Czech Republic
| | | | - Barbora Pipek
- Digestive Diseases Centre, Hospital AGEL Vitkovice, Ostrava, Czech Republic
- 2nd Department of Internal Medicine Gastroenterology and Geriatrics, Faculty of Medicine and Dentistry, Palacky University and University Hospital, Olomouc, Czech Republic
| | - Jana Svikova
- Department of Internal Medicine, Jihlava Hospital, Jihlava, Czech Republic
| | - Petra Minarikova
- Department of Medicine 1st Faculty of Medicine Charles University and Military Hospital, Military University Hospital Prague, Prague, Czech Republic
| | | | - Jan David
- Department of Children and Adolescents, Third Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Milan Lukas
- IBD Clinical and Research Centre, ISCARE a.s., Prague, Czech Republic
| | - Dana Duricova
- IBD Clinical and Research Centre, ISCARE a.s., Prague, Czech Republic
- Department of Pharmacology, 1st Faculty of Medicine, Charles University, Prague, Czech Republic
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Torres J, Mahadevan U. Ustekinumab and Vedolizumab Safety and Clearance in Pregnancy with Inflammatory Bowel Disease: Stop the Disease, not the Drug! Clin Gastroenterol Hepatol 2024:S1542-3565(24)00543-3. [PMID: 38878846 DOI: 10.1016/j.cgh.2024.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Accepted: 06/05/2024] [Indexed: 07/10/2024]
Affiliation(s)
- Joana Torres
- Division of Gastroenterology, Hospital da Luz, Lisbon, Portugal; Division of Gastroenterology, Hospital Beatriz Ângelo, Loures, Portugal; Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal.
| | - Uma Mahadevan
- Gastroenterology Division, Department of Medicine, University of California, San Francisco, San Francisco, California
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Wieringa JW, Kruizinga MD, Driessen GJA, van der Woude CJ, Julsgaard M. Validation of the Pharmacokinetic Model for Anti-TNFα Clearance in Infants Exposed to Anti-TNFα During Pregnancy. J Crohns Colitis 2024; 18:506-515. [PMID: 37823516 DOI: 10.1093/ecco-jcc/jjad172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND AND AIMS The ECCO guideline recommends postponing live attenuated vaccines in infants exposed to anti-tumour necrosis factor alpha [anti-TNFα] in utero until drug clearance. The aim was to validate the predictive performance of the anti-TNFα clearance model. METHODS Newborns and data for anti-TNFα concentrations from the prospective PETIT cohort were included. The anti-TNFα clearance model was used to predict all measured concentrations in the PETIT cohort, based on the measured cord blood concentration and the mean population clearance described in the model. Bayesian maximum a posteriori optimization was used to estimate the use of drug monitoring. Predictive capability and drug monitoring were assessed through mean absolute error [MAE], root mean squared prediction error, and limits of agreement according to Bland and Altman. RESULTS Observed drug concentrations after birth were within the 80% prediction interval in 94% of adalimumab samples and 93% of infliximab samples. The anti-TNFα clearance model accurately predicted the concentration at 6 months after birth with an MAE of 0.03 µg/mL [SD 0.03] for adalimumab and 0.11 µg/mL [SD 0.18] for infliximab based on cord blood concentrations. Addition of an additional sample between 1 and 4 months after birth improved the predictive accuracy for infliximab (MAE 0.05 [SD 0.09]) but not for adalimumab. Guidance for use in clinical practice was formulated. CONCLUSIONS The validity of the anti-TNFα clearance model is high, and hence can be used to guide clinicians regarding the timing of live vaccines in infants exposed to adalimumab or infliximab in utero.
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Affiliation(s)
- Jantien W Wieringa
- Department of Pediatrics, Haaglanden Medical Center, The Hague, The Netherlands
- Department of Pediatrics, Division of Paediatric Infectious Diseases and Immunology, Erasmus MC University Medical Center - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Matthijs D Kruizinga
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
- Juliana Children's Hospital, Haga Teaching Hospital, the Hague, The Netherlands
| | - Gertjan J A Driessen
- Department of Pediatrics, Maastricht University Medical Center, MosaKids Children's Hospital, Maastricht, The Netherlands
| | - C Janneke van der Woude
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Mette Julsgaard
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
- Center for Molecular Prediction of Inflammatory Bowel Disease [PREDICT], Department of Clinical Medicine, Aalborg University, Copenhagen, Denmark
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Nielsen OH, Gubatan JM, Kolho KL, Streett SE, Maxwell C. Updates on the management of inflammatory bowel disease from periconception to pregnancy and lactation. Lancet 2024; 403:1291-1303. [PMID: 38458222 DOI: 10.1016/s0140-6736(24)00052-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 12/29/2023] [Accepted: 01/09/2024] [Indexed: 03/10/2024]
Abstract
Inflammatory bowel disease (IBD) affects reproductive planning due to psychological effects and mechanical problems related to surgery. Children of people with IBD have an increased risk of about 10% if one parent has IBD and up to 33% if both parents have IBD. The fertility of people with IBD is similar to the general population, but fertility might be reduced in individuals with active IBD, ileal pouch-anal anastomosis, or perianal Crohn's disease. Flaring disease during pregnancy increases complications, such as preterm birth. Thus, disease management with appropriate medications can optimise outcomes. As most medications have minimal fetal risks, people with IBD should be informed about the risks of stopping medications and the importance of maintaining remission. A period of disease remission is advisable before pregnancy and could reduce the risks for both the pregnant person and the fetus. Flexible endoscopy, intestinal ultrasound, and gadolinium-free magnetic resonance enterography are safe during pregnancy. We provide state-of-the-art knowledge on the basis of the latest evidence to ensure successful pregnancy outcomes in controlled IBD.
