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Giles I, Thorne I, Schmidt NS, Reid C, Crossley A, Panca M, Freemantle N, Tower C, Dass S, Sharma SK, Williams D, O'Neill S, Dolhain RJEM, Toplak N, Hodson K, Nelson-Piercy C, Clowse MEB. The time of equipoise on the use of biological DMARDs in for inflammatory arthritis during pregnancy is finally over: a reappraisal of evidence to optimise pregnancy management. THE LANCET. RHEUMATOLOGY 2024:S2665-9913(24)00097-3. [PMID: 38876126 DOI: 10.1016/s2665-9913(24)00097-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 11/22/2023] [Accepted: 04/10/2024] [Indexed: 06/16/2024]
Abstract
Active inflammatory arthritis in pregnancy is associated with an increased risk of adverse pregnancy outcomes. Treatment of active inflammation and maintenance of low disease activity with medication reduces these risks. Therapeutic decisions on disease-modifying antirheumatic drugs (DMARDs) in pregnancy are complicated by safety concerns, which have led to inappropriate withdrawal of treatment and consequential harm to mother and fetus. Studies of inflammatory arthritis in pregnancy have consistently shown minimal safety concerns with the use of biological DMARDs and an increased risk of disease flare with discontinuation of biological DMARDs. It is our opinion that during pregnancy, the benefits of disease control with biological DMARDs, when required in addition to conventional synthetic DMARDs, outweigh the risks. In this Series paper, we review the reasons for reconsideration of equipoise and propose an agenda for future research to optimise the use of biological DMARDs in inflammatory arthritis during pregnancy.
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Affiliation(s)
- Ian Giles
- Centre for Rheumatology, Division of Medicine, University College London, London, UK.
| | - Iona Thorne
- Chelsea and Westminster Hospital NHS Trust, London, UK
| | - Nanna Surlemont Schmidt
- Danish Centre for Expertise in Rheumatology (CeViG), Danish Hospital for Rheumatic Diseases, Sønderborg, Denmark; Thrombosis and Haemostasis, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Claire Reid
- Department of Rheumatology, UCLH, London, UK
| | | | - Monica Panca
- Comprehensive Clinical Trials Unit, University College London, London, UK
| | - Nick Freemantle
- Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Clare Tower
- Obstetrics and Maternal and Fetal Medicine, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester, UK
| | - Shouvik Dass
- Department of Rheumatology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Shefali K Sharma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - David Williams
- UCL Elizabeth Garrett Anderson Institute for Women's Health, London, UK
| | - Sean O'Neill
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Department of Rheumatology, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Radboud J E M Dolhain
- Department of Rheumatology, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Nataša Toplak
- Department of Allergology, Rheumatology and Clinical Immunology, University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Kenneth Hodson
- Obstetrics and Maternal Medicine, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK; UK Teratology Information Service, Newcastle, UK
| | | | - Megan E B Clowse
- Division of Rheumatology and Immunology, Duke University School of Medicine, Durham, NC, USA
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Schenone C, Pacini G, Gotelli E, Hysa E, Campitiello R, Sammorì S, Paolino S, Sulli A, Cutolo M. Updating on pregnancy in rheumatoid arthritis. Expert Rev Clin Immunol 2024:1-12. [PMID: 38748553 DOI: 10.1080/1744666x.2024.2356164] [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: 12/10/2023] [Accepted: 05/13/2024] [Indexed: 05/21/2024]
Abstract
INTRODUCTION Rheumatoid arthritis (RA), the most prevalent autoimmune disease in reproductive years, exhibits a higher incidence in females, suggesting involvement of estrogens, genetics and environmental factors in disease onset. Literature shows smaller families in RA patients, driving increased interest in Assisted Reproductive Techniques. AREAS COVERED This review elucidates how immunotolerance mechanisms contribute to favorable pregnancy outcomes in RA, emphasizing the need for a careful pregnancy planning to mitigate fetal complications and postnatal flares, which surpass those in the general population. A thorough medication evaluation, orchestrated by a multidisciplinary team, is imperative during pregnancy, weighing potential teratogenic effects against safer alternatives to balance medication safety with disease control. A systematic literature search on PubMed and MEDLINE, using specific terms, covered relevant academic journals up to the latest date. EXPERT OPINION This narrative review comprehensively addresses pregnancy-related considerations in RA patients, prioritizing meticulous disease management with pregnancy and breastfeeding-compatible drugs in line with the latest recommendations and registry data. The focus remains on evaluating glucocorticoids, conventional, and biological disease-modifying drugs for compatibility during pregnancy and breastfeeding. Additionally, the evolving landscape of targeted synthetic drugs during pregnancy is explored, providing insights into the latest developments in rheumatological care.
