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Bozzi LM, Jacobson MH, Yost E, Sheahan A, Cafone J, Komatsu Y, Schwartz L, Levitan B, Nelson RM. A Benefit-Risk Conceptual Framework for Biologic Use During Pregnancy: A Mini-Review. Clin Pharmacol Ther 2024; 115:1251-1257. [PMID: 38506485 DOI: 10.1002/cpt.3239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 02/19/2024] [Indexed: 03/21/2024]
Abstract
Recent reports related to in utero exposure of marketed immunosuppressive biologics led to clinical recommendations to delay live vaccinations for infants due to the concern of reduced vaccine effectiveness and/or increased risk of vaccine-related disease. These delays can increase the risk of children contracting vaccine preventable diseases, yet the alternative cessation of biologics during pregnancy may result in increased autoimmune disease activity for the pregnant person, raising complex benefit-risk (B-R) considerations and trade-offs. Our goal is to develop a conceptual framework for B-R assessment based on the key benefits and risks pregnant people would consider for themselves and their children when continuing (vs. discontinuing) a biologic during pregnancy. The proposed framework defines the decision contexts, key domains and attributes for potential benefits, and risks of biologic use during pregnancy, informed by a literature review of indications for biologics and refined with key clinical stakeholders. The framework includes both the pregnant person taking the biologic and the infant potentially exposed to the biologic in utero, with potential benefit and risk domains and attributes for each participant. To advance this conceptual framework, there are considerations of potential biases and uncertainty of available data that will be imperative to address when quantifying the B-R framework. For these reasons, we recommend the formation of a consortium to ensure development of a robust, validated framework that can be adopted in the healthcare setting.
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Affiliation(s)
- Laura M Bozzi
- Janssen Research & Development, Raritan, New Jersey, USA
| | | | - Emily Yost
- Janssen Research & Development, Horsham, Pennsylvania, USA
| | - Anna Sheahan
- Janssen Research & Development, Horsham, Pennsylvania, USA
| | - Joseph Cafone
- Janssen Research & Development, Spring House, Pennsylvania, USA
| | - Yosuke Komatsu
- Janssen Research & Development, Spring House, Pennsylvania, USA
| | - Lisa Schwartz
- Janssen Research & Development, Raritan, New Jersey, USA
| | | | - Robert M Nelson
- Janssen Research & Development, Spring House, Pennsylvania, USA
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2
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Huang W, Zhang X, Zhang L, Dai X, Chen H, Xie Q. Anti-tumor necrosis factor-α therapy may not be safe during pregnancy in women with inflammatory bowel disease: an updated meta-analysis and systematic review. BMC Pregnancy Childbirth 2024; 24:251. [PMID: 38589784 PMCID: PMC11000337 DOI: 10.1186/s12884-024-06443-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 03/25/2024] [Indexed: 04/10/2024] Open
Abstract
BACKGROUND Inflammatory Bowel Disease (IBD) affects reproductive-aged women. Active disease can lead to decreased fertility. Although the vast majority of international guidelines recommend for the continuation of anti-TNF-α during pregnancy, recent studies have raised concerns about the safety of anti-tumor necrosis factor-α (TNF-α) therapy during pregnancy, both for patients and for physicians. METHODS Studies that evaluate the safety of anti-TNF-α therapy in pregnant women with IBD were identified using bibliographical searches. An updated meta-analysis was performed for pregnancy outcomes, such as live birth, abortion, still birth, preterm birth, low birth weight, congenital abnormalities, and neonatal infection. Odds ratio (OR) with 95% confidence interval (CI) are reported. Data on disease activity, timing of anti-TNF-α therapy were collected for further analysis. RESULTS Overall, 11 studies were screened from on-line databases and international meeting abstracts. An increased risk of abortion (OR, 1.33; 95% CI, 1.02-1.74; P = 0.04) and preterm birth (OR, 1.16; 95% CI, 1.05-1.28; P = 0.004), and a decreased risk of live birth (OR, 0.83; 95% CI, 0.74-0.94; P = 0.002]) were found in the anti-TNF-α therapy group compared with the control group (no use of anti-TNF-α therapy). The subgroup analyses based on the disease activity showed there is no significant association between the use of anti-TNF-α therapy during pregnancy on adverse pregnancy outcomes of abortion, preterm birth, and live birth. The rates of still birth, low birth weight, and congenital abnormalities in the anti-TNF-α therapy group were not significantly different from those in the control group. CONCLUSIONS Anti-TNF-α therapy does not increase the risks of still birth, low birth weight, and congenital abnormalities; however it may be assicated with increased risks of abortion and preterm birth, which are accompanied by a lower rate of live birth. Although these findings may be confounding by potential disease activity, they offer some opposite viewpoints with biologic agent use. Therefore, more studies are required to further confirm the safety of anti-TNF-α therapy in pregnancy with IBD.
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Affiliation(s)
- Wei Huang
- Department of Geriatric Medicine and Gastroenterology, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Xinxing Zhang
- Department of Geriatric Medicine and Gastroenterology, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Li Zhang
- Department of Geriatric Medicine and Gastroenterology, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Xiaosong Dai
- Department of Geriatric Medicine and Gastroenterology, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Heping Chen
- Department of Geriatric Medicine and Gastroenterology, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Qin Xie
- Department of Geriatric Medicine and Gastroenterology, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China.
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3
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Otero-Piñerio AM, Aykun N, Maspero M, Holubar S, Hull T, Lipman J, Steele SR, Lightner AL. The mode of delivery does not influence the occurrence of post-partum perianal disease flares in patients with inflammatory bowel disease. BMC Gastroenterol 2024; 24:34. [PMID: 38229023 DOI: 10.1186/s12876-023-03018-5] [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: 06/18/2023] [Accepted: 10/28/2023] [Indexed: 01/18/2024] Open
Abstract
INTRODUCTION Perianal disease occurs in up to 34% of inflammatory bowel disease (IBD) patients. An estimated 25% of women will become pregnant after the initial diagnosis, thus introducing the dilemma of whether mode of delivery affects perianal disease. The aim of our study was to analyze whether a cesarean section (C-section) or vaginal delivery influence perianal involvement. We hypothesized the delivery route would not alter post-partum perianal manifestations in the setting of previously healed perianal disease. METHODS All consecutive eligible IBD female patients between 1997 and 2022 who delivered were included. Prior perianal involvement, perianal flare after delivery and delivery method were noted. RESULTS We identified 190 patients with IBD who had a total of 322 deliveries; 169 (52%) were vaginal and 153 (48%) were by C-section. Nineteen women (10%) experienced 21/322 (6%) post-partum perianal flares. Independent predictors were previous abdominal surgery for IBD (OR, 2.7; 95% CI, 1-7.2; p = 0.042), ileocolonic involvement (OR, 3.3; 95% CI, 1.1-9.4; p = 0.030), previous perianal disease (OR, 22; 95% CI, 7-69; p < 0.001), active perianal disease (OR, 96; 95% CI, 21-446; p < 0.001) and biologic (OR, 4.4; 95% CI,1.4-13.6; p < 0.011) or antibiotic (OR, 19.6; 95% CI, 7-54; p < 0.001) treatment. Negative association was found for vaginal delivery (OR, 0.19; 95% CI, 0.06-0.61; p < 0.005). Number of post-partum flares was higher in the C-section group [17 (11%) vs. 4 (2%), p = 0.002]. CONCLUSIONS Delivery by C-section section was not protective of ongoing perianal disease activity post-delivery, but should be recommended for women with active perianal involvement.
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Affiliation(s)
- Ana M Otero-Piñerio
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - N Aykun
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - M Maspero
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Stefan Holubar
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Tracy Hull
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Jeremy Lipman
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Scott R Steele
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Amy L Lightner
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA.
- National Center for Regenerative Medicine, Cleveland, OH, USA.
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4
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Lakhmiri R, Cherrah Y, Serragui S. Tumor Necrosis Alpha (TNF-α) Antagonists Used in Chronic Inflammatory Rheumatic Diseases: Risks and their Minimization Measures. Curr Drug Saf 2024; 19:431-443. [PMID: 38204274 DOI: 10.2174/0115748863274863231222023853] [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: 08/26/2023] [Revised: 10/27/2023] [Accepted: 10/31/2023] [Indexed: 01/12/2024]
Abstract
Tumor necrosis factor alpha (TNF- α) inhibitors are widely employed for the management of chronic inflammatory rheumatism. However, their usage carries significant risks, including site and infusion reactions, serious infections, malignancy, heart failure autoimmune and demyelinating disorders. These risks are comprehensively outlined in risk management plans (RMPs) associated with these molecules. RMP provides information on the safety profile of a medicinal product as well as the measures that will be taken to minimize risks; these are known as risk minimization measures. These measures are divided into routine measures related to elements, such as the summary of product characteristics, labeling, pack size, package leaflet, or legal supply status of the product, while additional measures may include educational programs, including tools for healthcare providers and patients, controlled access or pregnancy prevention programs, among others. Additional measures can consist of one or more interventions that need to be implemented in a sustainable way in a defined target group, while respecting the timing and frequency of any intervention and procedures to reach the target population. An evaluation of the effectiveness of these measures is required to determine whether or not an intervention has been effective. This comprehensive review offers an in-depth exploration of the current treatment, uses, and associated risks of TNF-α inhibitors. Additionally, it provides a detailed account of risk minimization measures and risk management practices while shedding light on their real-world implementation and effectiveness.
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Affiliation(s)
- Rim Lakhmiri
- Pharmaco-Epidemiology and Pharmaco-Economics Research Team - Laboratory of Pharmacology and Toxicology - Faculty of Medicine and Pharmacy -Mohammed V University of Rabat, Morocco
| | - Yahia Cherrah
- Pharmaco-Epidemiology and Pharmaco-Economics Research Team - Laboratory of Pharmacology and Toxicology - Faculty of Medicine and Pharmacy -Mohammed V University of Rabat, Morocco
| | - Samira Serragui
- Pharmaco-Epidemiology and Pharmaco-Economics Research Team - Laboratory of Pharmacology and Toxicology - Faculty of Medicine and Pharmacy -Mohammed V University of Rabat, Morocco
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5
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Caballero-Mateos AM, Quesada-Caballero M, Cañadas-De la Fuente GA, Caballero-Vázquez A, Contreras-Chova F. IBD and Motherhood: A Journey through Conception, Pregnancy and Beyond. J Clin Med 2023; 12:6192. [PMID: 37834837 PMCID: PMC10573266 DOI: 10.3390/jcm12196192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 09/14/2023] [Accepted: 09/19/2023] [Indexed: 10/15/2023] Open
Abstract
Inflammatory Bowel Disease (IBD) presents distinct challenges during pregnancy due to its influence on maternal health and pregnancy outcomes. This literature review aims to dissect the existing scientific evidence on pregnancy in women with IBD and provide evidence-based recommendations for clinical management. A comprehensive search was conducted across scientific databases, selecting clinical studies, systematic reviews, and other pertinent resources. Numerous studies have underscored an increased risk of complications during pregnancy for women with IBD, including preterm birth, low birth weight, neonates small for gestational age, and congenital malformations. Nevertheless, it's evident that proactive disease management before and throughout pregnancy can mitigate these risks. Continuation of IBD treatment during pregnancy and breastfeeding is deemed safe with agents like thiopurines, anti-TNF, vedolizumab, or ustekinumab. However, there's a call for caution when combining treatments due to the heightened risk of severe infections in the first year of life. For small molecules, their use is advised against in both scenarios. Effective disease management, minimizing disease activity, and interdisciplinary care are pivotal in attending to women with IBD. The emphasis is placed on the continual assessment of maternal and infant outcomes and an expressed need for further research to enhance the understanding of the ties between IBD and adverse pregnancy outcomes.
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6
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Gubatan J, Barber GE, Nielsen OH, Juhl CB, Maxwell C, Eisenberg ML, Streett SE. Paternal Medications in Inflammatory Bowel Disease and Male Fertility and Reproductive Outcomes: A Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol 2023; 21:2222-2238. [PMID: 35870769 DOI: 10.1016/j.cgh.2022.07.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 07/04/2022] [Accepted: 07/07/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Studies evaluating reproductive outcomes among male patients with inflammatory bowel disease (IBD) are limited. We evaluated use of IBD medications and association with semen parameters, a proxy of male fertility, and adverse pregnancy outcomes (early pregnancy loss [EPL], preterm birth [PB], congenital malformations [CM]). METHODS We searched Medline, Embase, Scopus, and Web of Science (PROSPERO CRD42020197098) from inception to April 2022 for studies reporting semen parameters and adverse pregnancy outcomes among male patients exposed to biologics, thiopurine, or methotrexate. Standardized mean difference, prevalence, and odds ratios (ORs) of outcomes were pooled and analyzed using a random effects model. RESULTS Ten studies reporting semen parameters (268 patients with IBD) and 16 studies reporting adverse pregnancy outcomes (over 25,000 patients with IBD) were included. Biologic, thiopurine, or methotrexate use were not associated with decreased sperm count, motility, or abnormal morphology compared with nonexposed patients. The prevalence of adverse pregnancy outcomes with paternal biologic (5%), thiopurine (6%), or methotrexate (6%) exposure was comparable to nonexposed patients (5%). Biologic use was not associated with risk of EPL (OR, 1.26; I2 = 0%; P = .12), PB (OR, 1.10; I2 = 0%; P = .17), or CM (OR, 1.03; I2 = 0%; P = .69). Thiopurine use was not associated with risk of EPL (OR, 1.31; I2 = 19%; P = .17), PB (OR, 1.05; I2 = 0%; P = .20), or CM (OR, 1.07; I2 = 7%; P = .34). Methotrexate use was not associated with risk of PB (OR, 1.06; I2 = 0%; P = .62) or CM (OR, 1.03; I2 = 0%; P = .81). CONCLUSIONS Biologic, thiopurine, or methotrexate use among male patients with IBD are not associated with impairments in fertility or with increased odds of adverse pregnancy outcomes.
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Affiliation(s)
- John Gubatan
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California.
| | - Grant E Barber
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California
| | - Ole Haagen Nielsen
- Department of Gastroenterology, Medical Section, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Carsten Bogh Juhl
- Department of Sports Science and Biomechanics, University of Southern Denmark, Odense, Denmark; Department of Physiotherapy and Occupational Therapy, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Cynthia Maxwell
- Department of Obstetrics & Gynaecology, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Michael L Eisenberg
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California; Department of Urology, Stanford University School of Medicine, Stanford, California
| | - Sarah E Streett
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California
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7
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Brondfield MN, Mahadevan U. Inflammatory bowel disease in pregnancy and breastfeeding. Nat Rev Gastroenterol Hepatol 2023:10.1038/s41575-023-00758-3. [PMID: 37002407 DOI: 10.1038/s41575-023-00758-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/20/2023] [Indexed: 06/19/2023]
Abstract
Inflammatory bowel disease (IBD) has a peak age of diagnosis before the age of 35 years. Concerns about infertility, adverse pregnancy outcomes, and heritability of IBD have influenced decision-making for patients of childbearing age and their care providers. The interplay between the complex physiology in pregnancy and IBD can affect placental development, microbiome composition and responses to therapy. Current evidence has shown that effective disease management, including pre-conception counselling, multidisciplinary care and therapeutic agents to minimize disease activity, can improve pregnancy outcomes. This Review outlines the management of IBD in pregnancy and the safety of IBD therapies, including novel agents, with regard to both maternal and fetal health. The vast majority of IBD therapies can be used with low risk during pregnancy and lactation without substantial effects on neonatal outcomes.
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Affiliation(s)
- Max N Brondfield
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Uma Mahadevan
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA.
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8
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Laube R, Selinger CP, Seow CH, Christensen B, Flanagan E, Kennedy D, Mountifield R, Seeho S, Shand A, Williams AJ, Leong RW. Australian inflammatory bowel disease consensus statements for preconception, pregnancy and breast feeding. Gut 2023; 72:1040-1053. [PMID: 36944479 DOI: 10.1136/gutjnl-2022-329304] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 02/21/2023] [Indexed: 03/23/2023]
Abstract
OBJECTIVE Because pregnancy outcomes tend to be worse in women with inflammatory bowel disease (IBD) than in those without, we aimed to update consensus statements that guide the clinical management of pregnancy in patients with IBD. DESIGN A multidisciplinary working group was established to formulate these consensus statements. A modified RAND/UCLA appropriateness method was used, consisting of a literature review, online voting, discussion meeting and a second round of voting. The overall agreement among the delegates and appropriateness of the statement are reported. RESULTS Agreement was reached for 38/39 statements which provide guidance on management of pregnancy in patients with IBD. Most medications can and should be continued throughout pregnancy, except for methotrexate, allopurinol and new small molecules, such as tofacitinib. Due to limited data, no conclusion was reached on the use of tioguanine during pregnancy. Achieving and maintaining IBD remission before conception and throughout pregnancy is crucial to optimise maternofetal outcomes. This requires a multidisciplinary approach to engage patients, allay anxieties and maximise adherence tomedication. Intestinal ultrasound can be used for disease monitoring during pregnancy, and flexible sigmoidoscopy or MRI where clinically necessary. CONCLUSION These consensus statements provide up-to-date, comprehensive recommendations for the management of pregnancy in patients with IBD. This will enable a high standard of care for patients with IBD across all clinical settings.