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Affiliation(s)
- Ole Haagen Nielsen
- Department of Gastroenterology, Medical Section, Herlev Hospital, Copenhagen, Denmark; Faculty of Health and Medical Sciences, Department of Clinical Medicine, University of Copenhagen, Denmark.
| | - John Mark Gubatan
- Division of Gastroenterology and Hepatology, Department of Medicine, School of Medicine, Stanford University, Palo Alto, CA, USA
| | - Kaija-Leena Kolho
- Department of Pediatrics, Children's Hospital, University of Helsinki, Helsinki, Finland
| | - Sarah Elizabeth Streett
- Division of Gastroenterology and Hepatology, Department of Medicine, School of Medicine, Stanford University, Palo Alto, CA, USA
| | - Cynthia Maxwell
- Department of Obstetrics and Gynaecology, Women's College Hospital, Sinai Health, University of Toronto, ON, Canada
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7
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Prentice R, Flanagan E, Wright EK, Gibson PR, Rosella S, Rosella O, Begun J, An YK, Lawrance IC, Kamm MA, Sparrow M, Goldberg R, Prideaux L, Vogrin S, Kiburg KV, Ross AL, Burns M, Bell SJ. Vedolizumab and Ustekinumab Levels in Pregnant Women With Inflammatory Bowel Disease and Infants Exposed In Utero. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00252-0. [PMID: 38492905 DOI: 10.1016/j.cgh.2024.02.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 02/21/2024] [Accepted: 02/23/2024] [Indexed: 03/18/2024]
Abstract
BACKGROUND & AIMS Vedolizumab and ustekinumab pharmacokinetics in pregnancy and the infant after in utero exposure remain incompletely defined. We aim to define the antenatal stability of ustekinumab and vedolizumab levels and the time at which infant drug levels become undetectable. METHODS This multicenter prospective observational cohort study recruited pregnant or preconception women with inflammatory bowel disease receiving vedolizumab or ustekinumab. Trough drug levels, clinical data, and biochemical data were documented preconception, during each trimester of pregnancy, and postpartum. Maternal and cord blood drug levels were measured at delivery and in infants until undetectable. Infant outcomes were assessed until 2 years of age. RESULTS A total of 102 participants (vedolizumab, n = 58) were included. The majority of mothers were, and remained, in clinical and biochemical remission. Maternal vedolizumab levels decreased over the course of pregnancy in association with increasing weight, rather than increasing gestation. Maternal ustekinumab levels remained stable. The median time to drug becoming undetectable in the infant was shorter for vedolizumab (11 wk; range, 5-19 wk; n = 32) than ustekinumab (14 wk; range, 9-36 wk; n = 17) and correlated positively with infant delivery level. Thirty-two of 41 (88%) and 17 of 30 (67%) vedolizumab- and ustekinumab-exposed infants had undetectable drug levels by 15 weeks of age, respectively. Pregnancy and infant outcomes were favorable. Twenty infants with undetectable drug levels received the rotavirus vaccine, with no adverse reactions reported. CONCLUSIONS Maternal vedolizumab levels decreased, whereas ustekinumab levels remained stable over the course of pregnancy. Most vedolizumab- and approximately half of ustekinumab-exposed infants had undetectable drug levels by 15 weeks of age. No concerning maternal or infant safety signals were identified.