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Affiliation(s)
- Carlotta Schenone
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine and Specialties, University of Genova, Genova, Italy
| | - Greta Pacini
- Rheumatology Unit, Santa Chiara Hospital, APSS Trento, Trento, Italy
| | - Emanuele Gotelli
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine and Specialties, University of Genova, Genova, Italy
| | - Elvis Hysa
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine and Specialties, University of Genova, Genova, Italy
| | - Rosanna Campitiello
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine and Specialties, University of Genova, Genova, Italy
- IRCCS San Martino Polyclinic Hospital, Genoa, Italy
| | - Silvia Sammorì
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine and Specialties, University of Genova, Genova, Italy
- IRCCS San Martino Polyclinic Hospital, Genoa, Italy
| | - Sabrina Paolino
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine and Specialties, University of Genova, Genova, Italy
- IRCCS San Martino Polyclinic Hospital, Genoa, Italy
| | - Alberto Sulli
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine and Specialties, University of Genova, Genova, Italy
- IRCCS San Martino Polyclinic Hospital, Genoa, Italy
| | - Maurizio Cutolo
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine and Specialties, University of Genova, Genova, Italy
- IRCCS San Martino Polyclinic Hospital, Genoa, Italy
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Akira T, Shimazu Y, Hashimoto N, Okushima H, Suzuki T, Tada T, Ikoma M, Hosokawa T, Ueda Y, Takemura M, Fujiwara H. Successful Pregnancy Outcome in a Patient with Juvenile Idiopathic Arthritis in Adulthood, Amyloid A Amyloidosis, and Chronic Kidney Disease Using Tocilizumab with Strict Blood Pressure Control. Intern Med 2024; 63:1311-1316. [PMID: 37779073 PMCID: PMC11116017 DOI: 10.2169/internalmedicine.1951-23] [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: 03/10/2023] [Accepted: 08/15/2023] [Indexed: 10/03/2023] Open
Abstract
Pregnancies with chronic kidney disease (CKD) and high disease activity in rheumatic diseases are high-risk events with adverse outcomes for both the mother and fetus. We herein report a 35-year-old woman with juvenile idiopathic arthritis (JIA), amyloid A (AA) amyloidosis related to JIA, and CKD stage G4A2 who wished to have children. She achieved a successful pregnancy, even in the presence of these multiple risk factors, using tocilizumab to control the disease activity of JIA and AA amyloidosis, along with antihypertensive drugs to control her blood pressure before and during pregnancy.