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Affiliation(s)
- Robyn Laube
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
- Department of Gastroenterology, Macquarie University Hospital, Sydney, New South Wales, Australia
| | | | - Cynthia H Seow
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Britt Christensen
- Gastroenterology Department, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Emma Flanagan
- Department of Gastroenterology, University of Melbourne, Melbourne, Victoria, Australia
| | - Debra Kennedy
- MotherSafe, Royal Hospital for Women, Sydney, New South Wales, Australia
| | - Reme Mountifield
- Department of Gastroenterology, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Sean Seeho
- Department of Obstetrics and Gynaecology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Antonia Shand
- Department of Maternal Foetal Medicine, Royal Hospital for Women, Sydney, New South Wales, Australia
| | - Astrid-Jane Williams
- Department of Gastroenterology, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Rupert W Leong
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
- Department of Gastroenterology, Macquarie University Hospital, Sydney, New South Wales, Australia
- Gastroenterology and Liver Services, Concord Repatriation General Hospital, Concord, New South Wales, Australia
- The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia
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9
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Pregnancy in Patients with Inflammatory Bowel Diseases-A Literature Review. Life (Basel) 2023; 13:life13020475. [PMID: 36836832 PMCID: PMC9961380 DOI: 10.3390/life13020475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 02/03/2023] [Accepted: 02/04/2023] [Indexed: 02/11/2023] Open
Abstract
In recent years, we have faced an increasing incidence of inflammatory bowel disease (IBD), especially among young people, affecting them during their reproductive years. The paucity of data and reduced knowledge regarding the evolution of the disease during pregnancy and the adverse effects of the therapy on the mother and infant increase voluntary childlessness in this group of patients. Depending on the type of IBD, severity and surgical or medical management, this can negatively affect the pregnancy. C-sections and the risk of low-birth-weight babies are higher in women with IBD, independent of active/inactive disease, while preterm birth, stillbirth and miscarriage are associated with disease activity. In the last period, medicinal therapy has evolved, and new molecules have been developed for better control of the lesions, but the effect on pregnancy and breastfeeding is still controversial. We conducted this review by studying the literature and recent research in order to have a better image of the practical management of IBD during pregnancy.
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10
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Torres J, Chaparro M, Julsgaard M, Katsanos K, Zelinkova Z, Agrawal M, Ardizzone S, Campmans-Kuijpers M, Dragoni G, Ferrante M, Fiorino G, Flanagan E, Gomes CF, Hart A, Hedin CR, Juillerat P, Mulders A, Myrelid P, O'Toole A, Rivière P, Scharl M, Selinger CP, Sonnenberg E, Toruner M, Wieringa J, Van der Woude CJ. European Crohn's and Colitis Guidelines on Sexuality, Fertility, Pregnancy, and Lactation. J Crohns Colitis 2023; 17:1-27. [PMID: 36005814 DOI: 10.1093/ecco-jcc/jjac115] [Citation(s) in RCA: 77] [Impact Index Per Article: 77.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Indexed: 02/02/2023]
Affiliation(s)
- Joana Torres
- Division of Gastroenterology, Hospital Beatriz Ângelo, Loures, Portugal.,Division of Gastroenterology, Hospital da Luz, Lisboa, Portugal.,Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - María Chaparro
- Department of Gastroenterology, Hospital Universitario de La Princesa, IIS-Princesa, UAM, CIBEREHD, Madrid, Spain
| | - Mette Julsgaard
- Department of Hepatology & Gastroenterology, Aarhus University Hospital, Aarhus, Denmark.,Center for Molecular Prediction of Inflammatory Bowel Disease [PREDICT], Department of Clinical Medicine, Aalborg University, Copenhagen, Denmark
| | - Konstantinos Katsanos
- Department of Gastroenterology and Hepatology, University and Medical School of Ioannina, Ioannina, Greece
| | - Zuzana Zelinkova
- Department of Internal Medicine, Svet zdravia, Nemocnica Dunajska Streda, Slovakia.,Firstst Department of Internal Medicine of University Hospital and Slovak Medical University in Bratislava, Bratislava, Slovakia
| | - Manasi Agrawal
- Dr Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Center for Molecular Prediction of Inflammatory Bowel Disease [PREDICT], Department of Clinical Medicine, Aalborg University, Copenhagen, Denmark
| | - Sandro Ardizzone
- Gastrointestinal Unit, Department of Biomedical and Clinical Sciences. University of Milan, Milan, Italy
| | - Marjo Campmans-Kuijpers
- Department of Gastroenterology and Hepatology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Gabriele Dragoni
- Gastroenterology Research Unit, Department of Experimental and Clinical Biomedical Sciences 'Mario Serio', University of Florence, Florence, Italy.,Gastroenterology Department, Careggi University Hospital, Florence, Italy
| | - Marc Ferrante
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - Gionata Fiorino
- Department of Gastroenterology and Digestive Endoscopy, IRCCS San Raffaele Hospital and Vita-Salute San Raffaele University, Milan, Italy
| | - Emma Flanagan
- Department of Gastroenterology, St Vincent's Hospital Melbourne, Fitzroy, VIC, Australia
| | | | - Ailsa Hart
- Inflammatory Bowel Diseases Unit, St Mark's Hospital, Harrow, UK
| | - Charlotte Rose Hedin
- Karolinska Institutet, Department of Medicine Solna, Stockholm, Sweden.,Karolinska University Hospital, Department of Gastroenterology, Dermatovenereology and Rheumatology, Stockholm, Sweden
| | - Pascal Juillerat
- Clinic for Visceral Surgery and Medicine, Bern University Hospital, Bern, Switzerland.,Crohn's and Colitis Center, Gastroenterology Beaulieu SA, Lausanne, Switzerland
| | - Annemarie Mulders
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Fetal Medicine Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Pär Myrelid
- Department of Surgery, Linköping University Hospital, Linköping, Sweden.,Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Aoibhlinn O'Toole
- Beaumont Hospital, Department of Gastroenterology, Royal College of Surgeons, Dublin, Ireland
| | - Pauline Rivière
- Gastroenterology Unit, Bordeaux University Hospital, Pessac, France
| | - Michael Scharl
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | | | - Elena Sonnenberg
- Charité-Universitätsmedizin Berlin, Department of Gastroenterology, Infectious Diseases and Rheumatology, Germany
| | - Murat Toruner
- Department of Gastroenterology, Ankara University School of Medicine, Ankara, Turkey
| | - Jantien Wieringa
- Department of Paediatrics, Haaglanden Medical Center, The Hague, The Netherlands.,Department of Paediatrics, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - C Janneke Van der Woude
- Department of Gastroenterology & Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
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Lenti MV, Scribano ML, Biancone L, Ciccocioppo R, Pugliese D, Pastorelli L, Fiorino G, Savarino E, Caprioli FA, Ardizzone S, Fantini MC, Tontini GE, Orlando A, Sampietro GM, Sturniolo GC, Monteleone G, Vecchi M, Kohn A, Daperno M, D’Incà R, Corazza GR, Di Sabatino A. Personalize, participate, predict, and prevent: 4Ps in inflammatory bowel disease. Front Med (Lausanne) 2023; 10:1031998. [PMID: 37113615 PMCID: PMC10126747 DOI: 10.3389/fmed.2023.1031998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 03/14/2023] [Indexed: 04/29/2023] Open
Abstract
Inflammatory bowel disease (IBD), which includes Crohn's disease (CD) and ulcerative colitis (UC), is a complex, immune-mediated, disorder which leads to several gastrointestinal and systemic manifestations determining a poor quality of life, disability, and other negative health outcomes. Our knowledge of this condition has greatly improved over the last few decades, and a comprehensive management should take into account both biological (i.e., disease-related, patient-related) and non-biological (i.e., socioeconomic, cultural, environmental, behavioral) factors which contribute to the disease phenotype. From this point of view, the so called 4P medicine framework, including personalization, prediction, prevention, and participation could be useful for tailoring ad hoc interventions in IBD patients. In this review, we discuss the cutting-edge issues regarding personalization in special settings (i.e., pregnancy, oncology, infectious diseases), patient participation (i.e., how to communicate, disability, tackling stigma and resilience, quality of care), disease prediction (i.e., faecal markers, response to treatments), and prevention (i.e., dysplasia through endoscopy, infections through vaccinations, and post-surgical recurrence). Finally, we provide an outlook discussing the unmet needs for implementing this conceptual framework in clinical practice.
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Affiliation(s)
- Marco Vincenzo Lenti
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy
- Department of Internal Medicine, San Matteo Hospital Foundation, Pavia, Italy
| | | | - Livia Biancone
- Unit of Gastroenterology, Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Rachele Ciccocioppo
- Gastroenterology Unit, Department of Medicine, A.O.U.I. Policlinico G.B. Rossi and University of Verona, Verona, Italy
| | - Daniela Pugliese
- CEMAD Digestive Disease Center, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Luca Pastorelli
- Liver and Gastroenterology Unit, ASST Santi Paolo e Carlo, Milan, Italy
- Department of Health Sciences, University of Milan, Milan, Italy
| | - Gionata Fiorino
- IBD Unit, Ospedale San Camillo-Forlanini, Rome, Italy
- Department of Gastroenterology, San Raffaele Hospital and Vita-Salute San Raffaele University,, Milan, Italy
| | - Edoardo Savarino
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Flavio Andrea Caprioli
- Gastroenterology and Endoscopy Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Cà Granda, Ospedale Maggiore Policlinico and Università degli Studi di Milano, Milan, Italy
| | - Sandro Ardizzone
- Gastroenterology and Digestive Endoscopy Unit, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Massimo Claudio Fantini
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy
- Gastroenterology Unit, Azienda Ospedaliero-Universitaria (AOU) di Cagliari, Cagliari, Italy
| | - Gian Eugenio Tontini
- Department of Pathophysiology and Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milano, Italy
| | - Ambrogio Orlando
- Inflammatory Bowel Disease Unit, Azienda Ospedaliera Ospedali Riuniti "Villa Sofia-Cervello" Palermo, Palermo, Italy
| | | | - Giacomo Carlo Sturniolo
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Giovanni Monteleone
- Unit of Gastroenterology, Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Maurizio Vecchi
- Gastroenterology and Endoscopy Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Cà Granda, Ospedale Maggiore Policlinico and Università degli Studi di Milano, Milan, Italy
| | - Anna Kohn
- Gastroenterology Operative Unit, Azienda Ospedaliera San Camillo-Forlanini FR, Rome, Italy
| | - Marco Daperno
- Division of Gastroenterology, Ospedale Ordine Mauriziano di Torino, Turin, Italy
| | - Renata D’Incà
- Department of Gastroenterology, San Raffaele Hospital and Vita-Salute San Raffaele University,, Milan, Italy
| | - Gino Roberto Corazza
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy
- Department of Internal Medicine, San Matteo Hospital Foundation, Pavia, Italy
| | - Antonio Di Sabatino
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy
- Department of Internal Medicine, San Matteo Hospital Foundation, Pavia, Italy
- *Correspondence: Antonio Di Sabatino,
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12
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Wang H, Hu Y, Chen F, Shen M. Comparative safety of infliximab and adalimumab on pregnancy outcomes of women with inflammatory bowel diseases: a systematic review & meta-analysis. BMC Pregnancy Childbirth 2022; 22:854. [DOI: 10.1186/s12884-022-05191-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 11/07/2022] [Indexed: 11/20/2022] Open
Abstract
Abstract
Background
Inflammatory bowel disease (IBD) is a condition that affects most of the digestive tract. There is no report of fertility reduction in medically managed IBD women compared with the general population. On the other hand, active IBD can lead to significantly decreased fertility. Over the previous 2 decades, anti-tumor necrosis factor (anti-TNF) has been an effective treatment for managing patients with IBD, increasing the use of infliximab and adalimumab in clinical practice. However, it is unclear which biologics are better for pregnant women with IBD.
Aim
We conducted a systematic review and meta-analysis for the risk of adverse pregnancy outcomes following treatment with infliximab and adalimumab in women with IBD.
Methods
Bibliographic databases were retrieved from their inception to July 2022. The results were adverse pregnancy outcomes, including congenital malformations and spontaneous abortion.
Results
A total of 8 studies included 527 pregnant women with IBD. Of these, 343 received infliximab, and 184 received adalimumab therapy. Compared to adalimumab, adverse pregnancy outcomes were not increased in infliximab therapy including congenital malformations and spontaneous abortion.
Conclusion
Infliximab and adalimumab therapy did not show the difference of risk in adverse pregnancy outcomes in women with IBD.
Systematic review registration
http://www.crd.york.ac.uk/PROSPERO, identifier: CRD 42,021,277,869.
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Russell MD, Dey M, Flint J, Davie P, Allen A, Crossley A, Frishman M, Gayed M, Hodson K, Khamashta M, Moore L, Panchal S, Piper M, Reid C, Saxby K, Schreiber K, Senvar N, Tosounidou S, van de Venne M, Warburton L, Williams D, Yee CS, Gordon C, Giles I, Roddy E, Armon K, Astell L, Cotton C, Davidson A, Fordham S, Jones C, Joyce C, Kuttikat A, McLaren Z, Merrison K, Mewar D, Mootoo A, Williams E. British Society for Rheumatology guideline on prescribing drugs in pregnancy and breastfeeding: immunomodulatory anti-rheumatic drugs and corticosteroids. Rheumatology (Oxford) 2022; 62:e48-e88. [PMID: 36318966 PMCID: PMC10070073 DOI: 10.1093/rheumatology/keac551] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 09/15/2022] [Indexed: 11/07/2022] Open
Affiliation(s)
- Mark D Russell
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Mrinalini Dey
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Julia Flint
- Department of Rheumatology, Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Shropshire, UK
| | - Philippa Davie
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Alexander Allen
- Clinical Affairs, British Society for Rheumatology, London, UK
| | | | - Margreta Frishman
- Rheumatology, North Middlesex University Hospital NHS Trust, London, UK
| | - Mary Gayed
- Rheumatology, Sandwell and West Birmingham Hospitals, Birmingham, UK
| | | | - Munther Khamashta
- Lupus Research Unit, Division of Women's Health, King's College London, London, UK
| | - Louise Moore
- Rheumatic and Musculoskeletal Disease Unit, Our Lady's Hospice and Care Service, Dublin, Ireland
| | - Sonia Panchal
- Department of Rheumatology, South Warwickshire NHS Foundation Trust, Warwickshire, UK
| | - Madeleine Piper
- Royal National Hospital for Rheumatic Diseases, Royal United Hospital, Bath, UK
| | | | - Katherine Saxby
- Pharmacy, University College London Hospitals NHS Foundation Trust, London, UK
| | - Karen Schreiber
- Thrombosis and Haemostasis, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Department of Rheumatology, Danish Hospital for Rheumatic Diseases, Sonderborg, Denmark.,Department of Regional Health Research (IRS), University of Southern Denmark, Odense, Denmark
| | - Naz Senvar
- Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Sofia Tosounidou
- Lupus UK Centre of Excellence, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | | | | | - David Williams
- Obstetrics, University College London Hospitals NHS Foundation Trust, London, UK
| | - Chee-Seng Yee
- Department of Rheumatology, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, Doncaster, UK
| | - Caroline Gordon
- Rheumatology Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Ian Giles
- Centre for Rheumatology, Division of Medicine, University College London, London, UK
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Abraham BP, Ott E, Busse C, Murphy C, Miller L, Baumgart DC, Scherl E, Gasink C. Ustekinumab Exposure in Pregnant Women From Inflammatory Bowel Disease Clinical Trials: Pregnancy Outcomes Through Up To 5 Years in Crohn's Disease and 2 Years in Ulcerative Colitis. CROHN'S & COLITIS 360 2022; 4:otac025. [PMID: 36777422 PMCID: PMC9802371 DOI: 10.1093/crocol/otac025] [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: 03/23/2022] [Indexed: 11/13/2022] Open
Abstract
Background While no adverse developmental outcomes were observed in preclinical animal studies, limited data exist regarding effects of ustekinumab on human pregnancies. Previously, no data have been reported for women treated with ustekinumab in inflammatory bowel disease (IBD) clinical trials and corresponding pregnancy outcomes. Here, we present pregnancy outcomes from IBD clinical trials, incorporating 5 years of treatment in Crohn's disease (CD) and 2 in ulcerative colitis (UC). Methods All patients in the clinical trials agreed to use adequate birth control and were discontinued from treatment upon pregnancy confirmation. Nonetheless, 39 pregnancies occurred with maternal ustekinumab exposure from 4 CD and 1 UC study. Maternal and neonatal outcomes and data are presented with summary statistics, where available. Results Of 1289 women who received ≥1 dose of ustekinumab, 39 maternal pregnancies with outcomes were reported (pregnancy cohort). Median maternal age was 28.0 years and median duration of ustekinumab treatment before pregnancy was 63.7 weeks with the last dose of ustekinumab administered prior to or during the first trimester (terminal half-life of ~3 weeks). Outcomes for the 39 pregnancies were: 26 live births (all normal newborns), 8 spontaneous abortions, and 5 elective abortions. No congenital anomalies were reported among normal newborns and no safety signals emerged with neonatal outcomes. Conclusions Based on this series of 39 pregnancies with outcomes from IBD clinical trials, mothers treated with ustekinumab (limited to up to the first trimester) did not demonstrate a risk of negative outcomes. More data are needed to characterize the safety profile of ustekinumab use during pregnancy.