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Affiliation(s)
- Ralley Prentice
- Department of Gastroenterology, Monash Health, Clayton, Victoria, Australia; Department of Gastroenterology, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia; Centre of Inflammatory Disease, Department of Medicine, Monash University, Clayton, Victoria, Australia.
| | - Emma Flanagan
- Department of Gastroenterology, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia; University of Melbourne, Parkville, Victoria, Australia
| | - Emily K Wright
- Department of Gastroenterology, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia; University of Melbourne, Parkville, Victoria, Australia
| | - Peter R Gibson
- Department of Gastroenterology, Central Clinical School, Monash University and Alfred Health, Melbourne, Victoria, Australia
| | - Sam Rosella
- Department of Gastroenterology, Central Clinical School, Monash University and Alfred Health, Melbourne, Victoria, Australia
| | - Ourania Rosella
- Department of Gastroenterology, Central Clinical School, Monash University and Alfred Health, Melbourne, Victoria, Australia
| | - Jakob Begun
- Department of Gastroenterology, Mater Hospital, Brisbane, Queensland, Australia
| | - Yoon-Kyo An
- Department of Gastroenterology, Mater Hospital, Brisbane, Queensland, Australia
| | - Ian C Lawrance
- School of Medicine and Pharmacology, Faculty of Medicine and Dentistry at the University of Western Australia, Perth, Western Australia, Australia; St John of God Subiaco Hospital, Perth, Western Australia, Australia
| | - Michael A Kamm
- Department of Gastroenterology, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia; University of Melbourne, Parkville, Victoria, Australia
| | - Miles Sparrow
- Department of Gastroenterology, Central Clinical School, Monash University and Alfred Health, Melbourne, Victoria, Australia
| | - Rimma Goldberg
- Department of Gastroenterology, Monash Health, Clayton, Victoria, Australia; Centre of Inflammatory Disease, Department of Medicine, Monash University, Clayton, Victoria, Australia
| | - Lani Prideaux
- Department of Gastroenterology, Monash Health, Clayton, Victoria, Australia
| | - Sara Vogrin
- University of Melbourne, Parkville, Victoria, Australia
| | | | - Alyson L Ross
- Department of Gastroenterology, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
| | - Megan Burns
- Department of Gastroenterology, Monash Health, Clayton, Victoria, Australia
| | - Sally J Bell
- Department of Gastroenterology, Monash Health, Clayton, Victoria, Australia; Centre of Inflammatory Disease, Department of Medicine, Monash University, Clayton, Victoria, Australia; University of Melbourne, Parkville, Victoria, Australia
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Julsgaard M, Wieringa JW, Baunwall SMD, Bibby BM, Driessen GJA, Kievit L, Brodersen JB, Poulsen A, Kjeldsen J, Hansen MM, Tang HQ, Balmer CL, Glerup H, Seidelin JB, Haderslev KV, Svenningsen L, Wildt S, Juel MA, Neumann A, Fuglsang J, Jess T, Haase AM, Hvas CL, Kelsen J, Janneke van der Woude C. Infant Ustekinumab Clearance, Risk of Infection, and Development After Exposure During Pregnancy. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00083-1. [PMID: 38278191 DOI: 10.1016/j.cgh.2024.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 01/11/2024] [Accepted: 01/12/2024] [Indexed: 01/28/2024]
Abstract
BACKGROUND Evidence on ustekinumab safety in pregnancy is gradually expanding, but its clearance in the postnatal period is unknown. The aim of this study was to investigate ustekinumab concentrations in umbilical cord blood and rates of clearance after birth, as well as how these correlate with maternal drug concentrations, risk of infection, and developmental milestones during the first year of life. METHODS Pregnant women with inflammatory bowel disease were prospectively recruited from 19 hospitals in Denmark and the Netherlands between 2018 and 2022. Infant infections leading to hospitalization/antibiotics and developmental milestones were assessed. Serum ustekinumab concentrations were measured at delivery and specific time points. Nonlinear regression analysis was applied to estimate clearance. RESULTS In 78 live-born infants from 76 pregnancies, we observed a low risk of adverse pregnancy outcomes and normal developmental milestones. At birth, the median infant-mother ustekinumab ratio was 2.18 (95% confidence interval, 1.69-2.81). Mean time to infant clearance was 6.7 months (95% confidence interval, 6.1-7.3 months). One in 4 infants at 6 months had an extremely low median concentration of 0.015 μg/mL (range 0.005-0.12 μg/mL). No variation in median ustekinumab concentration was noted between infants with (2.8 [range 0.4-6.9] μg/mL) and without (3.1 [range 0.7-11.0] μg/mL) infections during the first year of life (P = .41). CONCLUSIONS No adverse signals after intrauterine exposure to ustekinumab were observed with respect to pregnancy outcome, infections, or developmental milestones during the first year of life. Infant ustekinumab concentration was not associated with risk of infections. With the ustekinumab clearance profile, live attenuated vaccination from 6 months of age seems of low risk.