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Affiliation(s)
- Taro Akira
- Division of Rheumatology and Allergy, Osaka General Medical Center, Japan
| | - Yukiko Shimazu
- Department of Obstetrics/Gynecology, Osaka General Medical Center, Japan
| | - Nobuhiro Hashimoto
- Department of Kidney Disease and Hypertension, Osaka General Medical Center, Japan
| | - Hiroki Okushima
- Department of Kidney Disease and Hypertension, Osaka General Medical Center, Japan
| | - Takehiro Suzuki
- Division of Rheumatology and Allergy, Osaka General Medical Center, Japan
| | - Tomomi Tada
- Division of Rheumatology and Allergy, Osaka General Medical Center, Japan
| | - Makiko Ikoma
- Division of Rheumatology and Allergy, Osaka General Medical Center, Japan
| | - Takashi Hosokawa
- Division of Rheumatology and Allergy, Osaka General Medical Center, Japan
| | - Yoshiyasu Ueda
- Department of Kidney Disease and Hypertension, Osaka General Medical Center, Japan
| | - Masahiko Takemura
- Department of Obstetrics/Gynecology, Osaka General Medical Center, Japan
| | - Hiroshi Fujiwara
- Division of Rheumatology and Allergy, Osaka General Medical Center, Japan
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Jia JN, Wang XL. Real-world pharmacological treatment of pregnant patients with rheumatic diseases from China: a retrospective analysis from 2016 to 2021. Front Pharmacol 2024; 15:1353293. [PMID: 38694907 PMCID: PMC11061436 DOI: 10.3389/fphar.2024.1353293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 03/25/2024] [Indexed: 05/04/2024] Open
Abstract
Introduction: We investigated trends in the use of therapeutic drugs for pregnant patients with rheumatic diseases in nine Chinese cities (Beijing, Chengdu, Guangzhou, Harbin, Hangzhou, Shanghai, Shenyang, Tianjin, and Zhengzhou) to provide a reference for drug use in clinic. Methods: Outpatient prescription data for pregnant patients diagnosed with rheumatic diseases in nine cities across China in 2016-2021 were extracted from the Hospital Prescription Cooperation Project of the Hospital Pharmacy Professional Committee of the Chinese Pharmaceutical Association. A retrospective analysis was then performed, incorporating data on patient age, defined daily doses (DDDs), defined daily cost (DDC), and other metrics. Results: In 2016-2020, more than 70% of the pregnant patients diagnosed with rheumatic diseases in these nine cities were 25 to < 35 years of age. The most common rheumatic diseases during pregnancy were antiphospholipid antibody syndrome (APS) and systemic lupus erythematosus (SLE). In terms of the routine use of daily therapeutic drugs, the DDDs of low molecular weight heparins (LMWHs), glucocorticoids, and immunosuppressive agents dominated the top three. Intravenous immunoglobulin (IVIG) and tumor necrosis factor inhibitors (TNFi) have been used since 2019 and had been in the forefront of the DDC. Conclusion: The number and total cost of prescriptions for therapeutic drugs of pregnancy complicated by rheumatic diseases, have increased significantly over the study interval. Conventional therapeutic drugs, especially glucocorticoids, LMWHs, and hydroxychloroquine were the most widely used drugs in pregnant patients with rheumatic diseases. However, IVIG and TNFi, relatively high cost, have shown gradual increases in clinical use since 2019.
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Affiliation(s)
| | - Xian-Li Wang
- Department of Pharmacy, The Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
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5
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Caporali R, Germinario S, Kacsándi D, Choy E, Szekanecz Z. Start RA treatment - Biologics or JAK-inhibitors? Autoimmun Rev 2024; 23:103429. [PMID: 37634678 DOI: 10.1016/j.autrev.2023.103429] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 08/24/2023] [Indexed: 08/29/2023]
Abstract
Janus Kinase inhibitors (JAKi) have been approved for the treatment of Rheumatoid Arthritis (RA) for several years. They are the first oral advanced treatment with efficacy similar to, if not greater than, biologic agents. Recently, concerns over their safety was raised by the results from Oral Surveillance trial suggesting that tofacitinib, one of the JAKi, was associated with higher cardiovascular adverse events and malignancies than TNF inhibitors (TNFi). Since then, regulatory authorities have added warnings to the labels of JAKi. On this purpose, whether rheumatologists should use JAKi as first line advance treatment has become a controversial topic. Some rheumatologists have argued that biologics should be first line advance treatment since there are extensive effectiveness and safety data. In addition, with the advent of biosimilar drugs, they are the most cost-effective treatment. On the other hand, JAKi are very efficacious and are generally safe apart from older and high-risk patients. When TNFi are contraindicated and in certain RA patients ,especially when an oral drug is preferable, JAKi have significant advantage providing patients are involved in the decision-making process.