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Affiliation(s)
- Bincy P Abraham
- Address correspondence to: Bincy P. Abraham, MD, MS, AGAF, FACG, Houston Methodist Academic Institute, Weill Cornell Medical College, Houston Methodist Gastroenterology Associates, 6550 Fannin St., Suite 1201, Houston, TX 77030, USA ()
| | - Elyssa Ott
- Medical Affairs, Janssen Scientific Affairs, LLC, Horsham, Pennsylvania, USA
| | - Christopher Busse
- Medical Affairs, Janssen Scientific Affairs, LLC, Horsham, Pennsylvania, USA
| | - Conor Murphy
- Immunology, Janssen Research & Development LLC, Spring House, Pennsylvania, USA
| | - Lindsay Miller
- Medical Affairs, Janssen Scientific Affairs, LLC, Horsham, Pennsylvania, USA
| | - Daniel C Baumgart
- Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada
| | - Ellen Scherl
- Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Christopher Gasink
- Medical Affairs, Janssen Scientific Affairs, LLC, Horsham, Pennsylvania, USA
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15
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Malhi G, Tandon P, Perlmutter JW, Nguyen G, Huang V. Risk Factors for Postpartum Disease Activity in Women With Inflammatory Bowel Disease: A Systematic Review and Meta-analysis. Inflamm Bowel Dis 2022; 28:1090-1099. [PMID: 34427643 DOI: 10.1093/ibd/izab206] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND Women with inflammatory bowel disease (IBD) have an increased risk of postpartum disease activity. We aimed to systematically determine the effect of various risk factors on postpartum IBD disease activity. METHODS Electronic databases were searched through January 2021 for studies that reported risk of postpartum disease activity in women with IBD. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated for the impact of IBD phenotype, disease activity, therapy de-escalation, mode of delivery, and breastfeeding on postpartum disease activity. Study bias was determined using the Quality in Prognostic Studies tool. RESULTS Twenty-seven observational studies (3825 patients) were included, 15 of which had a high risk of confounding bias. The pooled incidence of women with postpartum active IBD was 31.9% (95% CI, 25.6-38.1). Similar results were seen with ulcerative colitis and Crohn's disease (CD; OR, 0.96; 95% CI, 0.58-1.59). Those with stricturing (OR, 3.64; 95% CI, 1.31-10.08) and penetrating (OR, 4.25; 95% CI, 1.11-16.26) CD had higher odds of postpartum active IBD. Active disease at conception (OR, 10.59; 95% CI, 1.48-76.02) and during pregnancy (OR, 4.91; 95% CI, 1.82-13.23) increased the odds of postpartum disease activity. Similarly, biologic discontinuation in the third trimester (OR, 1.77; 95% CI, 1.01-3.10) and therapy de-escalation after delivery (OR, 7.36; 95% CI, 3.38-16.0) was associated with postpartum disease activity. CONCLUSIONS Complicated Crohn's disease, disease activity at conception and during pregnancy, and de-escalation of biologics during pregnancy or after delivery are associated with postpartum disease activity in women with IBD.
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Affiliation(s)
- Gurpreet Malhi
- Department of Medicine, Western University, London, Ontario, Canada
| | - Parul Tandon
- Division of Gastroenterology and Hepatology, University of Toronto, Toronto, Ontario, Canada
| | | | - Geoffrey Nguyen
- Division of Gastroenterology and Hepatology, University of Toronto, Toronto, Ontario, Canada
| | - Vivian Huang
- Division of Gastroenterology and Hepatology, University of Toronto, Toronto, Ontario, Canada
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16
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Abstract
Pregnancy is a complex biological process. The establishment and maintenance of foetal-maternal interface are pivotal events. Decidual immune cells and inflammatory cytokines play indispensable roles in the foetal-maternal interface. The disfunction of decidual immune cells leads to adverse pregnancy outcome. Tumour necrosis factor (TNF)-α, a common inflammatory cytokine, has critical roles in different stages of normal pregnancy process. However, the relationship between the disorder of TNF-α and adverse pregnancy outcomes, including preeclampsia (PE), intrauterine growth restriction (IUGR), spontaneous abortion (SA), preterm birth and so on, is still indefinite. In this review, we thoroughly reviewed the effect of TNF-α disorder on pathological conditions. Moreover, we summarized the reports about the adverse pregnancy outcomes (PE, IUGR, SA and preterm birth) of using anti-TNF-α drugs (infliximab, etanercept and adalimumab, certolizumab and golimumab) currently in the clinical studies. Overall, IUGR, SA and preterm birth are the most common adverse pregnancy outcomes of anti-TNF-α drugs. Our review may provide insight for the immunological treatment of pregnancy-related complication, and help practitioners make informed decisions based on the current evidences.
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Hart A, D'Haens G, Bereswill M, Finney-Hayward T, Kalabic J, Levy G, Liang H, Seow CH, Loftus EV, Panaccione R, Reinisch W, Satsangi J. Observational data from the adalimumab post-marketing PYRAMID registry of patients with Crohn's disease who became pregnant: A post hoc analysis. United European Gastroenterol J 2022; 10:485-495. [PMID: 35560533 PMCID: PMC9189454 DOI: 10.1002/ueg2.12236] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 04/14/2022] [Indexed: 12/11/2022] Open
Abstract
Background PYRAMID was an international post‐marketing registry that aimed to collect data on the long‐term safety and effectiveness of adalimumab treatment per local standard of care in patients with moderately to severely active Crohn's disease (CD). Here, we present post hoc analyses of observational data from patients who became pregnant while participating in this registry and receiving adalimumab. Methods From the subpopulation of patients receiving adalimumab who became pregnant while taking part in PYRAMID, data on patient characteristics, pregnancy outcomes, and complications of pregnancy were analysed retrospectively. Results Across the PYRAMID registry, 293 pregnancies occurred in patients who had gestational adalimumab exposure (average disease duration at last menstrual period: 8.6 years), resulting in 300 pregnancy outcomes. A total of 197 pregnancies (67.2%) were exposed to adalimumab in all trimesters per physician's decision. Of the known reported outcomes (96.3%), 81.7% (236/289) were live births, 10.4% (30/289) were spontaneous abortions, 4.8% (14/289) elective terminations, 2.8% (8/289) ectopic pregnancies, and 0.3% (1/289) was a stillbirth. Congenital malformations (pulmonary valve stenosis and tricuspid valve incompetence) were reported in one infant. In addition to the pregnancy outcomes described above, 23 complications of pregnancy were reported in 20 patients. Conclusions This analysis showed that adalimumab treatment in patients with CD, who became pregnant whilst participating in the PYRAMID registry, contributed no additional adverse effects during the pregnancy course or on pregnancy outcomes.
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Affiliation(s)
- Ailsa Hart
- IBD Unit, St Mark's Hospital, London, UK
| | - Geert D'Haens
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Mareike Bereswill
- Pharmaceutical Research and Development, AbbVie Deutschland GmbH & Co. KG, Ludwigshafen, Germany
| | | | - Jasmina Kalabic
- Pharmaceutical Research and Development, AbbVie Deutschland GmbH & Co. KG, Ludwigshafen, Germany
| | - Gweneth Levy
- Research and Development, AbbVie Inc., North Chicago, Illinois, USA
| | - Huifang Liang
- Research and Development, AbbVie Inc., North Chicago, Illinois, USA
| | - Cynthia H Seow
- Division of Gastroenterology and Hepatology, Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Edward V Loftus
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Remo Panaccione
- Inflammatory Bowel Disease Unit, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Walter Reinisch
- Clinical Department of Gastroenterology and Hepatology, Medical University Vienna, Vienna, Wien, Austria
| | - Jack Satsangi
- Nuffield Department of Medicine, Translational Gastroenterology Unit, Experimental Medicine Division, University of Oxford, John Radcliffe Hospital, Oxford, UK
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Volger S, Scherl E. Biologics for Inflammatory Bowel Disease and Their Safety in Pregnancy. Clin Gastroenterol Hepatol 2022; 20:962-963. [PMID: 33864935 DOI: 10.1016/j.cgh.2021.04.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 04/10/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Sheri Volger
- Janssen Research & Development, LLC, Spring House, Pennsylvania
| | - Ellen Scherl
- New York-Presbyterian Weill Cornell Medical Center, New York, New York
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Nielsen OH, Gubatan J, Juhl CB. Reply. Clin Gastroenterol Hepatol 2022; 20:963-964. [PMID: 33989789 DOI: 10.1016/j.cgh.2021.05.009] [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: 04/22/2021] [Revised: 05/05/2021] [Accepted: 05/07/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Ole Haagen Nielsen
- Department of Gastroenterology, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark
| | - John Gubatan
- Division of Gastroenterology & Hepatology, Stanford University School of Medicine, Stanford, California
| | - Carsten Bogh Juhl
- Cochrane Musculoskeletal Group, Research Unit for Musculoskeletal Function, University of Southern Denmark, Southern Denmark, Denmark
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Araujo GG, dos Passos Junior RR, Lunardi RR, Volpato GT, Soares TS, Giachini FR, Lima VV. Maternal and Fetal-Placental Effects of Etanercept Treatment During Rats’ Pregnancy. Front Physiol 2022; 12:787369. [PMID: 35185598 PMCID: PMC8851240 DOI: 10.3389/fphys.2021.787369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 12/17/2021] [Indexed: 11/29/2022] Open
Abstract
Etanercept is a tumor necrosis factor alpha (TNF-α) inhibitor chronically used to treat autoimmune diseases. However, the use of etanercept during pregnancy still needs to be further investigated. The aim of this study is to evaluate the etanercept treatment during pregnancy, analyzing maternal reproductive performance, fetal outcomes, and placental repercussions. Wistar rats (200–250 g) were mated and randomly distributed into two experimental groups: control and etanercept (n = 10 animals/group). Treatments with etanercept (0.8 mg/kg, s.c.), or saline (control group) were carried out on days 0, 6, 12, and 18 of gestation. On the morning of the 21st day of pregnancy, rats were euthanized in a CO2 chamber and submitted to laparotomy to remove the fetuses, placentas, ovaries, and maternal organs. There were no differences between groups in the following parameters: water and food consumption; placental efficiency; reproductive parameters, including number of corpora lutea and implants, reabsorption, and pre- and post-implantation losses. However, etanercept treatment increased liver weight, reduced fetal and placental weight, decreased the placental junction zone, reduced the percentage of normal fetuses, and increased visceral or skeletal fetal abnormalities. Therefore, etanercept resulted in damages more related to fetus and placenta. However, more studies with different doses are required to better predict possible injuries elicited using etanercept during pregnancy.
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Affiliation(s)
- Gabriel Gomes Araujo
- Institute of Biological Sciences and Health, Federal University of Mato Grosso, Barra do Garças, Brazil
| | | | - Rosaline Rocha Lunardi
- Institute of Biological Sciences and Health, Federal University of Mato Grosso, Barra do Garças, Brazil
| | - Gustavo Tadeu Volpato
- Institute of Biological Sciences and Health, Federal University of Mato Grosso, Barra do Garças, Brazil
| | - Thaigra Sousa Soares
- Institute of Biological Sciences and Health, Federal University of Mato Grosso, Barra do Garças, Brazil
| | - Fernanda Regina Giachini
- Institute of Biological Sciences and Health, Federal University of Mato Grosso, Barra do Garças, Brazil
- Institute of Biological Sciences, Federal University of Goias, Goiânia, Brazil
- *Correspondence: Fernanda Regina Giachini,
| | - Victor Vitorino Lima
- Institute of Biological Sciences and Health, Federal University of Mato Grosso, Barra do Garças, Brazil
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Nielsen OH, Gubatan JM, Juhl CB, Streett SE, Maxwell C. Biologics for Inflammatory Bowel Disease and Their Safety in Pregnancy: A Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol 2022; 20:74-87.e3. [PMID: 32931960 DOI: 10.1016/j.cgh.2020.09.021] [Citation(s) in RCA: 50] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 09/01/2020] [Accepted: 09/09/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Biologics are used routinely in pregnant women with inflammatory bowel disease (IBD), but large-scale data reporting adverse pregnancy outcomes among biologic users are lacking. We sought to estimate the prevalence of adverse pregnancy outcomes in women with IBD on biologic therapies. METHODS We searched major databases from inception to June 2020 for studies estimating the prevalence of adverse pregnancy outcomes in IBD when using biologics (anti-tumor necrosis factor [TNF], anti-integrins, and anticytokines). Prevalence and relative risk (RR) were pooled using a random-effects model. RESULTS Forty-eight studies were included in the meta-analysis comprising 6963 patients. Biologic therapy in IBD pregnancies was associated with a pooled prevalence of 8% (95% CI, 6%-10%; I2 = 87.4%) for early pregnancy loss, 9% (95% CI, 7%-11%; I2 = 89.9%) for preterm birth, 0% (95% CI, 0%-0%; I2 = 0%) for stillbirth, 8% (95% CI, 5%-10%; I2 = 87.0%) for low birth weight, and 1% (95% CI, 1%-2%; I2 = 78.3%) for congenital malformations. These rates are comparable with those published in the general population. In subgroup analyses of a small number of studies, the prevalence of early pregnancy loss and preterm birth were higher in vedolizumab vs anti-TNF users. Meta-regression did not show an association of disease activity or concomitant thiopurine on adverse outcomes. Continued TNF inhibitor use during the third trimester was not associated with risk of preterm birth (RR, 1.41; 95% CI, 0.77-2.60; I2 = 0%), low birth weight (RR, 1.32; 95% CI, 0.80-2.18; I2 = 0%), or congenital malformations (RR, 1.28; 95% CI, 0.47-3.49; I2 = 0%). CONCLUSIONS Adverse pregnancy outcomes among pregnant IBD women using biologics are comparable with that of the general population. PROSPERO protocol #CRD42019135721.
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Affiliation(s)
- Ole Haagen Nielsen
- Department of Gastroenterology, Medical Section, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark.
| | - John Mark Gubatan
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Carsten Bogh Juhl
- Research Unit for Musculoskeletal Function and Physiotherapy, University of Southern Denmark, Odense, Denmark; Department of Physiotherapy and Occupational Therapy, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Sarah Elizabeth Streett
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Cynthia Maxwell
- Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Ontario, Canada
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de Aragão MC, Beraldo RF, Marcondes MB, de Barros JR, Herrerias GSP, Saad-Hossne R, Baima JP, Sassaki LY. Management of inflammatory bowel disease and serum level of infliximab in newborn exposed to anti-TNF therapy during pregnancy: Case report and literature review. Medicine (Baltimore) 2021; 100:e28274. [PMID: 34941109 PMCID: PMC8702279 DOI: 10.1097/md.0000000000028274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 11/25/2021] [Indexed: 12/05/2022] Open
Abstract
RATIONALE Heightened inflammatory bowel disease (IBD) activity during pregnancy is associated with higher rates of preterm birth, miscarriage, and low birth weight. Therefore, its adequate treatment is essential, considering the risk-benefit of medication use. Although previous literature has described the management of IBD during pregnancy, few studies have assessed the pharmacokinetics of IBD drugs in the newborn. In this case report, we describe the management of ulcerative colitis during pregnancy and discuss the benefits of checking serum levels of infliximab in newborns exposed to the medication during pregnancy. PATIENT CONCERN A 37-year-old patient with ulcerative colitis in clinical and endoscopic remission had been undergoing treated with infliximab since 2008. The patient became pregnant in 2018. DIAGNOSIS AND INTERVENTION Infliximab medication was discontinued at the 29th week of pregnancy. OUTCOMES The pregnancy was uneventful, and the levels of infliximab in the umbilical cord were >20 μg/dL. Live vaccinations were postponed until the baby was 6 months old, when a new serum drug level proved to be undetectable. LESSONS Our case suggests that the use of infliximab is safe in pregnancy, and drug discontinuation could be considered from the 24th week of pregnancy onward to reduce placental transfer to the newborn in patients at low risk of relapse. Vaccines with live attenuated organisms should be delayed for at least 6 months or until the serum level of the medication is undetectable.
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Affiliation(s)
- Maria Cecília de Aragão
- Department of Internal Medicine, São Paulo State University (Unesp), Medical School, Botucatu, São Paulo, Brazil
| | - Rodrigo Fedatto Beraldo
- Department of Internal Medicine, São Paulo State University (Unesp), Medical School, Botucatu, São Paulo, Brazil
| | - Mariana Barros Marcondes
- Department of Internal Medicine, São Paulo State University (Unesp), Medical School, Botucatu, São Paulo, Brazil
| | - Jaqueline Ribeiro de Barros
- Department of Internal Medicine, São Paulo State University (Unesp), Medical School, Botucatu, São Paulo, Brazil
| | | | - Rogerio Saad-Hossne
- Department of Surgery, São Paulo State University (Unesp), Medical School, Botucatu, São Paulo, Brazil
| | - Júlio Pinheiro Baima
- Department of Internal Medicine, São Paulo State University (Unesp), Medical School, Botucatu, São Paulo, Brazil
| | - Ligia Yukie Sassaki
- Department of Internal Medicine, São Paulo State University (Unesp), Medical School, Botucatu, São Paulo, Brazil
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23
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Wang H, Chen F, Hu Y, Shen M. Adverse Pregnancy Outcomes Following Exposure to Biologics in Women With Crohn's Disease: A Systematic Review and Meta-Analysis. Front Med (Lausanne) 2021; 8:753088. [PMID: 34760901 PMCID: PMC8573108 DOI: 10.3389/fmed.2021.753088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 09/27/2021] [Indexed: 11/13/2022] Open
Abstract
Crohn's disease is a chronic disease, which commonly affects women during their reproductive years. Poorly treated Crohn's disease is associated with adverse pregnancy outcomes. Biologics, a group of therapeutic drugs targeting inflammatory mediators including anti-TNF, anti-integrins and anti-interleukins, are increasingly used in pregnant women with Crohn's disease, exposing both the women and their fetuses to treatment-related complications. At present, it is unclear which biologics are more superior. This study performed a systematic review and meta-analysis to assess the risk of adverse pregnancy outcomes in women with Crohn's disease after exposure to biologics. Bibliographic databases were searched from inception to May 2021. The outcomes of interest were preterm delivery, low birth weight, spontaneous abortion, and congenital abnormalities. A total of 11 studies comprised of 1,875 pregnancies among women with Crohn's disease were included. Of these, 1,162 received biologics and 713 received non-biologic therapy. During the remission phase of the disease, the use of biological therapy increased the risk of adverse pregnancy outcomes, of which anti-integrins were associated with a higher incidence of adverse pregnancy outcomes than anti-TNF and anti-interleukins. Systematic Review Registration: http://www.crd.york.ac.uk/PROSPERO, identifier: CRD42020191275.