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Affiliation(s)
- Mette Julsgaard
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark; Center for Molecular Prediction of Inflammatory Bowel Disease, Department of Clinical Medicine, Aalborg University, Copenhagen, Denmark.
| | - Jantien W Wieringa
- Department of Pediatrics, Haaglanden Medical Center, The Hague, the Netherlands; Division of Paediatric Infectious Diseases and Immunology, Department of Pediatrics, Sophia Children's Hospital, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Simon M D Baunwall
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Bo M Bibby
- Department of Biostatistics, University of Aarhus, Aarhus, Denmark
| | - Gertjan J A Driessen
- Department of Pediatrics, MosaKids Children's Hospital, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Linda Kievit
- Department of Medicine, Gjødstrup Hospital, Gjødstrup, Denmark
| | - Jacob B Brodersen
- Department of Gastroenterology, Esbjerg Hospital, University Hospital of Southern Denmark, Esbjerg, Denmark; Department of Regional Health Science, University of Southern Denmark, Esbjerg, Denmark
| | - Anja Poulsen
- Digestive Disease Center, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Jens Kjeldsen
- Department of Medical Gastrointestinal Diseases, Odense University Hospital, Odense, Denmark
| | - Mette M Hansen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Hai Q Tang
- Department of Obstetrics and Gynaecology, Aarhus University Hospital, Denmark
| | - Christina L Balmer
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Henning Glerup
- Diagnostic Centre, University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Silkeborg, Denmark
| | - Jakob B Seidelin
- Department of Gastroenterology and Hepatology, Herlev Hospital, University of Copenhagen, Herlev, Denmark
| | - Kent V Haderslev
- Department of Gastroenterology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Lise Svenningsen
- Department of Internal Medicine, Horsens Regional Hospital, Horsens, Denmark
| | - Signe Wildt
- Unit of Medical and Surgical Gastroenterology, Hvidovre University Hospital, Hvidovre, Denmark
| | - Mie A Juel
- Department of Gastroenterology, Esbjerg Hospital, University Hospital of Southern Denmark, Esbjerg, Denmark; Department of Internal Medicine, Vejle Hospital, Vejle, Denmark
| | - Anders Neumann
- Department of Internal Medicine, Viborg Regional Hospital, Viborg, Denmark
| | - Jens Fuglsang
- Department of Obstetrics and Gynaecology, Aarhus University Hospital, Denmark
| | - Tine Jess
- Center for Molecular Prediction of Inflammatory Bowel Disease, Department of Clinical Medicine, Aalborg University, Copenhagen, Denmark; Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Anne-Mette Haase
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Christian L Hvas
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark; Institute of Clinical Medicine, Health, Aarhus University, Aarhus, Denmark
| | - Jens Kelsen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark; Institute of Clinical Medicine, Health, Aarhus University, Aarhus, Denmark
| | - C Janneke van der Woude
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
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Ernest-Suarez K, Murguía-Favela LE, Novak KL, Panaccione R, Constantinescu C, Seow CH. Normal Infant Immunologic Assessment and Uneventful Live Rotavirus Vaccination Despite Continuous Tofacitinib Exposure In Utero and During Breastfeeding. CROHN'S & COLITIS 360 2024; 6:otae006. [PMID: 38317692 PMCID: PMC10841763 DOI: 10.1093/crocol/otae006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Indexed: 02/07/2024] Open
Abstract
Background Janus kinase (JAK) inhibitors are effective for the treatment of inflammatory bowel disease (IBD). However, this class of medications is not recommended during pregnancy or breastfeeding based on animal data suggesting teratogenesis and recent reports of transmammary transfer after maternal ingestion, raising concerns for immune system development in babies exposed to these drugs. Methods We present the case of a patient with IBD treated with a JAK inhibitor who decided to continue the medication throughout her pregnancy and during breastfeeding. This is the first reported case of a detailed immunologic profile in a baby exposed to tofacitinib in utero and during lactation. Results A 30-year-old female with ulcerative colitis with previous exposure to vedolizumab and infliximab achieved complete remission with tofacitinib therapy. The patient became pregnant after 5 months of JAK inhibitor therapy and decided to continue tofacitinib during pregnancy and while breastfeeding. The patient delivered a healthy offspring with no congenital malformations, a normal detailed immunologic profile, and subsequent safe provision of the live oral rotavirus vaccine. Conclusions This case highlights the importance of individualized counseling for patients of childbearing age who are candidates for JAK inhibition. Those who are pregnant or breastfeeding with refractory disease may have limited medical therapeutic options. Ongoing effective therapy for IBD resulted in complete disease remission in the mother and favorable outcomes in the infant. Further, an in-depth infant immunological assessment can lead to specific vaccination recommendations in exposed infants.
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Affiliation(s)
- Kenneth Ernest-Suarez
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Luis E Murguía-Favela
- Section of Hematology/Immunology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Kerri L Novak
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Remo Panaccione
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Cora Constantinescu
- Section of Infectious Diseases, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Cynthia H Seow
- Division of Gastroenterology and Hepatology, Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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