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Affiliation(s)
- Roberto Caporali
- Department of Clinical Sciences and Community Health, University of Milan and ASST G. Pini-CTO, Milan, Italy.
| | - Sabino Germinario
- Department of Clinical Sciences and Community Health, University of Milan and ASST G. Pini-CTO, Milan, Italy
| | - Dorottya Kacsándi
- Department of Rheumatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Ernest Choy
- CREATE Centre, Division of Infection and Immunity, Cardiff University, Cardiff, UK
| | - Zoltán Szekanecz
- Department of Rheumatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
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6
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Schreiber K, Giles I, Costedoat-Chalumeau N, Nelson-Piercy C, Dolhain RJ, Mosca M, Förger F, Fischer-Betz R, Molto A, Tincani A, Pasquier E, Marin B, Elefant E, Salmon J, Bermas BL, Sammaritano L, Clowse MEB, Chambers C, Buyon J, Inoue SA, Agmon-Levin N, Aguilera S, Emadi SA, Andersen J, Andrade D, Antovic A, Arnaud L, Christiansen AA, Avcin T, Badreh-Wirström S, Bertsias G, Bini I, Bobirca A, Branch W, Brucato A, Bultink I, Capela S, Cecchi I, Cervera R, Chighizola C, Cobilinschi C, Cuadrado MJ, Dey D, Etomi O, Espinosa G, Flint J, Fonseca JE, Fritsch-Stork R, Gerosa M, Glintborg B, Skorpen CG, Goulden B, Graversgaard C, Gunnarsson I, Gupta L, Hetland M, Hodson K, Hunt BJ, Isenberg D, Jacobsen S, Khamashta M, Levy R, Linde L, Lykke J, Meissner Y, Moore L, Morand E, Navarra S, Opris-Belinski D, Østensen M, Ozawa H, Perez-Garcia LF, Petri M, Pons-Estel GJ, Radin M, Raio L, Rottenstreich A, Ruiz-Irastorza G, Tunjić SR, Rygg M, Sciascia S, Strangfeld A, Svenungsson E, Tektonidou M, Troldborg A, Vinet E, Vojinovic J, Voss A, Wallenius M, Andreoli L. Global comment on the use of hydroxychloroquine during the periconception period and pregnancy in women with autoimmune diseases. THE LANCET. RHEUMATOLOGY 2023; 5:e501-e506. [PMID: 38251494 DOI: 10.1016/s2665-9913(23)00215-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Affiliation(s)
- Karen Schreiber
- Danish Centre for Expertise in Rheumatology (CeViG), Danish Hospital for Rheumatic Diseases, Sonderborg, Denmark (KS); Institute for Regional Health, Southern Danish University, Odense, Denmark.
| | - Ian Giles
- Centre for Rheumatology, UCL Division of Medicine, London, UK
| | - Nathalie Costedoat-Chalumeau
- AP-HP, Hôpital Cochin, Centre de Référence Maladies Auto-Immunes et Systémiques Rares, Paris, France; Université Paris Cité, Paris, France
| | - Catherine Nelson-Piercy
- Department of Obstetric Medicine, Guy's and St Thomas' NHS Foundation Trust, London, UK (CN-P, OE)
| | - Radboud Jem Dolhain
- Erasmus MC, University Medical Centre, Department of Rheumatology, Rotterdam, Netherlands
| | - Marta Mosca
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Frauke Förger
- Department of Rheumatology, Immunology and Allergology, University Hospital of Bern, Bern, Switzerland
| | - Rebecca Fischer-Betz
- Department for Rheumatology and Hiller Research Institute, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Anna Molto
- Rheumatology Department, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France; INSERM (U1153), PRES Sorbonne Paris-Cité, Paris, France
| | - Angela Tincani
- Rheumatology and Clinical Immunology Unit, ASST-Spedali Civili and University, Brescia, Italy
| | - Elisabeth Pasquier
- Département de Médecine Interne et Pneumologie, CHRU de Brest, Hôpital de la Cavale Blanche, Brest, France; INSERM, Centre d'Investigation Clinique 1412, CHRU de Brest, Brest, France
| | - Benoit Marin
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Trousseau, Département de Santé Publique, Centre de Référence sur les Agents Tératogènes, F75012, Paris, France
| | - Elisabeth Elefant
- AP-HP, Sorbonne Université, Hôpital Trousseau, Département de Santé Publique, Centre de Référence sur les Agents Tératogènes, F75012, Paris, France
| | - Jane Salmon
- Weill Cornell Medicine, Hospital for Special Surgery, New York, New York, USA
| | | | - Lisa Sammaritano
- Weill Cornell Medicine, Hospital for Special Surgery, New York, New York, USA