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Affiliation(s)
- Han Wang
- Department of Gynecology and Obstetrics, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Fang Chen
- Department of Gastroenterology, Hangzhou Red Cross Hospital, Hangzhou, China
| | - Yue Hu
- Department of Gastroenterology, First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
| | - Mengdie Shen
- Department of Internal Medicine, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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24
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De Felice KM, Kane S. Safety of anti-TNF agents in pregnancy. J Allergy Clin Immunol 2021; 148:661-667. [PMID: 34489011 DOI: 10.1016/j.jaci.2021.07.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 07/02/2021] [Accepted: 07/06/2021] [Indexed: 02/07/2023]
Abstract
Inflammatory bowel disease, rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, and psoriasis are associated with adverse pregnancy outcomes. Active maternal disease during pregnancy is associated with additional negative outcomes. Anti-TNF agents are effective treatments for inflammatory bowel disease, rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, and psoriasis. These agents cross the placenta starting in the second trimester, with levels detected for several months after birth. This has led to safety concerns, with continued therapy during pregnancy for both the mother and the infant. This review covers retrospective and prospective data published from various cohorts of pregnant women exposed to anti-TNF agents during pregnancy. It highlights the safety of anti-TNF drugs in pregnancy, breast-feeding, and during the first year of life of the infant.
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Affiliation(s)
- Kara M De Felice
- Department of Gastroenterology, Louisiana State University, Department of Gastroenterology, New Orleans, La.
| | - Sunanda Kane
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minn
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25
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Meserve J, Luo J, Zhu W, Veeravalli N, Bandoli G, Chambers CD, Singh AG, Boland BS, Sandborn WJ, Mahadevan U, Singh S. Paternal Exposure to Immunosuppressive and/or Biologic Agents and Birth Outcomes in Patients With Immune-Mediated Inflammatory Diseases. Gastroenterology 2021; 161:107-115.e3. [PMID: 33744307 PMCID: PMC8238837 DOI: 10.1053/j.gastro.2021.03.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 03/02/2021] [Accepted: 03/10/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS We conducted a retrospective cohort study to inform the safety of exposure to immunosuppressive and/or biologic agents around conception in expectant fathers with immune-mediated inflammatory diseases (IMIDs) on birth outcomes. METHODS Using a deidentified administrative claims database (OptumLabs Data Warehouse), we identified 7453 expectant fathers with IMIDs (inflammatory bowel diseases, rheumatoid arthritis, psoriasis/psoriatic arthritis, and ankylosing spondylitis) linked to newborns with periconception medication exposure between 38 and 60 weeks before the newborn birth date (34-58 weeks prior for preterm newborns) and neonatal follow-up for 3 months after the birth date. Through logistic regression adjusting for paternal age and race (and, in a subset, for maternal age, race, presence of IMIDs, and nonsingleton births), we compared the risk of major congenital malformations (primary outcome) and preterm birth and low birth weight in fathers exposed to thiopurines (n = 461), methotrexate (n = 171), tumor necrosis factor (TNF) α antagonists (n = 1082), or non-TNF-targeting biologic agents (n = 132) vs fathers not exposed to any of these medications (n = 5607). RESULTS As compared to unexposed fathers (3.4% prevalence of major congenital malformations), exposure to thiopurines (relative risk [RR], 1.12; 95% confidence interval [CI], 0.66-1.76), methotrexate (RR, 0.67; 95% CI, 0.21-1.55), TNF-α antagonists (RR, 1.14; 95% CI, 0.81-1.57), and non-TNF-targeting biologic agents (RR, 1.75; 95% CI, 0.80-3.24) was not associated with increased risk of major congenital malformations. No association was observed between paternal medication exposure and risk of preterm birth or low birth weight. Results were stable on subanalyses of linked father-mother-newborn triads. CONCLUSIONS In a large cohort study of 7453 expectant fathers with IMIDs, exposure to immunosuppressive or biologic agents around conception was not associated with increased risk of adverse birth outcomes.
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Affiliation(s)
- Joseph Meserve
- Division of Gastroenterology, University of California San Diego, La Jolla, California
| | - Jiyu Luo
- Division of Biostatistics and Bioinformatics, Department of Family Medicine and Public Health, University of California San Diego, La Jolla, California;,OptumLabs Visiting Fellow, Eden Prairie, Minnesota
| | - Wenhong Zhu
- OptumLabs Visiting Fellow, Eden Prairie, Minnesota;,Altman Clinical and Translational Research Institute, University of California San Diego, La Jolla, California
| | | | - Gretchen Bandoli
- Department of Pediatrics and Department of Family Medicine and Public Health, University of California San Diego, La Jolla, California
| | - Christina D. Chambers
- Department of Pediatrics and Department of Family Medicine and Public Health, University of California San Diego, La Jolla, California
| | - Abha G. Singh
- Division of Rheumatology, Allergy and Immunology, University of California San Diego, La Jolla, California
| | - Brigid S. Boland
- Division of Gastroenterology, University of California San Diego, La Jolla, California
| | - William J. Sandborn
- Division of Gastroenterology, University of California San Diego, La Jolla, California
| | - Uma Mahadevan
- Division of Gastroenterology, University of California San Francisco, San Francisco, California
| | - Siddharth Singh
- Division of Gastroenterology, University of California San Diego, La Jolla, California; OptumLabs Visiting Fellow, Eden Prairie, Minnesota; Division of Biomedical Informatics, University of California San Diego, La Jolla, California.
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26
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Guerrero Vinsard D, Kane SV. Biologics and pregnancy: a clinician's guide to the management of IBD in pregnant women. Expert Rev Gastroenterol Hepatol 2021; 15:633-641. [PMID: 33440996 DOI: 10.1080/17474124.2021.1876562] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: Women with inflammatory bowel disease (IBD) endorse a tremendous amount of concern about medication exposure during pregnancy and their effects on the fetus. Medical providers caring for this patient population should be well informed and feel comfortable counseling their patients for the best pregnancy outcome possible.Areas covered: It is of particular importance to understand the implications of use of biologics in preconception, pregnancy, and postpartum timeframes. Herein, we aim to inform the clinician about the impact of uncontrolled inflammation during pregnancy, the mechanisms of biologic transport through the placenta, the effects of biologics in maternal and neonatal outcomes, and additional postpartum considerations such as breastfeeding and vaccination safety.Expert opinion: The groundwork already set by previous research in terms of safety of biologic therapy during pregnancy has been reassuring. With the advent of more mechanisms of action but similar protein structure, i.e. they are IgG1 antibodies; the authors anticipate the recommendation of continuation of therapy throughout pregnancy will be sustained.
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Affiliation(s)
| | - Sunanda V Kane
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, MN, USA
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27
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Perez-Garcia LF, Dolhain RJEM, Vorstenbosch S, Bramer W, van Puijenbroek E, Hazes JMW, Te Winkel B. The effect of paternal exposure to immunosuppressive drugs on sexual function, reproductive hormones, fertility, pregnancy and offspring outcomes: a systematic review. Hum Reprod Update 2021; 26:961-1001. [PMID: 32743663 PMCID: PMC7600290 DOI: 10.1093/humupd/dmaa022] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 04/17/2020] [Accepted: 05/01/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Information regarding the possible influence of immunosuppressive drugs on male sexual function and reproductive outcomes is scarce. Men diagnosed with immune-mediated diseases and a wish to become a father represent an important neglected population since they lack vital information to make balanced decisions about their treatment. OBJECTIVE AND RATIONALE The aim of this research was to systematically review the literature for the influence of paternal immunosuppressive drug use on many aspects of male sexual health, such as sexual function, fertility, pregnancy outcomes and offspring health outcomes. SEARCH METHODS A systematic literature search was performed in the bibliographic databases: Embase (via Elsevier embase.com), MEDLINE ALL via Ovid, Cochrane Central Register of Trials (via Wiley) and Web of Science Core Collection. Additionally, Google Scholar and the Clinical trial registries of Europe and the USA were searched. The databases were searched from inception until 31 August 2019. The searches combined keywords regarding male sexual function and fertility, pregnancy outcomes and offspring health with a list of immunosuppressive drugs. Studies were included if they were published in English and if they included original data on male human exposure to immunosuppressive drugs. A meta-analysis was not possible to perform due to the heterogeneity of the data. OUTCOMES A total of 5867 references were identified, amongst which we identified 161 articles fulfilling the eligibility criteria. Amongst these articles, 50 included pregnancy and offspring outcomes and 130 included sexual health outcomes. Except for large Scandinavian cohorts, most of the identified articles included a small number of participants. While a clear negative effect on sperm quality was evident for sulfasalazine and cyclophosphamide, a dubious effect was identified for colchicine, methotrexate and sirolimus. In three articles, exposure to tumour necrosis factor-α inhibitors in patients diagnosed with ankylosing spondylitis resulted in improved sperm quality. The information regarding pregnancy and offspring outcomes was scant but no large negative effect associated with paternal immunosuppressive drug exposure was reported. WIDER IMPLICATIONS Evidence regarding the safety of immunosuppressive drugs in men with a wish to become a father is inconclusive. The lack of standardisation on how to evaluate and report male sexual function, fertility and reproduction as study outcomes in men exposed to immunosuppressive drugs is an important contributor to this result. Future research on this topic is needed and should be preferably done using standardised methods.
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Affiliation(s)
- L F Perez-Garcia
- Department of Rheumatology, Erasmus MC, University Medical Center, 3000 CA Rotterdam, The Netherlands
| | - R J E M Dolhain
- Department of Rheumatology, Erasmus MC, University Medical Center, 3000 CA Rotterdam, The Netherlands
| | - S Vorstenbosch
- Netherlands Pharmacovigilance Centre Lareb, 5237 MH 's-Hertogenbosch, The Netherlands
| | - W Bramer
- Medical Library, Erasmus MC, University Medical Center, 3000 CA Rotterdam, The Netherlands
| | - E van Puijenbroek
- Netherlands Pharmacovigilance Centre Lareb, 5237 MH 's-Hertogenbosch, The Netherlands.,Groningen Research Institute of Pharmacy, PharmacoTherapy, Epidemiology and Economics, University of Groningen, 9712 CP Groningen, The Netherlands
| | - J M W Hazes
- Department of Rheumatology, Erasmus MC, University Medical Center, 3000 CA Rotterdam, The Netherlands
| | - B Te Winkel
- Netherlands Pharmacovigilance Centre Lareb, 5237 MH 's-Hertogenbosch, The Netherlands
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28
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Mountifield R. Anti-tumor necrosis factors (TNFs) are outdated-It's time to move on: Session three summary. J Gastroenterol Hepatol 2021; 36 Suppl 1:25-26. [PMID: 33817852 DOI: 10.1111/jgh.15455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Réme Mountifield
- Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia, Australia.,Department of Medicine, Flinders University, Bedford Park, South Australia, Australia
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29
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Leung KK, Tandon P, Govardhanam V, Maxwell C, Huang V. The Risk of Adverse Neonatal Outcomes With Maternal Inflammatory Bowel Disease: A Systematic Review and Meta-analysis. Inflamm Bowel Dis 2021; 27:550-562. [PMID: 32469057 DOI: 10.1093/ibd/izaa122] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Patients with inflammatory bowel disease (IBD) may be at increased risk of adverse neonatal outcomes. The aim of this study was to determine pooled incidences and risk factors for these outcomes. METHODS Medline, Embase, and Cochrane Library were searched through May 2019 for studies reporting adverse neonatal outcomes in IBD. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. RESULTS The pooled incidence of preterm birth, low birth weight, congenital anomalies, and infants transferred to the neonatal intensive care unit was 8.6% (95% CI, 7.0%-10.1%), 8.9% (95% CI, 7.3%-10.5%), 2.1% (95% CI, 1.6%-2.6%), and 4.9% (95% CI, 2.9%-6.9), respectively. Compared with healthy controls, patients with IBD were more likely to deliver infants with low birth weight (<2500 grams; OR, 2.78; 95% CI, 1.16-6.66) and infants admitted to the intensive care unit (OR, 3.33; 95% CI, 1.83-6.05). Patients with Crohn's disease had an increased incidence of congenital anomalies (OR, 3.03; 95% CI, 1.43-6.42). Among IBD patients, active disease was associated with increased incidence of preterm birth (OR, 2.06; 95% CI, 1.21-3.51), low birth weight (OR, 2.96; 95% CI, 1.54-5.70), and small for gestational age (OR, 2.62; 95% CI, 1.18-5.83). Antitumor necrosis factor (anti-TNF) use during pregnancy was associated with an increased incidence of neonatal intensive care unit admission (OR, 2.42; 95% CI, 1.31-4.45) and low birth weight (OR, 1.54; 95% CI, 1.01-2.35). CONCLUSIONS Patients with IBD, particularly with active disease or requiring anti-TNF therapy, may be at increased risk of developing adverse neonatal outcomes.
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Affiliation(s)
- Kristel K Leung
- Division of Gastroenterology, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Parul Tandon
- Division of Gastroenterology, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Vivek Govardhanam
- Division of Gastroenterology, University of Toronto, Toronto, Ontario, Canada
| | - Cynthia Maxwell
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Vivian Huang
- Division of Gastroenterology, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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30
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Raine T, Gkini MA, Irving PM, Kaul A, Korendowych E, Laws P, Foulkes AC. Maintaining Clinical Freedom Whilst Achieving Value in Biologics Prescribing: An Integrated Cross-Specialty Consensus of UK Dermatologists, Rheumatologists and Gastroenterologists. BioDrugs 2021; 35:187-199. [PMID: 33635522 PMCID: PMC7952361 DOI: 10.1007/s40259-020-00464-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2020] [Indexed: 11/01/2022]
Abstract
BACKGROUND Biologics are now key drugs in the management of immune-mediated inflammatory diseases. However, the increasingly complex biologics environment and growing cost pressures in the UK have led to variability in drug commissioning and inequity of patient access across regions. OBJECTIVES Our objectives were to provide consensus recommendations for enhancing the current situation in biologic prescribing in the UK by balancing clinical freedom with equitable distribution of biologics given the limited availability of resources. METHODS A modified Delphi approach was used to reach integrated, cross-specialty consensus among dermatologists, rheumatologists and gastroenterologists practising within the English National Health Service (NHS). RESULTS We describe the concepts of clinical freedom and clinical judgement and demonstrate how, together with patient choice, they can be exercised in the context of biologic prescribing in the NHS. We highlight that in England, local variations occur that are at odds with National Institute for Health and Care Excellence (NICE) guidance; these variably limit the degree to which clinicians can exercise clinical freedom and impact on equity of patient access to treatments. We define factors encompassing a drug's value and identify challenges to the measurement and interpretation of this concept, which can raise barriers to the freedom of clinical choice and appropriate prescribing decisions allowing practices of holistic and personalised medicine. Cross-specialty consensus recommendations on ensuring equitable access to biologics in the NHS while protecting appropriate and individualised drug selection for patients are provided. We have also provided strategies for improving physician-commissioner communication to harmonise equity of patient access to biologics across England and improve patient outcomes. Commentary from patient advisory groups indicates that they welcome our exploration that value does not equal cost and agree that there should be an emphasis on shared decision making, which requires the clinician to practice clinical freedom by aligning the patient's needs and preferences with available treatment choices. CONCLUSIONS This consensus highlights the need to strike a balance between clinical freedom and short-term cost restrictions to support equitable resource distribution within the English NHS. Consideration of these recommendations may help to harmonise local, regional and national services and balance equity of patient access to biologic treatments with excellence in the NHS.
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Affiliation(s)
- Tim Raine
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
| | | | - Peter M Irving
- IBD Centre, Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK
- School of Immunology and Microbial Sciences, King's College London, London, UK
| | - Arvind Kaul
- Centre for Rheumatology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Eleanor Korendowych
- Department of Rheumatology, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - Philip Laws
- Department of Dermatology, The Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Amy C Foulkes
- The Dermatology Centre, Salford Royal NHS Foundation Trust, NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Manchester, UK
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31
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Grišić AM, Dorn-Rasmussen M, Ungar B, Brynskov J, Ilvemark JFKF, Bolstad N, Warren DJ, Ainsworth MA, Huisinga W, Ben-Horin S, Kloft C, Steenholdt C. Infliximab clearance decreases in the second and third trimesters of pregnancy in inflammatory bowel disease. United European Gastroenterol J 2021; 9:91-101. [PMID: 33079627 PMCID: PMC8259366 DOI: 10.1177/2050640620964619] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 09/16/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Infliximab therapy during pregnancy in inflammatory bowel disease is challenged by a dilemma between maintaining adequate maternal disease control while minimizing fetal infliximab exposure. We investigated the effects of pregnancy on infliximab pharmacokinetics. METHODS The study population comprised 23 retrospectively identified pregnancies. Patients with inflammatory bowel disease were generally in clinical remission at pregnancy conception (74%) and received steady infliximab maintenance therapy (5 mg/kg q8w n = 17; q6w n = 4; q10w n = 1; 10 mg/kg q8w n = 1). Trough blood samples had been obtained in the same patients prior to pregnancy (n = 119), the first trimester (n = 16), second trimester (n = 18), third trimester (n = 7), and postpregnancy (n = 12). Data were analyzed using nonlinear mixed-effects population pharmacokinetic modeling. RESULTS Dose-normalized infliximab concentrations were significantly higher during the second trimester (median 15 mg/ml/kg, interquartile range 10-21) compared to prepregnancy (7, 2-12; p = 0.003), the first trimester (9, 1-12; p = 0.04), or postpregnancy (6, interquartile range 3-11; p > 0.05) in patients with inflammatory bowel disease. Similar trends were observed in the third trimester (13, 7-36; p > 0.05). A one-compartment model with linear elimination described the pharmacokinetics of infliximab (volume of distribution n = 18.2 L; clearance 0.61 L/day). Maternal infliximab exposure was influenced by the second and third trimester of pregnancy and anti-infliximab antibodies, and not by pregnancy-imposed physiological changes in, for example, body weight or albumin. Infliximab clearance decreased significantly during the second and third trimesters by up to 15% as compared to pre- and postpregnancy and the first trimester. The increased maternal infliximab exposure was weakly associated with lowered clinical disease activity. Pharmacokinetic model simulations of virtual patients indicated the increased maternal infliximab trough concentrations imposed by pregnancy will not completely counteract the decrease in infliximab concentration if therapy is paused in the third trimester. CONCLUSION Infliximab clearance decreases significantly in the second and third trimesters, leading to increasing maternal infliximab concentrations in any given regimen. Maternal infliximab levels may thus be maintained as constant in a de-intensified regimen by therapeutic drug monitoring guidance in inflammatory bowel disease.
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Affiliation(s)
- Ana-Marija Grišić
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany.,Graduate Research Training Program, PharMetrX, Berlin, Germany
| | - Maria Dorn-Rasmussen
- Department of Gastroenterology, Copenhagen University Hospital Herlev, Herlev, Denmark
| | - Bella Ungar
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer, Sackler School of Medicine, Tel-Aviv University, Ramat Gan, Israel
| | - Jørn Brynskov
- Department of Gastroenterology, Copenhagen University Hospital Herlev, Herlev, Denmark
| | - Johan F K F Ilvemark
- Department of Gastroenterology, Copenhagen University Hospital Herlev, Herlev, Denmark
| | - Nils Bolstad
- Department of Medical Biochemistry, Oslo University Hospital, Oslo, Norway
| | - David J Warren
- Department of Medical Biochemistry, Oslo University Hospital, Oslo, Norway
| | - Mark A Ainsworth
- Department of Gastroenterology, Copenhagen University Hospital Herlev, Herlev, Denmark
| | | | - Shomron Ben-Horin
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer, Sackler School of Medicine, Tel-Aviv University, Ramat Gan, Israel
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany
| | - Casper Steenholdt
- Department of Gastroenterology, Copenhagen University Hospital Herlev, Herlev, Denmark
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32
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Beltagy A, Aghamajidi A, Trespidi L, Ossola W, Meroni PL. Biologics During Pregnancy and Breastfeeding Among Women With Rheumatic Diseases: Safety Clinical Evidence on the Road. Front Pharmacol 2021; 12:621247. [PMID: 34122062 PMCID: PMC8189556 DOI: 10.3389/fphar.2021.621247] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 01/04/2021] [Indexed: 12/31/2022] Open
Abstract
Females are generally more affected by autoimmune diseases, a fact that underlines the relationship with pregnancy and the safety of anti-rheumatic drugs in pregnancy and lactation. Biologic therapies are increasingly prescribed to treat and maintain remission in a significant number of systemic autoimmune rheumatic diseases. The experience with the use of biologics during gestation is extremely lacking because of the observational nature of the available studies and the difficulty in designing proper clinical trials in pregnancy. Among the studied biologics, more information was published on TNFα inhibitors and, in particular, on their potential passage through the placenta and impact on the fetus. Currently, a fragment of anti-TNFα monoclonal IgG, certolizumab pegol, is considered safe with almost no placental transfer. Subsequent observations are suggesting a comparable safety for the soluble TNFα receptor etanercept. Another biologic, eculizumab, the anti-C5a antibody used to treat complement-mediated microangiopathies, is also considered safe due to the unique engineered IgG2/4κ formulation that limits its passage through the placental barrier. Still, long-term data about children born to women treated with biologics in pregnancy are not attainable. Data on breastfeeding are currently available for several biologics. This article reviews the literature available about which drugs are considered safe during pregnancy and lactation, which are not, and on future prospects.
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Affiliation(s)
- Asmaa Beltagy
- Istituto Auxologico Italiano, IRCCS, Immunorheumatology Research Laboratory, Milan, Italy.,Rheumatology and Clinical Immunology Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Azin Aghamajidi
- Department of Immunology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Laura Trespidi
- Department of Obstetrics and Gynaecology, Fondazione Ca Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Wally Ossola
- Department of Obstetrics and Gynaecology, Fondazione Ca Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Pier Luigi Meroni
- Istituto Auxologico Italiano, IRCCS, Immunorheumatology Research Laboratory, Milan, Italy
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Laube R, Paramsothy S, Leong RW. Use of medications during pregnancy and breastfeeding for Crohn's disease and ulcerative colitis. Expert Opin Drug Saf 2021; 20:275-292. [PMID: 33412078 DOI: 10.1080/14740338.2021.1873948] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Introduction: The peak age of diagnosis of inflammatory bowel disease (IBD) occurs during childbearing years, therefore management of IBD during pregnancy is a frequent occurrence. Maintenance of disease remission is crucial to optimize pregnancy outcomes, and potential maternal or fetal toxicity from medications must be balanced against the risks of untreated IBD.Areas covered: This review summarizes the literature on safety and use of medications for IBD during pregnancy and lactation.Expert opinion: 5-aminosalicylates, corticosteroids and thiopurines are safe for use during pregnancy, while methotrexate and tofacitinib should only be used with extreme caution. Anti-TNF agents (except certolizumab), vedolizumab, ustekinumab and tofacitinib readily traverse the placenta via active transport, therefore theoretically may affect fetal development. Certolizumab only undergoes passive transfer across the placenta, thus has markedly lower cord blood levels making it likely the safest biologic agent for infants. There is reasonable evidence to support the safety of anti-TNF monotherapy and combination therapy during pregnancy and lactation. Vedolizumab and ustekinumab are also thought to be safe in pregnancy and lactation, while tofacitinib is generally avoided due to teratogenic effects in animal studies.
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Affiliation(s)
- Robyn Laube
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia.,Department of Gastroenterology, Macquarie University Hospital, Sydney, Australia
| | - Sudarshan Paramsothy
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia.,Department of Gastroenterology, Macquarie University Hospital, Sydney, Australia.,Department of Gastroenterology and Hepatology, Concord Repatriation General Hospital, Sydney, Australia
| | - Rupert W Leong
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia.,Department of Gastroenterology, Macquarie University Hospital, Sydney, Australia.,Department of Gastroenterology and Hepatology, Concord Repatriation General Hospital, Sydney, Australia
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Reinisch W, Gecse K, Halfvarson J, Irving PM, Jahnsen J, Peyrin-Biroulet L, Rogler G, Schreiber S, Danese S. Clinical Practice of Adalimumab and Infliximab Biosimilar Treatment in Adult Patients With Crohn's Disease. Inflamm Bowel Dis 2021; 27:106-122. [PMID: 32634212 PMCID: PMC7737159 DOI: 10.1093/ibd/izaa078] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Indexed: 12/16/2022]
Abstract
The introduction of tumor necrosis factor (TNF) inhibitors has significantly changed the treatment landscape in Crohn's disease (CD). The overall therapeutic achievements with TNF inhibitors such as infliximab, adalimumab, and certolizumab pegol paved the way to push the boundaries of treatment goals beyond symptomatic relief and toward cessation of objective signs of inflammation, including endoscopic remission. Even though these agents are widely used for the treatment of moderate to severe CD, heterogeneity still exists in translating evidence-based guidelines on the use of anti-TNF agents into actual treatment algorithms in CD. This might be due to several reasons including disparities in health expenditure policies; lack of harmonization between countries; and variations in assessment of disease severity, use of disease monitoring tools, or application of treatment targets by physicians. With the advent of biosimilars, patent-free versions of reference biologics are now available to minimize health inequalities in drug availability. In this context, this article aims to provide practical clinical guidance for the use of infliximab and adalimumab biosimilars in patients with moderate to severe CD by outlining different clinical scenarios that patients may encounter during their treatment journey.
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Affiliation(s)
- Walter Reinisch
- Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Krisztina Gecse
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Jonas Halfvarson
- Department of Gastroenterology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Peter M Irving
- Department of Gastroenterology, Guy’s and St. Thomas’ NHS Foundation Trust, London, UK
| | - Jørgen Jahnsen
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Gastroenterology, Akershus University Hospital, Lørenskog, Norway
| | - Laurent Peyrin-Biroulet
- Department of Hepato-Gastroenterology and Inserm U954, University Hospital of Nancy, Lorraine University, Vandoeuvre-lès-Nancy, France
| | - Gerhard Rogler
- Department of Gastroenterology and Hepatology, University Hospital, University of Zurich, Zurich, Switzerland
| | - Stefan Schreiber
- Institute of Clinical Molecular Biology, Christian-Albrechts-Universität zu Kiel, Kiel, Germany
- Clinic of Internal Medicine I, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Silvio Danese
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center, Milan, Italy
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35
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Ghalandari N, Dolhain RJEM, Hazes JMW, van Puijenbroek EP, Kapur M, Crijns HJMJ. Intrauterine Exposure to Biologics in Inflammatory Autoimmune Diseases: A Systematic Review. Drugs 2020; 80:1699-1722. [PMID: 32852745 PMCID: PMC7568712 DOI: 10.1007/s40265-020-01376-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Inflammatory autoimmune diseases are chronic diseases that often affect women of childbearing age. Therefore, detailed knowledge of the safety profile of medications used for management of inflammatory autoimmune diseases during pregnancy is important. However, in many cases the potential harmful effects of medications (especially biologics) during pregnancy (and lactation) on mother and child have not been fully identified. OBJECTIVE Our aim was to update the data on the occurrence of miscarriages and (major) congenital malformations when using biologics during pregnancy based on newly published articles. Additionally, we selected several different secondary outcomes that may be of interest for clinicians, especially information on adverse events in the use of a specific biologic during pregnancy. MATERIAL AND METHODS A search was conducted from 1 January 2015 until 4 July 2019 in Embase.com, Medline Ovid, Web of Science, Cochrane CENTRAL, and Google Scholar with specific search terms for each database. Selection of publications was based on title/abstract and followed by full text (double blinded, two researchers). An overview was made based on outcomes of interest. References of the included publications were reviewed to include and minimize the missing publications. RESULTS A total of 143 publications were included. The total number of cases ranged from nine for canakinumab to 4276 for infliximab. The rates of miscarriages and major congenital malformations did not show relevant differences from those rates in the general population. CONCLUSION Despite limitations to our study, no major safety issues were reported and no trend could be identified in the reported malformations.
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Affiliation(s)
- N Ghalandari
- Department of Rheumatology, Erasmus University Medical Center, Rotterdam, The Netherlands.
- Medicines Evaluation Board (MEB), Graadt van Roggenweg 500, 3531 AH, Utrecht, The Netherlands.
- Academic Center of Inflammunity, Erasmus University Medical Center, Rotterdam, The Netherlands.
| | - R J E M Dolhain
- Department of Rheumatology, Erasmus University Medical Center, Rotterdam, The Netherlands
- Academic Center of Inflammunity, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - J M W Hazes
- Department of Rheumatology, Erasmus University Medical Center, Rotterdam, The Netherlands
- Medicines Evaluation Board (MEB), Graadt van Roggenweg 500, 3531 AH, Utrecht, The Netherlands
- Academic Center of Inflammunity, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - E P van Puijenbroek
- Netherlands Pharmacovigilance Centre Lareb, 's Hertogenbosch, The Netherlands
| | - M Kapur
- Utrecht University of Medical Sciences, Utrecht, The Netherlands
| | - H J M J Crijns
- Medicines Evaluation Board (MEB), Graadt van Roggenweg 500, 3531 AH, Utrecht, The Netherlands
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36
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D'Amico F, Fiorino G, Furfaro F, Allocca M, Roda G, Loy L, Zilli A, Solitano V, Peyrin-Biroulet L, Danese S. Patient's profiling for therapeutic management of inflammatory bowel disease: a tailored approach. Expert Rev Gastroenterol Hepatol 2020; 14:765-773. [PMID: 32427002 DOI: 10.1080/17474124.2020.1772057] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Introduction: Several biological drugs and a new small molecule are available for the treatment of Crohn's disease and ulcerative colitis. However, to date, no reliable predictors of response to treatment have yet been identified. Areas covered: We focused on studies evaluating the therapeutic management of patients with chronic inflammatory bowel diseases in order to identify any predictive factors of response to drugs and to guide therapeutic decisions based on patient and disease characteristics. Expert opinion: The heterogeneity of literature data, the main retrospective nature of the scientific evidence, and the lack of comparative head-to-head trials are the most relevant limitations for identifying factors predicting drug response. In the near future, a personalized approach to patients with chronic inflammatory diseases will be based on patient's profile to define not only the best drug to use, but also the appropriate follow-up, and the possibility of home care.
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Affiliation(s)
- Ferdinando D'Amico
- Department of Biomedical Sciences, Humanitas University , Milan, Italy.,Department of Gastroenterology and Inserm NGERE U1256, University Hospital of Nancy, University of Lorraine , Vandoeuvre-lès-Nancy, France
| | - Gionata Fiorino
- Department of Biomedical Sciences, Humanitas University , Milan, Italy.,IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center, IRCCS , Milan, Italy
| | - Federica Furfaro
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center, IRCCS , Milan, Italy
| | - Mariangela Allocca
- Department of Biomedical Sciences, Humanitas University , Milan, Italy.,IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center, IRCCS , Milan, Italy
| | - Giulia Roda
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center, IRCCS , Milan, Italy
| | - Laura Loy
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center, IRCCS , Milan, Italy
| | - Alessandra Zilli
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center, IRCCS , Milan, Italy
| | - Virginia Solitano
- Department of Biomedical Sciences, Humanitas University , Milan, Italy
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology and Inserm NGERE U1256, University Hospital of Nancy, University of Lorraine , Vandoeuvre-lès-Nancy, France
| | - Silvio Danese
- Department of Biomedical Sciences, Humanitas University , Milan, Italy.,IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center, IRCCS , Milan, Italy
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37
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Truta B, Leeds IL, Canner JK, Efron JE, Fang SH, Althumari A, Safar B. Early Discontinuation of Infliximab in Pregnant Women With Inflammatory Bowel Disease. Inflamm Bowel Dis 2020; 26:1110-1117. [PMID: 31670762 DOI: 10.1093/ibd/izz250] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Early discontinuation of infliximab (IFX) in pregnant women with inflammatory bowel disease (IBD) decreases the intrauterine fetal exposure to the drug but may increase the risk of disease flaring leading to poor pregnancy outcomes. In this study, we assessed the impact of early IFX discontinuation on mother's disease activity and on their at-risk babies. METHODS In a retrospective study of the Truven Health Analytics MarketScan database from 2011 to 2015, we compared IBD patients who discontinued IFX more than 90 days ("early IFX") with those who discontinue IFX 90 days or less ("late IFX) before delivery. We evaluated the risk of flaring, defined by new steroid prescriptions, visits to emergency room and/or hospital admissions, the pregnancy outcomes, and the at-risk babies. RESULTS After IFX discontinuation, the early IFX group (68 deliveries) required significantly more steroid prescriptions than the late IFX group (318 deliveries) to control disease activity (P < 001). There were more preterm babies in the early IFX group (P < 049), but no difference within the 2 groups was noticed in the rate of intrauterine growth retardation, small for gestation, and stillborn babies. Similarly, there was no increase in acute respiratory infections, development delays, and congenital malformations in babies of the mothers from the late IFX vs early IFX groups. CONCLUSIONS Steroid-free remission IBD mothers are at risk for disease flares and preterm babies when IFX is discontinued early in pregnancy. Continuation of IFX seems to be safe at least for the first year of life.