| | - Megan E B Clowse
- Division of Rheumatology and Immunology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Christina Chambers
- Department of Paediatrics, University of California, San Diego, La Jolla, CA, USA
| | - Jill Buyon
- Division of Rheumatology, New York University Grossman School of Medicine, New York, NY, USA
| | - Saori Abe Inoue
- Department of Rheumatology, Institute of Medicine, University of Tsukuba, Japan
| | - Nancy Agmon-Levin
- The Zabludowicz Centre for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Israel; The Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | | | | | - Danieli Andrade
- Rheumatology, University of Sao Paulo, Sao Paulo, Sao Paulo, Brazil
| | - Aleksandra Antovic
- Department of Medicine, Division of Rheumatology Karolinska Institutet and Rheumatology, Karolinska University Hospital Stockholm, Sweden
| | - Laurent Arnaud
- Service de Rhumatologie, Hôpitaux Universitaires de Strasbourg, Centre National de Références Maladies Auto-Immunes, Strasbourg, France
| | - Alice Ashouri Christiansen
- Danish Center for Expertise in Rheumatology, Danish Hospital for Rheumatic Diseases, Sønderborg, Denmark
| | - Tadej Avcin
- Department of Allergology, Rheumatology and Clinical Immunology, University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Sara Badreh-Wirström
- Senior European and Regulatory Affairs Project Manager, EULAR PARE, Brussels, Belgium
| | - George Bertsias
- Rheumatology, University of Crete School of Medicine, Iraklio, Greece; Laboratory of Autoimmunity-Inflammation, Institute of Molecular Biology and Biotechnology, Heraklion, Greece
| | | | - Anca Bobirca
- Department of Internal Medicine and Rheumatology, Dr I Cantacuzino Clinical Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Ware Branch
- Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Antonio Brucato
- Department of Biomedical and Clinical Sciences, University of Milano, Fatebenefratelli Hospital, Milano, Italy
| | - Irene Bultink
- Department of Rheumatology, Amsterdam Rheumatology and immunology Centre, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Susanna Capela
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte EPE, Faculty of Medicine, University of Lisbon, Lisbon Academic Medical Centre, Lisbon, Portugal
| | - Irene Cecchi
- Centre of Research of Immunopathology and Rare Diseases, Department of Clinical and Biological Sciences, University of Turin, San Giovanni Hospital, Turin, Italy
| | - Ricard Cervera
- Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Cecilia Chighizola
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy; Paediatric Rheumatology Unit, ASST Pini, CTO, Milan, Italy
| | - Claudia Cobilinschi
- Department of Internal Medicine and Rheumatology Sânta Maria Clinical Hospital, Bucharest, Romania; Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | | | - Dzifa Dey
- Rheumatology Unit, Department of Medicine and Therapeutics, Korle Bu Teaching Hospital, University of Ghana Medical School, Accra, Ghana
| | - Oseme Etomi
- Department of Obstetric Medicine, Guy's and St Thomas' NHS Foundation Trust, London, UK (CN-P, OE)
| | - Gerard Espinosa
- Department of Autoimmune Diseases, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer, University of Barcelona, Barcelona, Spain
| | - Julia Flint
- Department of Rheumatology, Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Oswestry, UK
| | - João-Eurico Fonseca
- Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa and Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | - Ruth Fritsch-Stork
- Health Care Centre Mariahilf, ÖGK and Rheumatology Department at the Sigmund Freud Private University, Vienna, Austria
| | - Maria Gerosa
- Department of Clinical Sciences and Community Health, Research Centre for Adult and Paediatric Rheumatic Diseases, University of Milan, Milan, Italy; Clinical Rheumatology Unit, ASST G Pini and CTO, Milan, Italy
| | - Bente Glintborg
- DANBIO and Copenhagen Centre for Arthritis Research, Centre for Rheumatology and Spine Diseases, Centre of Head and Orthopaedics, Copenhagen University Hospital, Rigshospitalet, Glostrup, Denmark