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Affiliation(s)
- Brindusa Truta
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ira L Leeds
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joseph K Canner
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jonathan E Efron
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sandy H Fang
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Azah Althumari
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Bashar Safar
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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38
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Selinger CP, Nelson-Piercy C, Fraser A, Hall V, Limdi J, Smith L, Smith M, Nasur R, Gunn M, King A, Mohan A, Mulgabal K, Kent A, Kok KB, Glanville T. IBD in pregnancy: recent advances, practical management. Frontline Gastroenterol 2020; 12:214-224. [PMID: 33912333 PMCID: PMC8040511 DOI: 10.1136/flgastro-2019-101371] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 04/27/2020] [Accepted: 05/04/2020] [Indexed: 02/04/2023] Open
Abstract
Inflammatory bowel disease (IBD) poses complex issues in pregnancy, but with high-quality care excellent pregnancy outcomes are achievable. In this article, we review the current evidence and recommendations for pregnant women with IBD and aim to provide guidance for clinicians involved in their care. Many women with IBD have poor knowledge about pregnancy-related issues and a substantial minority remains voluntarily childless. Active IBD is associated with an increased risk of preterm birth, low for gestation weight and fetal loss. With the exception of methotrexate and tofacitinib the risk of a flare outweighs the risk of IBD medication and maintenance of remission from IBD should be the main of care. Most women with IBD will experience a normal pregnancy and can have a vaginal delivery. Active perianal Crohn's disease is an absolute and ileal pouch surgery a relative indication for a caesarean section. Breast feeding is beneficial to the infant and the risk from most IBD medications is negligible.
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Affiliation(s)
| | | | - Aileen Fraser
- Gastroenterology, United Hospitals Bristol, Bristol, Avon, UK
| | - Veronica Hall
- Gastroenterology, Royal Bolton Foundation NHS Trust, Bolton, UK
| | - Jimmy Limdi
- Section of iBD- Division of Gastroenterology, The Pennine Acute Hospitals NHS Trust, Manchester, UK,Gastroenterology, Manchester Academic Health Science Centre, Manchester, UK
| | - Lyn Smith
- Gastroenterology, NHS Greater Glasgow and Clyde North Glasgow University Hospitals Division, Glasgow, UK
| | - Marie Smith
- Obstetrics, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Reem Nasur
- Obstetrics, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Melanie Gunn
- Gastroenterology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, Tyne and Wear, UK
| | - Andrew King
- Gastroenterology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, Tyne and Wear, UK
| | - Aarthi Mohan
- Obstetrics, United Hospitals Bristol, Bristol, Avon, UK
| | | | - Alexandra Kent
- Gastroenterology, King's College Hospital NHS Foundation Trust, London, UK
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Geldhof A, Slater J, Clark M, Chandran U, Coppola D. Exposure to Infliximab During Pregnancy: Post-Marketing Experience. Drug Saf 2020; 43:147-161. [PMID: 31677004 PMCID: PMC7007430 DOI: 10.1007/s40264-019-00881-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background Women of childbearing potential are often treated with monoclonal antibodies to control chronic and debilitating inflammatory diseases. Remicade® (innovator infliximab [IFX]) may cross the placenta after the first trimester of pregnancy. Hence, evidence is needed to optimize treatment while carefully weighing benefits and risks to the mother and child. Here, we report on birth and infant outcomes (up to 2 years) following gestational exposure to IFX based on a summary of cumulative pregnancy reports in women exposed to IFX during pregnancy from the Janssen global safety database. Methods Prospective and medically confirmed safety data on IFX-exposed pregnancies from Janssen’s global safety surveillance database since authorization in 1998 are summarized. Descriptive statistics were used to summarize pregnancy and infant outcomes overall, by disease and timing of exposure. Results As of 23 August 2018, 1850 maternally IFX-exposed pregnancies with known outcomes were identified from the safety database. Of the 1850 pregnancies (mean age 29.7 years), 1526 (82.5%) resulted in live births. When reported, most women had Crohn’s disease (67.7%) or ulcerative colitis (18.4%), and 82.8% of live births were exposed to IFX in the first trimester. Spontaneous abortion/intrauterine death/ectopic pregnancy/molar pregnancy (12.1%), preterm births (9.2%), low birth weight infants (3.6%), congenital anomalies (2.0%), and infant infections (1.2%) were documented. The type of congenital anomalies and frequency of serious infant infections observed were consistent with the general population. Frequencies of congenital anomalies and other adverse outcomes were similar in women exposed to IFX in the first trimester and those exposed in the third trimester. More preterm births (13–18.8%) and infant complications (8.7–12.5%) were reported with concomitant immunosuppressant use. Conclusions The observed prevalence of adverse pregnancy and infant outcomes including congenital anomalies following exposure to IFX did not exceed estimates reported for the general population and no unexpected patterns were observed.
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Affiliation(s)
- Anja Geldhof
- Janssen Biologics B.V., Medical Affairs, Einsteinweg 101, 2333, Leiden, CB, The Netherlands.
| | | | - Michael Clark
- Janssen Research and Development, Spring House, PA, USA
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40
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Bröms G, Kieler H, Ekbom A, Gissler M, Hellgren K, Lahesmaa-Korpinen AM, Pedersen L, Schmitt-Egenolf M, Sørensen HT, Granath F. Anti-TNF treatment during pregnancy and birth outcomes: A population-based study from Denmark, Finland, and Sweden. Pharmacoepidemiol Drug Saf 2020; 29:316-327. [PMID: 32020767 DOI: 10.1002/pds.4930] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 09/24/2019] [Accepted: 10/29/2019] [Indexed: 12/17/2022]
Abstract
PURPOSE To study the risk of preterm birth, caesarean section, and small for gestational age after anti-tumor necrosis factor agent treatment (anti-TNF) in pregnancy. METHODS Population-based study including women with inflammatory bowel disease, rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, and psoriasis, and their infants born 2006 to 2013 from the national health registers in Denmark, Finland, and Sweden. Women treated with anti-TNF were compared with women with nonbiologic systemic treatment. Adalimumab, etanercept, and infliximab were compared pairwise. Continuation of treatment in early pregnancy was compared with discontinuation. Odds ratios with 95% confidence intervals were calculated in logistic regression models adjusted for country and maternal characteristics. RESULTS Among 1 633 909 births, 1027 infants were to women treated with anti-TNF and 9399 to women with nonbiologic systemic treatment. Compared with non-biologic systemic treatment, women with anti-TNF treatment had a higher risk of preterm birth, odds ratio 1.61 (1.29-2.02) and caesarean section, 1.57 (1.35-1.82). The odds ratio for small for gestational age was 1.36 (0.96-1.92). In pairwise comparisons, infliximab was associated with a higher risk of severely small for gestational age for inflammatory joint and skin diseases but not for inflammatory bowel disease. Discontinuation of anti-TNF had opposite effects on preterm birth for inflammatory bowel disease and inflammatory joint and skin diseases. CONCLUSIONS Anti-TNF agents were associated with increased risks of preterm birth, caesarean section, and small for gestational age. However, the diverse findings across disease groups may indicate an association related to the underlying disease activity, rather than to agent-specific effects.
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Affiliation(s)
- Gabriella Bröms
- Centre for Pharmacoepidemiology, Department of Medicine Solna, Karolinska Institutet and Department of Internal Medicine, Danderyd Hospital, Stockholm, Sweden
| | - Helle Kieler
- Centre for Pharmacoepidemiology, Department of Medicine Solna and Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Anders Ekbom
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska institutet, Stockholm, Sweden
| | - Mika Gissler
- Information Services Department, THL National Institute for Health and Welfare, Helsinki, Finland and Division of Family Medicine, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - Karin Hellgren
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska institutet, Stockholm, Sweden
| | | | - Lars Pedersen
- Department of Clinical Epidemiology, Aarhus University, Denmark
| | - Marcus Schmitt-Egenolf
- Dermatology, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | | | - Fredrik Granath
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska institutet, Stockholm, Sweden
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Tandon P, Govardhanam V, Leung K, Maxwell C, Huang V. Systematic review with meta-analysis: risk of adverse pregnancy-related outcomes in inflammatory bowel disease. Aliment Pharmacol Ther 2020; 51:320-333. [PMID: 31912546 DOI: 10.1111/apt.15587] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 09/19/2019] [Accepted: 10/28/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND The effect of inflammatory bowel disease (IBD) on pregnancy-related outcomes remains unknown. AIM To determine the risk of adverse maternal, placental and obstetric outcomes in IBD METHODS: We searched Medline, Embase and Cochrane library through May 2019 for studies reporting adverse maternal, placental and obstetric outcomes in patients with IBD. Odds ratios (OR) with 95% confidence intervals (CI) were calculated for these outcomes in patients with IBD compared to healthy controls. RESULTS Fifty-three studies were included (7917 IBD pregnancies and 3253 healthy control pregnancies). Caesarean delivery was more common in patients with IBD compared to healthy controls (OR 1.79, 95% CI, 1.16-2.77). This remained significant for UC (OR 1.80, 95% CI, 1.21-2.90) but not CD (OR 1.48, 95% CI, 0.94-2.34). Similarly, gestational diabetes occurred more commonly in IBD (OR 2.96, 95% CI, 1.47-5.98). The incidences of placental diseases were 2.0% (95% CI, 0.9%-3.1%) for pre-eclampsia, 3.3% (95% CI, 0%-7.2%) for placental abruption, 0.5% (95% CI, 0.2%-0.9%) for placenta previa and 0.3% (95% CI, 0%-0.5%) for chorioamnionitis. Patients with IBD were more likely to experience preterm prelabour rupture of membranes (OR 12.10, 95% CI, 2.15-67.98), but not early pregnancy loss (OR 1.63, 95% CI 0.49-5.43). Anti-tumour necrosis factor therapy was not associated with chorioamnionitis (OR 1.12, 95% CI, 0.16-7.67), early pregnancy loss (OR 1.49, 95% CI, 0.83-2.64) or placenta previa (OR 1.58, 95% CI, 0.30-8.47). CONCLUSIONS Gestational diabetes and preterm prelabour rupture of membranes occurs more commonly in patients with IBD, although the incidence of placental diseases remains low.
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Affiliation(s)
- Parul Tandon
- Division of Gastroenterology, University of Toronto, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
| | | | - Kristel Leung
- Division of Gastroenterology, University of Toronto, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Cynthia Maxwell
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Vivian Huang
- Division of Gastroenterology, University of Toronto, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
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42
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Uyaroglu OA, Seyhoglu E, Erden A, Kilic L, Karadag O, Akdogan A, Bilgen SA, Ertenli AI, Kiraz S, Kalyoncu U. Pregnancy outcomes in partners of male ankylosing spondylitis patients treated with anti-tumour necrosis factor-α biologics: real-life results from a single-centre cross-sectional study. Rheumatol Int 2020; 40:1501-1507. [PMID: 31993731 DOI: 10.1007/s00296-020-04518-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Accepted: 01/16/2020] [Indexed: 10/25/2022]
Abstract
Most patients with inflammatory arthritis are at their reproductive ages. Use of anti-tumour necrosis factor alpha (anti-TNF-α) agents, one of the important treatment options for inflammatory arthritis, can cause foetal morbidity and mortality. While most studies on the effects of anti-TNF-α agents on pregnancy outcomes are about maternal exposure, the number of studies on the risks related to paternal exposure is insufficient. This study aimed to assess pregnancy periods and outcomes of the partners of male ankylosing spondylitis (AS) patients receiving anti-TNF-α treatment during the preconception period. Totally, 163 male AS patients using anti-TNF-α agents were identified from the Hacettepe University Biological Registry. Of these patients, 45 (27.6%) who declared that their partners got pregnant after initiation on anti-TNF-α agents were included. Data regarding demographics and drug exposure and pregnancy and infant outcomes were evaluated. Of 45 pregnancies, 39 (86.7%) resulted in healthy live births, 3 (6.7%) resulted in spontaneous abortion, and 3 (6.7%) were terminated with curettage. Of 39 live births, 34 (87.2%) were term and 5 (12.8%) were preterm, 30 (76.9%) had normal birth weight, 6 (15.4%) had low birth weight, and 3 (7.7%) had fetal macrosomia. No congenital malformations related to paternal exposure were observed. This study is valuable as being one of the studies providing pregnancy outcomes of partners of male AS patients receiving anti-TNF-α agents with its relatively high number of patients. The results suggested that paternal exposure to anti-TNF-α agents during preconception period could be safe on pregnancy outcomes.
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Affiliation(s)
- Oguz Abdullah Uyaroglu
- Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Sihhiye, 06100, Ankara, Turkey.
| | - Emrah Seyhoglu
- Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Sihhiye, 06100, Ankara, Turkey
| | - Abdulsamet Erden
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Levent Kilic
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Omer Karadag
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Ali Akdogan
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Sule Apras Bilgen
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Ali Ihsan Ertenli
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Sedat Kiraz
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Umut Kalyoncu
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
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Romano C, Esposito S, Ferrara R, Cuomo G. Choosing the most appropriate biologic therapy for Crohn’s disease according to concomitant extra-intestinal manifestations, comorbidities, or physiologic conditions. Expert Opin Biol Ther 2019; 20:49-62. [DOI: 10.1080/14712598.2020.1689953] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Ciro Romano
- Division of Internal Medicine, Department of Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Sergio Esposito
- Division of Internal Medicine, Department of Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Roberta Ferrara
- Division of Internal Medicine, Department of Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Giovanna Cuomo
- Division of Internal Medicine, Department of Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
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Shannahan SE, Erlich JM, Peppercorn MA. Insights into the treatment of inflammatory bowel disease in pregnancy. Therap Adv Gastroenterol 2019; 12:1756284819852231. [PMID: 31191713 PMCID: PMC6540496 DOI: 10.1177/1756284819852231] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 04/17/2019] [Indexed: 02/04/2023] Open
Abstract
Patients diagnosed with inflammatory bowel disease (IBD) are most commonly diagnosed in late adolescence or early adulthood, with half of patients being diagnosed before age 32, thus impacting peak years of reproduction and family planning. While controlled IBD has no negative effects on the ability to conceive, there is overall a trend towards voluntary childlessness due to patients' concerns for adverse fetal outcomes from underlying IBD and from adverse medication effects. Active disease at the time of conception is associated with worsening disease activity during pregnancy and carries a higher risk of poor fetal outcomes. It is therefore important to maintain remission during pregnancy, which is often achieved with pharmacologic therapy. The goal of this paper is to provide a comprehensive review of the current literature and safety data for pharmacologic treatment of IBD in pregnancy, in breastfeeding women, and in men planning to have children.
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Affiliation(s)
- Sarah E. Shannahan
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Jonathan M. Erlich
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Mark A. Peppercorn
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Lai JH, Ling XC, Ho LJ. Useful message in choosing optimal biological agents for patients with autoimmune arthritis. Biochem Pharmacol 2019; 165:99-111. [PMID: 30876919 DOI: 10.1016/j.bcp.2019.03.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Accepted: 03/07/2019] [Indexed: 02/07/2023]
Abstract
The introduction of biological disease-modifying antirheumatic drug (bDMARD) treatments for various types of autoimmune arthritis, such as rheumatoid arthritis, psoriatic arthropathy and ankylosing spondylitis, represents a new era of treatment for patients with a refractory response to conventional synthetic DMARDs (csDMARDs). Many new bDMARDs with different modalities or that target different pro-inflammatory molecules, likely cytokines, are rapidly emerging. Hence, physicians in the field may be confused about choosing appropriate bDMARDs for their patients. Considering the high cost of bDMARDs and the rapid destructive process of autoimmune arthritis in patients, the choice of optimal bDMARDs for patients who fail to respond or show an inadequate therapeutic response to csDMARDs designed to control the disease is very critical. Here, we summarize the strengths and weaknesses of bDMARDs and specifically focus on their uses in patients with comorbid conditions or with specific medical conditions, such as pregnancy. This commentary provides a solid up-to-date review on commercially available bDMARDs and very useful information for physicians to facilitate the choice of more appropriate bDMARDs to treat patients with autoimmune arthritis and for basic researchers to understand the current strategies of bDMARD usage and hopefully to develop more powerful bDMARDs with fewer safety concerns.
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Affiliation(s)
- Jenn-Haung Lai
- Division of Allergy, Immunology, and Rheumatology, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University, Tao-Yuan, Taiwan, ROC; Graduate Institute of Medical Science, National Defense Medical Center, Taipei, Taiwan, ROC.
| | - Xiao Chun Ling
- Department of Ophthalmology, Chang Gung Memorial Hospital, Chang Gung University, Tao-Yuan, Taiwan, ROC
| | - Ling-Jun Ho
- Institute of Cellular and System Medicine, National Health Research Institute, Zhunan, Taiwan, ROC.
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Micu MC, Ostensen M, Bojincă V, Șerban O, Mihai M, Suța C, Ramazan A, Enache L, Bobircă A, Pătcaș SF, Micu R, Ionescu R. Pregnancy Outcomes in Couples with Males Exposed to Longterm Anti-tumor Necrosis Factor- α Inhibitor Therapies: A Prospective Study. J Rheumatol 2019; 46:1084-1088. [PMID: 30824658 DOI: 10.3899/jrheum.180588] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/18/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To examine the pregnancy achievement and outcomes in couples in which men with spondyloarthritis (SpA) were exposed to tumor necrosis factor inhibitors (TNFi). METHODS Information about pregnancies involving fathers with SpA was prospectively collected by 6 Romanian rheumatology centers. RESULTS Twenty-seven patients achieved 33 pregnancies and fathered 30 healthy children. Three elective abortions (personal reasons) and no spontaneous abortions, preeclampsia/eclampsia, stillbirths, congenital malformations, or pathologies in the children were recorded. Five patients showed normospermia before and after longterm TNFi treatment. CONCLUSION Pregnancy and child outcomes in male patients with SpA exposed to longterm TNFi therapy were reassuring.