| | - Carina Gøtestam Skorpen
- Department of Neuromedicine and Movement Science, The Norwegian University of Science and Technology, Trondheim, Norway; Department of Rheumatology Ålesund, Helse More og Romsdal, Ålesund, Norway
| | - Bethan Goulden
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Centre for Rheumatology Research, UCL Division of Medicine, University College London, London; Women's Health, University College London Hospital, London, UK
| | - Christine Graversgaard
- Danish Hospital for Rheumatic Diseases, Sønderborg, Denmark; Department of Rheumatology, Aarhus Universitetshospital, Aarhus, Denmark
| | - Iva Gunnarsson
- Department of Medicine, Division of Rheumatology, Karolinska Institutet, Stockholm, Sweden; Solna and Rheumatology, Karolinska University Hospital, Stockholm, Sweden
| | - Latika Gupta
- Department of Rheumatology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK; Division of Musculoskeletal and Dermatological Sciences, Centre for Musculoskeletal Research, School of Biological Sciences, The University of Manchester, Manchester, UK; Department of Rheumatology, City Hospital, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Merete Hetland
- DANBIO and Copenhagen Centre for Arthritis Research, Centre for Rheumatology and Spine Diseases, Centre of Head and Orthopaedics, Copenhagen University Hospital, Rigshospitalet, Glostrup, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Ken Hodson
- UK Teratology Information Service, Newcastle upon Tyne, UK
| | - Beverley J Hunt
- Thrombosis and Haemophilia, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - David Isenberg
- Centre for Rheumatology, UCL Division of Medicine, London, UK
| | - Søren Jacobsen
- Copenhagen Research Centre for Autoimmune Connective Tissue Diseases, COPEACT, Rigshospitalet, Copenhagen, Denmark
| | | | | | - Louise Linde
- Copenhagen Research Centre for Autoimmune Connective Tissue Diseases, Lupus and Vasculitis Clinic, Copenhagen university hospital, Rigshospitalet, Denmark
| | - Jacob Lykke
- Department of Obstetrics, Copenhagen university hospital, Rigshospitalet, Denmark
| | - Yvette Meissner
- Epidemiology and Health Services Research, German Rheumatism Research Centre, Berlin, Germany
| | - Louise Moore
- Rheumatic and Musculoskeletal Disease Unit, Our Lady's Hospice and Care Services, Harold's Cross, Dublin, Ireland
| | - Eric Morand
- Centre for Inflammatory Disease, Monash University, Melbourne, VIC, Australia
| | - Sandra Navarra
- Centre for Inflammatory Disease, Monash University, Melbourne, VIC, Australia
| | - Daniela Opris-Belinski
- Joint and Bone Center, University of Santo Tomas Hospital, Manila, Philippines; Rheumatology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Monika Østensen
- Department of Rheumatology, Sorlandet Hospital Kristiansand, Kristiansand, Norway (MØ)
| | - Hiroki Ozawa
- Immuno-Rheumatology Centre, St Luke's International Hospital, Tokyo, Japan
| | | | - Michelle Petri
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Massimo Radin
- Centre of Research of Immunopathology and Rare Diseases, Department of Clinical and Biological Sciences, University of Turin, San Giovanni Hospital, Turin, Italy
| | - Luigi Raio
- Department of Obstetrics and Gynaecology, University Hospital of Bern, Inselspital, Bern, Switzerland
| | - Amihai Rottenstreich
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Zucker School of Medicine at Hofstra and Northwell, New York, NY, USA; Laboratory of Blood and Vascular Biology, Rockefeller University, New York, NY, USA; Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Israel
| | - Guillermo Ruiz-Irastorza
- Autoimmune Diseases Research Unit, Biocruces Bizkaia Health Research Institute, University of the Basque Country, Bizkaia, Spain
| | | | - Marite Rygg
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway; Department of Pediatrics, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Savino Sciascia
- Centre of Research of Immunopathology and Rare Diseases, Department of Clinical and Biological Sciences, University of Turin, San Giovanni Hospital, Turin, Italy
| | - Anja Strangfeld
- Epidemiology and Health Care Research, German Rheumatism Research Center Berlin, Berlin, Germany
| | - Elisabet Svenungsson
- Department of Medicine, Division of Rheumatology, Karolinska Institutet, Solna and Rheumatology, Karolinska University Hospital, Stockholm, Sweden
| | - Maria Tektonidou
- First Department of Propaedeutic and Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Anne Troldborg
- Department of Rheumatology, Aarhus University Hospital, and Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Evelyne Vinet
- McGill University, McGill University Health Centre, Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Jelena Vojinovic
- University of Nis, Faculty of Medicine, Clinic for Pediatrics University Clinical Center Nis, Nis, Serbia
| | - Anne Voss
- Department of Rheumatology C, Odense University Hospital, Odense, Denmark
| | - Marianne Wallenius
- Norwegian National Advisory Unit on Pregnancy and Rheumatic Diseases, Department of Rheumatology, Trondheim University Hospital, St Olavs Hospital, Trondheim, Norway; Department of Neuromedicine and Movement Science, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
| | - Laura Andreoli
- Department of Clinical and Experimental Sciences, Rheumatology and Clinical Immunology Unit, Spedali Civili and University of Brescia, Brescia, Italy
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Maguire S, Al-Emadi S, Alba P, Aguiar MC, Al Lawati T, Alle G, Bermas B, Bhana S, Branimir A, Bulina I, Clowse M, Cogo K, Colunga I, Cook C, Cortez KJ, Dao K, Gianfrancesco M, Gore-Massey M, Gossec L, Grainger R, Hausman J, Hsu TYT, Hyrich K, Isnardi C, Kawano Y, Kilding R, Kusevich DA, Lawson-Tovey S, Liew J, McCarthy E, Montgumery A, Moyano S, Nasir N, Padjen I, Papagoras C, Patel NJ, Pera M, Pisoni C, Pons-Estel G, Quiambao AL, Quintana R, Ruderman E, Sattui S, Savio V, Sciascia S, Sencarova M, Morales RS, Siddique F, Sirotich E, Sparks J, Strangfeld A, Sufka P, Tanner H, Tissera Y, Wallace Z, Werner ML, Wise L, Worthing AB, Zell J, Zepa J, Machado PM, Yazdany J, Robinson P, Conway R. Obstetric outcomes in women with rheumatic disease and COVID-19 in the context of vaccination status. Rheumatology (Oxford) 2023; 62:1621-1626. [PMID: 36124987 PMCID: PMC11181869 DOI: 10.1093/rheumatology/keac534] [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: 06/11/2022] [Revised: 08/30/2022] [Accepted: 09/04/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To describe obstetric outcomes based on COVID-19 vaccination status, in women with rheumatic and musculoskeletal diseases (RMDs) who developed COVID-19 during pregnancy. METHODS Data regarding pregnant women entered into the COVID-19 Global Rheumatology Alliance registry from 24 March 2020-25 February 2022 were analysed. Obstetric outcomes were stratified by number of COVID-19 vaccine doses received prior to COVID-19 infection in pregnancy. Descriptive differences between groups were tested using the chi-squared or Fisher's exact test. RESULTS There were 73 pregnancies in 73 women with RMD and COVID-19. Overall, 24.7% (18) of pregnancies were ongoing, while of the 55 completed pregnancies, 90.9% (50) of pregnancies resulted in livebirths. At the time of COVID-19 diagnosis, 60.3% (n = 44) of women were unvaccinated, 4.1% (n = 3) had received one vaccine dose while 35.6% (n = 26) had two or more doses. Although 83.6% (n = 61) of women required no treatment for COVID-19, 20.5% (n = 15) required hospital admission. COVID-19 resulted in delivery in 6.8% (n = 3) of unvaccinated women and 3.8% (n = 1) of fully vaccinated women. There was a greater number of preterm births (PTB) in unvaccinated women compared with fully vaccinated 29.5% (n = 13) vs 18.2% (n = 2). CONCLUSIONS In this descriptive study, unvaccinated pregnant women with RMD and COVID-19 had a greater number of PTB compared with those fully vaccinated against COVID-19. Additionally, the need for COVID-19 pharmacological treatment was uncommon in pregnant women with RMD regardless of vaccination status. These results support active promotion of COVID-19 vaccination in women with RMD who are pregnant or planning a pregnancy.