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Affiliation(s)
- Mihaela C Micu
- From the Rheumatology Division, 2nd Rehabilitation Department, Rehabilitation Clinical Hospital, Cluj-Napoca; Department of Internal Medicine and Rheumatology, "Sfânta Maria" Hospital, Bucharest; 2nd Internal Medicine Department, Mother and Child Department, and Assisted Reproduction Department, 1st Gynecology Clinic, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca; ASTRA Outpatient Clinic, Sibiu; Rheumatology Department, 2nd Internal Medicine Department, "Sf. Apostol Andrei" Emergency County Hospital, Constanța; Clinical Center of Rheumatic Diseases, Bucharest; Department of Internal Medicine and Rheumatology, Dr. I. Cantacuzino Clinical Hospital, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania; Norwegian National Advisory Unit on Pregnancy and Rheumatic Diseases, Department of Rheumatology, St. Olav's Hospital, Trondheim University Hospital, Trondheim; Department of Rheumatology, Sørlandet Sykehus, Kristiansand, Norway.,M.C. Micu, MD, Rheumatology Division, 2nd Rehabilitation Department, Rehabilitation Clinical Hospital; M. Ostensen, Professor, Norwegian National Advisory Unit on Pregnancy and Rheumatic Diseases, Department of Rheumatology, St. Olav's Hospital, Trondheim University Hospital and Department of Rheumatology, Sørlandet Sykehus; V. Bojincă, Lecturer, Department of Internal Medicine and Rheumatology, "Sfânta Maria" Hospital, Bucharest "Carol Davila" University of Medicine and Pharmacy; O. Șerban, Assistant Professor, 2nd Internal Medicine Department, "Iuliu Hatieganu" University of Medicine and Pharmacy; M. Mihai, MD, ASTRA Outpatient Clinic; C. Suța, Assistant Professor, Rheumatology Department, 2nd Internal Medicine Department, "Sf. Apostol Andrei" Emergency County Hospital; A. Ramazan, MD, Rheumatology Department, 2nd Internal Medicine Department, "Sf. Apostol Andrei" Emergency County Hospital; L. Enache, Assistant Professor, Clinical Center of Rheumatic Diseases; A. Bobircă, Assistant Professor, Department of Internal Medicine and Rheumatology, Dr I. Cantacuzino Clinical Hospital, Bucharest "Carol Davila" University of Medicine and Pharmacy; S.F. Pătcaș, MD, Mother and Child Department, 1st Gynecology Clinic, "Iuliu Hatieganu" University of Medicine and Pharmacy; R. Micu, Associate Professor, Assisted Reproduction Department, 1st Gynecology Clinic, "Iuliu Hatieganu" University of Medicine and Pharmacy; R. Ionescu, Professor, Department of Internal Medicine and Rheumatology, "Sfânta Maria" Hospital, Bucharest "Carol Davila" University of Medicine and Pharmacy. Dr. M.C. Micu and Prof. M. Ostensen made equal contributions to this report
| | - Monika Ostensen
- From the Rheumatology Division, 2nd Rehabilitation Department, Rehabilitation Clinical Hospital, Cluj-Napoca; Department of Internal Medicine and Rheumatology, "Sfânta Maria" Hospital, Bucharest; 2nd Internal Medicine Department, Mother and Child Department, and Assisted Reproduction Department, 1st Gynecology Clinic, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca; ASTRA Outpatient Clinic, Sibiu; Rheumatology Department, 2nd Internal Medicine Department, "Sf. Apostol Andrei" Emergency County Hospital, Constanța; Clinical Center of Rheumatic Diseases, Bucharest; Department of Internal Medicine and Rheumatology, Dr. I. Cantacuzino Clinical Hospital, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania; Norwegian National Advisory Unit on Pregnancy and Rheumatic Diseases, Department of Rheumatology, St. Olav's Hospital, Trondheim University Hospital, Trondheim; Department of Rheumatology, Sørlandet Sykehus, Kristiansand, Norway.,M.C. Micu, MD, Rheumatology Division, 2nd Rehabilitation Department, Rehabilitation Clinical Hospital; M. Ostensen, Professor, Norwegian National Advisory Unit on Pregnancy and Rheumatic Diseases, Department of Rheumatology, St. Olav's Hospital, Trondheim University Hospital and Department of Rheumatology, Sørlandet Sykehus; V. Bojincă, Lecturer, Department of Internal Medicine and Rheumatology, "Sfânta Maria" Hospital, Bucharest "Carol Davila" University of Medicine and Pharmacy; O. Șerban, Assistant Professor, 2nd Internal Medicine Department, "Iuliu Hatieganu" University of Medicine and Pharmacy; M. Mihai, MD, ASTRA Outpatient Clinic; C. Suța, Assistant Professor, Rheumatology Department, 2nd Internal Medicine Department, "Sf. Apostol Andrei" Emergency County Hospital; A. Ramazan, MD, Rheumatology Department, 2nd Internal Medicine Department, "Sf. Apostol Andrei" Emergency County Hospital; L. Enache, Assistant Professor, Clinical Center of Rheumatic Diseases; A. Bobircă, Assistant Professor, Department of Internal Medicine and Rheumatology, Dr I. Cantacuzino Clinical Hospital, Bucharest "Carol Davila" University of Medicine and Pharmacy; S.F. Pătcaș, MD, Mother and Child Department, 1st Gynecology Clinic, "Iuliu Hatieganu" University of Medicine and Pharmacy; R. Micu, Associate Professor, Assisted Reproduction Department, 1st Gynecology Clinic, "Iuliu Hatieganu" University of Medicine and Pharmacy; R. Ionescu, Professor, Department of Internal Medicine and Rheumatology, "Sfânta Maria" Hospital, Bucharest "Carol Davila" University of Medicine and Pharmacy. Dr. M.C. Micu and Prof. M. Ostensen made equal contributions to this report
| | - Violeta Bojincă
- From the Rheumatology Division, 2nd Rehabilitation Department, Rehabilitation Clinical Hospital, Cluj-Napoca; Department of Internal Medicine and Rheumatology, "Sfânta Maria" Hospital, Bucharest; 2nd Internal Medicine Department, Mother and Child Department, and Assisted Reproduction Department, 1st Gynecology Clinic, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca; ASTRA Outpatient Clinic, Sibiu; Rheumatology Department, 2nd Internal Medicine Department, "Sf. Apostol Andrei" Emergency County Hospital, Constanța; Clinical Center of Rheumatic Diseases, Bucharest; Department of Internal Medicine and Rheumatology, Dr. I. Cantacuzino Clinical Hospital, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania; Norwegian National Advisory Unit on Pregnancy and Rheumatic Diseases, Department of Rheumatology, St. Olav's Hospital, Trondheim University Hospital, Trondheim; Department of Rheumatology, Sørlandet Sykehus, Kristiansand, Norway.,M.C. Micu, MD, Rheumatology Division, 2nd Rehabilitation Department, Rehabilitation Clinical Hospital; M. Ostensen, Professor, Norwegian National Advisory Unit on Pregnancy and Rheumatic Diseases, Department of Rheumatology, St. Olav's Hospital, Trondheim University Hospital and Department of Rheumatology, Sørlandet Sykehus; V. Bojincă, Lecturer, Department of Internal Medicine and Rheumatology, "Sfânta Maria" Hospital, Bucharest "Carol Davila" University of Medicine and Pharmacy; O. Șerban, Assistant Professor, 2nd Internal Medicine Department, "Iuliu Hatieganu" University of Medicine and Pharmacy; M. Mihai, MD, ASTRA Outpatient Clinic; C. Suța, Assistant Professor, Rheumatology Department, 2nd Internal Medicine Department, "Sf. Apostol Andrei" Emergency County Hospital; A. Ramazan, MD, Rheumatology Department, 2nd Internal Medicine Department, "Sf. Apostol Andrei" Emergency County Hospital; L. Enache, Assistant Professor, Clinical Center of Rheumatic Diseases; A. Bobircă, Assistant Professor, Department of Internal Medicine and Rheumatology, Dr I. Cantacuzino Clinical Hospital, Bucharest "Carol Davila" University of Medicine and Pharmacy; S.F. Pătcaș, MD, Mother and Child Department, 1st Gynecology Clinic, "Iuliu Hatieganu" University of Medicine and Pharmacy; R. Micu, Associate Professor, Assisted Reproduction Department, 1st Gynecology Clinic, "Iuliu Hatieganu" University of Medicine and Pharmacy; R. Ionescu, Professor, Department of Internal Medicine and Rheumatology, "Sfânta Maria" Hospital, Bucharest "Carol Davila" University of Medicine and Pharmacy. Dr. M.C. Micu and Prof. M. Ostensen made equal contributions to this report
| | - Oana Șerban
- From the Rheumatology Division, 2nd Rehabilitation Department, Rehabilitation Clinical Hospital, Cluj-Napoca; Department of Internal Medicine and Rheumatology, "Sfânta Maria" Hospital, Bucharest; 2nd Internal Medicine Department, Mother and Child Department, and Assisted Reproduction Department, 1st Gynecology Clinic, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca; ASTRA Outpatient Clinic, Sibiu; Rheumatology Department, 2nd Internal Medicine Department, "Sf. Apostol Andrei" Emergency County Hospital, Constanța; Clinical Center of Rheumatic Diseases, Bucharest; Department of Internal Medicine and Rheumatology, Dr. I. Cantacuzino Clinical Hospital, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania; Norwegian National Advisory Unit on Pregnancy and Rheumatic Diseases, Department of Rheumatology, St. Olav's Hospital, Trondheim University Hospital, Trondheim; Department of Rheumatology, Sørlandet Sykehus, Kristiansand, Norway.,M.C. Micu, MD, Rheumatology Division, 2nd Rehabilitation Department, Rehabilitation Clinical Hospital; M. Ostensen, Professor, Norwegian National Advisory Unit on Pregnancy and Rheumatic Diseases, Department of Rheumatology, St. Olav's Hospital, Trondheim University Hospital and Department of Rheumatology, Sørlandet Sykehus; V. Bojincă, Lecturer, Department of Internal Medicine and Rheumatology, "Sfânta Maria" Hospital, Bucharest "Carol Davila" University of Medicine and Pharmacy; O. Șerban, Assistant Professor, 2nd Internal Medicine Department, "Iuliu Hatieganu" University of Medicine and Pharmacy; M. Mihai, MD, ASTRA Outpatient Clinic; C. Suța, Assistant Professor, Rheumatology Department, 2nd Internal Medicine Department, "Sf. Apostol Andrei" Emergency County Hospital; A. Ramazan, MD, Rheumatology Department, 2nd Internal Medicine Department, "Sf. Apostol Andrei" Emergency County Hospital; L. Enache, Assistant Professor, Clinical Center of Rheumatic Diseases; A. Bobircă, Assistant Professor, Department of Internal Medicine and Rheumatology, Dr I. Cantacuzino Clinical Hospital, Bucharest "Carol Davila" University of Medicine and Pharmacy; S.F. Pătcaș, MD, Mother and Child Department, 1st Gynecology Clinic, "Iuliu Hatieganu" University of Medicine and Pharmacy; R. Micu, Associate Professor, Assisted Reproduction Department, 1st Gynecology Clinic, "Iuliu Hatieganu" University of Medicine and Pharmacy; R. Ionescu, Professor, Department of Internal Medicine and Rheumatology, "Sfânta Maria" Hospital, Bucharest "Carol Davila" University of Medicine and Pharmacy. Dr. M.C. Micu and Prof. M. Ostensen made equal contributions to this report
| | - Minodora Mihai
- From the Rheumatology Division, 2nd Rehabilitation Department, Rehabilitation Clinical Hospital, Cluj-Napoca; Department of Internal Medicine and Rheumatology, "Sfânta Maria" Hospital, Bucharest; 2nd Internal Medicine Department, Mother and Child Department, and Assisted Reproduction Department, 1st Gynecology Clinic, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca; ASTRA Outpatient Clinic, Sibiu; Rheumatology Department, 2nd Internal Medicine Department, "Sf. Apostol Andrei" Emergency County Hospital, Constanța; Clinical Center of Rheumatic Diseases, Bucharest; Department of Internal Medicine and Rheumatology, Dr. I. Cantacuzino Clinical Hospital, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania; Norwegian National Advisory Unit on Pregnancy and Rheumatic Diseases, Department of Rheumatology, St. Olav's Hospital, Trondheim University Hospital, Trondheim; Department of Rheumatology, Sørlandet Sykehus, Kristiansand, Norway.,M.C. Micu, MD, Rheumatology Division, 2nd Rehabilitation Department, Rehabilitation Clinical Hospital; M. Ostensen, Professor, Norwegian National Advisory Unit on Pregnancy and Rheumatic Diseases, Department of Rheumatology, St. Olav's Hospital, Trondheim University Hospital and Department of Rheumatology, Sørlandet Sykehus; V. Bojincă, Lecturer, Department of Internal Medicine and Rheumatology, "Sfânta Maria" Hospital, Bucharest "Carol Davila" University of Medicine and Pharmacy; O. Șerban, Assistant Professor, 2nd Internal Medicine Department, "Iuliu Hatieganu" University of Medicine and Pharmacy; M. Mihai, MD, ASTRA Outpatient Clinic; C. Suța, Assistant Professor, Rheumatology Department, 2nd Internal Medicine Department, "Sf. Apostol Andrei" Emergency County Hospital; A. Ramazan, MD, Rheumatology Department, 2nd Internal Medicine Department, "Sf. Apostol Andrei" Emergency County Hospital; L. Enache, Assistant Professor, Clinical Center of Rheumatic Diseases; A. Bobircă, Assistant Professor, Department of Internal Medicine and Rheumatology, Dr I. Cantacuzino Clinical Hospital, Bucharest "Carol Davila" University of Medicine and Pharmacy; S.F. Pătcaș, MD, Mother and Child Department, 1st Gynecology Clinic, "Iuliu Hatieganu" University of Medicine and Pharmacy; R. Micu, Associate Professor, Assisted Reproduction Department, 1st Gynecology Clinic, "Iuliu Hatieganu" University of Medicine and Pharmacy; R. Ionescu, Professor, Department of Internal Medicine and Rheumatology, "Sfânta Maria" Hospital, Bucharest "Carol Davila" University of Medicine and Pharmacy. Dr. M.C. Micu and Prof. M. Ostensen made equal contributions to this report
| | - Cristina Suța
- From the Rheumatology Division, 2nd Rehabilitation Department, Rehabilitation Clinical Hospital, Cluj-Napoca; Department of Internal Medicine and Rheumatology, "Sfânta Maria" Hospital, Bucharest; 2nd Internal Medicine Department, Mother and Child Department, and Assisted Reproduction Department, 1st Gynecology Clinic, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca; ASTRA Outpatient Clinic, Sibiu; Rheumatology Department, 2nd Internal Medicine Department, "Sf. Apostol Andrei" Emergency County Hospital, Constanța; Clinical Center of Rheumatic Diseases, Bucharest; Department of Internal Medicine and Rheumatology, Dr. I. Cantacuzino Clinical Hospital, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania; Norwegian National Advisory Unit on Pregnancy and Rheumatic Diseases, Department of Rheumatology, St. Olav's Hospital, Trondheim University Hospital, Trondheim; Department of Rheumatology, Sørlandet Sykehus, Kristiansand, Norway.,M.C. Micu, MD, Rheumatology Division, 2nd Rehabilitation Department, Rehabilitation Clinical Hospital; M. Ostensen, Professor, Norwegian National Advisory Unit on Pregnancy and Rheumatic Diseases, Department of Rheumatology, St. Olav's Hospital, Trondheim University Hospital and Department of Rheumatology, Sørlandet Sykehus; V. Bojincă, Lecturer, Department of Internal Medicine and Rheumatology, "Sfânta Maria" Hospital, Bucharest "Carol Davila" University of Medicine and Pharmacy; O. Șerban, Assistant Professor, 2nd Internal Medicine Department, "Iuliu Hatieganu" University of Medicine and Pharmacy; M. Mihai, MD, ASTRA Outpatient Clinic; C. Suța, Assistant Professor, Rheumatology Department, 2nd Internal Medicine Department, "Sf. Apostol Andrei" Emergency County Hospital; A. Ramazan, MD, Rheumatology Department, 2nd Internal Medicine Department, "Sf. Apostol Andrei" Emergency County Hospital; L. Enache, Assistant Professor, Clinical Center of Rheumatic Diseases; A. Bobircă, Assistant Professor, Department of Internal Medicine and Rheumatology, Dr I. Cantacuzino Clinical Hospital, Bucharest "Carol Davila" University of Medicine and Pharmacy; S.F. Pătcaș, MD, Mother and Child Department, 1st Gynecology Clinic, "Iuliu Hatieganu" University of Medicine and Pharmacy; R. Micu, Associate Professor, Assisted Reproduction Department, 1st Gynecology Clinic, "Iuliu Hatieganu" University of Medicine and Pharmacy; R. Ionescu, Professor, Department of Internal Medicine and Rheumatology, "Sfânta Maria" Hospital, Bucharest "Carol Davila" University of Medicine and Pharmacy. Dr. M.C. Micu and Prof. M. Ostensen made equal contributions to this report
| | - Anamaria Ramazan
- From the Rheumatology Division, 2nd Rehabilitation Department, Rehabilitation Clinical Hospital, Cluj-Napoca; Department of Internal Medicine and Rheumatology, "Sfânta Maria" Hospital, Bucharest; 2nd Internal Medicine Department, Mother and Child Department, and Assisted Reproduction Department, 1st Gynecology Clinic, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca; ASTRA Outpatient Clinic, Sibiu; Rheumatology Department, 2nd Internal Medicine Department, "Sf. Apostol Andrei" Emergency County Hospital, Constanța; Clinical Center of Rheumatic Diseases, Bucharest; Department of Internal Medicine and Rheumatology, Dr. I. Cantacuzino Clinical Hospital, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania; Norwegian National Advisory Unit on Pregnancy and Rheumatic Diseases, Department of Rheumatology, St. Olav's Hospital, Trondheim University Hospital, Trondheim; Department of Rheumatology, Sørlandet Sykehus, Kristiansand, Norway.,M.C. Micu, MD, Rheumatology Division, 2nd Rehabilitation Department, Rehabilitation Clinical Hospital; M. Ostensen, Professor, Norwegian National Advisory Unit on Pregnancy and Rheumatic Diseases, Department of Rheumatology, St. Olav's Hospital, Trondheim University Hospital and Department of Rheumatology, Sørlandet Sykehus; V. Bojincă, Lecturer, Department of Internal Medicine and Rheumatology, "Sfânta Maria" Hospital, Bucharest "Carol Davila" University of Medicine and Pharmacy; O. Șerban, Assistant Professor, 2nd Internal Medicine Department, "Iuliu Hatieganu" University of Medicine and Pharmacy; M. Mihai, MD, ASTRA Outpatient Clinic; C. Suța, Assistant Professor, Rheumatology Department, 2nd Internal Medicine Department, "Sf. Apostol Andrei" Emergency County Hospital; A. Ramazan, MD, Rheumatology Department, 2nd Internal Medicine Department, "Sf. Apostol Andrei" Emergency County Hospital; L. Enache, Assistant Professor, Clinical Center of Rheumatic Diseases; A. Bobircă, Assistant Professor, Department of Internal Medicine and Rheumatology, Dr I. Cantacuzino Clinical Hospital, Bucharest "Carol Davila" University of Medicine and Pharmacy; S.F. Pătcaș, MD, Mother and Child Department, 1st Gynecology Clinic, "Iuliu Hatieganu" University of Medicine and Pharmacy; R. Micu, Associate Professor, Assisted Reproduction Department, 1st Gynecology Clinic, "Iuliu Hatieganu" University of Medicine and Pharmacy; R. Ionescu, Professor, Department of Internal Medicine and Rheumatology, "Sfânta Maria" Hospital, Bucharest "Carol Davila" University of Medicine and Pharmacy. Dr. M.C. Micu and Prof. M. Ostensen made equal contributions to this report
| | - Luminița Enache
- From the Rheumatology Division, 2nd Rehabilitation Department, Rehabilitation Clinical Hospital, Cluj-Napoca; Department of Internal Medicine and Rheumatology, "Sfânta Maria" Hospital, Bucharest; 2nd Internal Medicine Department, Mother and Child Department, and Assisted Reproduction Department, 1st Gynecology Clinic, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca; ASTRA Outpatient Clinic, Sibiu; Rheumatology Department, 2nd Internal Medicine Department, "Sf. Apostol Andrei" Emergency County Hospital, Constanța; Clinical Center of Rheumatic Diseases, Bucharest; Department of Internal Medicine and Rheumatology, Dr. I. Cantacuzino Clinical Hospital, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania; Norwegian National Advisory Unit on Pregnancy and Rheumatic Diseases, Department of Rheumatology, St. Olav's Hospital, Trondheim University Hospital, Trondheim; Department of Rheumatology, Sørlandet Sykehus, Kristiansand, Norway.,M.C. Micu, MD, Rheumatology Division, 2nd Rehabilitation Department, Rehabilitation Clinical Hospital; M. Ostensen, Professor, Norwegian National Advisory Unit on Pregnancy and Rheumatic Diseases, Department of Rheumatology, St. Olav's Hospital, Trondheim University Hospital and Department of Rheumatology, Sørlandet Sykehus; V. Bojincă, Lecturer, Department of Internal Medicine and Rheumatology, "Sfânta Maria" Hospital, Bucharest "Carol Davila" University of Medicine and Pharmacy; O. Șerban, Assistant Professor, 2nd Internal Medicine Department, "Iuliu Hatieganu" University of Medicine and Pharmacy; M. Mihai, MD, ASTRA Outpatient Clinic; C. Suța, Assistant Professor, Rheumatology Department, 2nd Internal Medicine Department, "Sf. Apostol Andrei" Emergency County Hospital; A. Ramazan, MD, Rheumatology Department, 2nd Internal Medicine Department, "Sf. Apostol Andrei" Emergency County Hospital; L. Enache, Assistant Professor, Clinical Center of Rheumatic Diseases; A. Bobircă, Assistant Professor, Department of Internal Medicine and Rheumatology, Dr I. Cantacuzino Clinical Hospital, Bucharest "Carol Davila" University of Medicine and Pharmacy; S.F. Pătcaș, MD, Mother and Child Department, 1st Gynecology Clinic, "Iuliu Hatieganu" University of Medicine and Pharmacy; R. Micu, Associate Professor, Assisted Reproduction Department, 1st Gynecology Clinic, "Iuliu Hatieganu" University of Medicine and Pharmacy; R. Ionescu, Professor, Department of Internal Medicine and Rheumatology, "Sfânta Maria" Hospital, Bucharest "Carol Davila" University of Medicine and Pharmacy. Dr. M.C. Micu and Prof. M. Ostensen made equal contributions to this report
| | - Anca Bobircă
- From the Rheumatology Division, 2nd Rehabilitation Department, Rehabilitation Clinical Hospital, Cluj-Napoca; Department of Internal Medicine and Rheumatology, "Sfânta Maria" Hospital, Bucharest; 2nd Internal Medicine Department, Mother and Child Department, and Assisted Reproduction Department, 1st Gynecology Clinic, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca; ASTRA Outpatient Clinic, Sibiu; Rheumatology Department, 2nd Internal Medicine Department, "Sf. Apostol Andrei" Emergency County Hospital, Constanța; Clinical Center of Rheumatic Diseases, Bucharest; Department of Internal Medicine and Rheumatology, Dr. I. Cantacuzino Clinical Hospital, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania; Norwegian National Advisory Unit on Pregnancy and Rheumatic Diseases, Department of Rheumatology, St. Olav's Hospital, Trondheim University Hospital, Trondheim; Department of Rheumatology, Sørlandet Sykehus, Kristiansand, Norway.,M.C. Micu, MD, Rheumatology Division, 2nd Rehabilitation Department, Rehabilitation Clinical Hospital; M. Ostensen, Professor, Norwegian National Advisory Unit on Pregnancy and Rheumatic Diseases, Department of Rheumatology, St. Olav's Hospital, Trondheim University Hospital and Department of Rheumatology, Sørlandet Sykehus; V. Bojincă, Lecturer, Department of Internal Medicine and Rheumatology, "Sfânta Maria" Hospital, Bucharest "Carol Davila" University of Medicine and Pharmacy; O. Șerban, Assistant Professor, 2nd Internal Medicine Department, "Iuliu Hatieganu" University of Medicine and Pharmacy; M. Mihai, MD, ASTRA Outpatient Clinic; C. Suța, Assistant Professor, Rheumatology Department, 2nd Internal Medicine Department, "Sf. Apostol Andrei" Emergency County Hospital; A. Ramazan, MD, Rheumatology Department, 2nd Internal Medicine Department, "Sf. Apostol Andrei" Emergency County Hospital; L. Enache, Assistant Professor, Clinical Center of Rheumatic Diseases; A. Bobircă, Assistant Professor, Department of Internal Medicine and Rheumatology, Dr I. Cantacuzino Clinical Hospital, Bucharest "Carol Davila" University of Medicine and Pharmacy; S.F. Pătcaș, MD, Mother and Child Department, 1st Gynecology Clinic, "Iuliu Hatieganu" University of Medicine and Pharmacy; R. Micu, Associate Professor, Assisted Reproduction Department, 1st Gynecology Clinic, "Iuliu Hatieganu" University of Medicine and Pharmacy; R. Ionescu, Professor, Department of Internal Medicine and Rheumatology, "Sfânta Maria" Hospital, Bucharest "Carol Davila" University of Medicine and Pharmacy. Dr. M.C. Micu and Prof. M. Ostensen made equal contributions to this report
| | - Sergiu F Pătcaș
- From the Rheumatology Division, 2nd Rehabilitation Department, Rehabilitation Clinical Hospital, Cluj-Napoca; Department of Internal Medicine and Rheumatology, "Sfânta Maria" Hospital, Bucharest; 2nd Internal Medicine Department, Mother and Child Department, and Assisted Reproduction Department, 1st Gynecology Clinic, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca; ASTRA Outpatient Clinic, Sibiu; Rheumatology Department, 2nd Internal Medicine Department, "Sf. Apostol Andrei" Emergency County Hospital, Constanța; Clinical Center of Rheumatic Diseases, Bucharest; Department of Internal Medicine and Rheumatology, Dr. I. Cantacuzino Clinical Hospital, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania; Norwegian National Advisory Unit on Pregnancy and Rheumatic Diseases, Department of Rheumatology, St. Olav's Hospital, Trondheim University Hospital, Trondheim; Department of Rheumatology, Sørlandet Sykehus, Kristiansand, Norway.,M.C. Micu, MD, Rheumatology Division, 2nd Rehabilitation Department, Rehabilitation Clinical Hospital; M. Ostensen, Professor, Norwegian National Advisory Unit on Pregnancy and Rheumatic Diseases, Department of Rheumatology, St. Olav's Hospital, Trondheim University Hospital and Department of Rheumatology, Sørlandet Sykehus; V. Bojincă, Lecturer, Department of Internal Medicine and Rheumatology, "Sfânta Maria" Hospital, Bucharest "Carol Davila" University of Medicine and Pharmacy; O. Șerban, Assistant Professor, 2nd Internal Medicine Department, "Iuliu Hatieganu" University of Medicine and Pharmacy; M. Mihai, MD, ASTRA Outpatient Clinic; C. Suța, Assistant Professor, Rheumatology Department, 2nd Internal Medicine Department, "Sf. Apostol Andrei" Emergency County Hospital; A. Ramazan, MD, Rheumatology Department, 2nd Internal Medicine Department, "Sf. Apostol Andrei" Emergency County Hospital; L. Enache, Assistant Professor, Clinical Center of Rheumatic Diseases; A. Bobircă, Assistant Professor, Department of Internal Medicine and Rheumatology, Dr I. Cantacuzino Clinical Hospital, Bucharest "Carol Davila" University of Medicine and Pharmacy; S.F. Pătcaș, MD, Mother and Child Department, 1st Gynecology Clinic, "Iuliu Hatieganu" University of Medicine and Pharmacy; R. Micu, Associate Professor, Assisted Reproduction Department, 1st Gynecology Clinic, "Iuliu Hatieganu" University of Medicine and Pharmacy; R. Ionescu, Professor, Department of Internal Medicine and Rheumatology, "Sfânta Maria" Hospital, Bucharest "Carol Davila" University of Medicine and Pharmacy. Dr. M.C. Micu and Prof. M. Ostensen made equal contributions to this report
| | - Romeo Micu
- From the Rheumatology Division, 2nd Rehabilitation Department, Rehabilitation Clinical Hospital, Cluj-Napoca; Department of Internal Medicine and Rheumatology, "Sfânta Maria" Hospital, Bucharest; 2nd Internal Medicine Department, Mother and Child Department, and Assisted Reproduction Department, 1st Gynecology Clinic, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca; ASTRA Outpatient Clinic, Sibiu; Rheumatology Department, 2nd Internal Medicine Department, "Sf. Apostol Andrei" Emergency County Hospital, Constanța; Clinical Center of Rheumatic Diseases, Bucharest; Department of Internal Medicine and Rheumatology, Dr. I. Cantacuzino Clinical Hospital, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania; Norwegian National Advisory Unit on Pregnancy and Rheumatic Diseases, Department of Rheumatology, St. Olav's Hospital, Trondheim University Hospital, Trondheim; Department of Rheumatology, Sørlandet Sykehus, Kristiansand, Norway. .,M.C. Micu, MD, Rheumatology Division, 2nd Rehabilitation Department, Rehabilitation Clinical Hospital; M. Ostensen, Professor, Norwegian National Advisory Unit on Pregnancy and Rheumatic Diseases, Department of Rheumatology, St. Olav's Hospital, Trondheim University Hospital and Department of Rheumatology, Sørlandet Sykehus; V. Bojincă, Lecturer, Department of Internal Medicine and Rheumatology, "Sfânta Maria" Hospital, Bucharest "Carol Davila" University of Medicine and Pharmacy; O. Șerban, Assistant Professor, 2nd Internal Medicine Department, "Iuliu Hatieganu" University of Medicine and Pharmacy; M. Mihai, MD, ASTRA Outpatient Clinic; C. Suța, Assistant Professor, Rheumatology Department, 2nd Internal Medicine Department, "Sf. Apostol Andrei" Emergency County Hospital; A. Ramazan, MD, Rheumatology Department, 2nd Internal Medicine Department, "Sf. Apostol Andrei" Emergency County Hospital; L. Enache, Assistant Professor, Clinical Center of Rheumatic Diseases; A. Bobircă, Assistant Professor, Department of Internal Medicine and Rheumatology, Dr I. Cantacuzino Clinical Hospital, Bucharest "Carol Davila" University of Medicine and Pharmacy; S.F. Pătcaș, MD, Mother and Child Department, 1st Gynecology Clinic, "Iuliu Hatieganu" University of Medicine and Pharmacy; R. Micu, Associate Professor, Assisted Reproduction Department, 1st Gynecology Clinic, "Iuliu Hatieganu" University of Medicine and Pharmacy; R. Ionescu, Professor, Department of Internal Medicine and Rheumatology, "Sfânta Maria" Hospital, Bucharest "Carol Davila" University of Medicine and Pharmacy. Dr. M.C. Micu and Prof. M. Ostensen made equal contributions to this report.
| | - Ruxandra Ionescu
- From the Rheumatology Division, 2nd Rehabilitation Department, Rehabilitation Clinical Hospital, Cluj-Napoca; Department of Internal Medicine and Rheumatology, "Sfânta Maria" Hospital, Bucharest; 2nd Internal Medicine Department, Mother and Child Department, and Assisted Reproduction Department, 1st Gynecology Clinic, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca; ASTRA Outpatient Clinic, Sibiu; Rheumatology Department, 2nd Internal Medicine Department, "Sf. Apostol Andrei" Emergency County Hospital, Constanța; Clinical Center of Rheumatic Diseases, Bucharest; Department of Internal Medicine and Rheumatology, Dr. I. Cantacuzino Clinical Hospital, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania; Norwegian National Advisory Unit on Pregnancy and Rheumatic Diseases, Department of Rheumatology, St. Olav's Hospital, Trondheim University Hospital, Trondheim; Department of Rheumatology, Sørlandet Sykehus, Kristiansand, Norway.,M.C. Micu, MD, Rheumatology Division, 2nd Rehabilitation Department, Rehabilitation Clinical Hospital; M. Ostensen, Professor, Norwegian National Advisory Unit on Pregnancy and Rheumatic Diseases, Department of Rheumatology, St. Olav's Hospital, Trondheim University Hospital and Department of Rheumatology, Sørlandet Sykehus; V. Bojincă, Lecturer, Department of Internal Medicine and Rheumatology, "Sfânta Maria" Hospital, Bucharest "Carol Davila" University of Medicine and Pharmacy; O. Șerban, Assistant Professor, 2nd Internal Medicine Department, "Iuliu Hatieganu" University of Medicine and Pharmacy; M. Mihai, MD, ASTRA Outpatient Clinic; C. Suța, Assistant Professor, Rheumatology Department, 2nd Internal Medicine Department, "Sf. Apostol Andrei" Emergency County Hospital; A. Ramazan, MD, Rheumatology Department, 2nd Internal Medicine Department, "Sf. Apostol Andrei" Emergency County Hospital; L. Enache, Assistant Professor, Clinical Center of Rheumatic Diseases; A. Bobircă, Assistant Professor, Department of Internal Medicine and Rheumatology, Dr I. Cantacuzino Clinical Hospital, Bucharest "Carol Davila" University of Medicine and Pharmacy; S.F. Pătcaș, MD, Mother and Child Department, 1st Gynecology Clinic, "Iuliu Hatieganu" University of Medicine and Pharmacy; R. Micu, Associate Professor, Assisted Reproduction Department, 1st Gynecology Clinic, "Iuliu Hatieganu" University of Medicine and Pharmacy; R. Ionescu, Professor, Department of Internal Medicine and Rheumatology, "Sfânta Maria" Hospital, Bucharest "Carol Davila" University of Medicine and Pharmacy. Dr. M.C. Micu and Prof. M. Ostensen made equal contributions to this report
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