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Affiliation(s)
- Sinead Maguire
- Department of Rheumatology, St James’s Hospital, Dublin, Ireland
- School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Samar Al-Emadi
- Department of Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Paula Alba
- Rheumatology Unit, Hospital Cordoba, Cordoba, Argentina
- School of Medicine, Universidad Nacional de Cordoba, Cordoba, Argentina
| | | | - Talal Al Lawati
- Department of Rheumatology, Sultan Qaboos University Hospital, Muscat, Oman
| | - Gelsomina Alle
- Department of Rheumatology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | - Suleman Bhana
- Department of Rheumatology, Crystal Run Healthcare, Middleton, NY, USA
| | - Anic Branimir
- School of Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
- Division of Immunology and Rheumatology, Department of Internal Medicine, University of Zagreb, Zagreb, Croatia
| | - Inita Bulina
- Department of Rheumatology, Paul Stradins Clinical University Hospital, Riga, Latvia
- Department of Internal Diseases, Riga Stradins University, Riga, Latvia
| | - Megan Clowse
- Duke University School of Medicine, Durham, NC, USA
| | - Karina Cogo
- Department of Rheumatology, Hospital Interzonal Luis Guemes, Buenos Aires, Argentina
- Department of Rheumatology, Hospital San Juan De Dios, Buenos Aires, Argentina
| | - Iris Colunga
- Department of Rheumatology, Hospital Universitario Dr Jose Eleuterio Gonzalez, Monterrey, Mexico
| | - Claire Cook
- Division of Rheumatology, Massachusetts General Hospital, Allergy & Immunology, Boston, MA, USA
| | - Karen J Cortez
- Department of Rheumatology, Baguio General Hospital and Medical Center, Baguio City, Philippines
| | - Kathryn Dao
- UT Southwestern Medical Center, Dallas, TX, USA
| | - Milena Gianfrancesco
- Division of Rheumatology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | | | - Laure Gossec
- Sorbonne Universite, Paris, France
- Pitie-Salpetriere Hospital, Paris, France
| | - Rebecca Grainger
- Department of Medicine, University of Otago, Wellington, New Zealand
| | - Jonathon Hausman
- Department of Pediatric Rheumatology, Boston Children’s Hospital, Boston, MA, USA
- Department of Rheumatology and Clinical Immunology, Beth Isreal Deaconess Medical Center, Boston, MA, USA
| | - Tiffany Y T Hsu
- Division of Rheumatology, Inflammation and Immunity, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Kimme Hyrich
- Centre for Epidemiology Versus Arthritis, The University of Manchester, Manchester, UK
- Department of MSK Research, Manchester Academic Health Science Centre, Manchester, UK
- Department of Biomedical Research, UK and National Institute of Health Research Manchester, Manchester, UK
| | - Carolina Isnardi
- Research Unit, Argenitine Society of Rheumatology, Buenos Aires, Argentina
| | - Yumeko Kawano
- Division of Rheumatology, Inflammation and Immunity, Brigham and Women’s Hospital, Boston, MA, USA
| | - Rachael Kilding
- Department of Rheumatology, Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, UK
| | - Daria A Kusevich
- Department of Rheumatology, Nasonova Research Institute of Rheumatology, Vidnoe, Russia
| | - Saskia Lawson-Tovey
- Department of MSK Research, Manchester Academic Health Science Centre, Manchester, UK
- Department of Biomedical Research, UK and National Institute of Health Research Manchester, Manchester, UK
- University of Manchester, Centre for Musculoskeletal Research, Centre for Genetics and Genomics Versus Arthritis, Manchester, UK
- Department of Biomedical Research, Manchester University NHS Foundation Trust, Manchester, UK
| | - Jean Liew
- Boston University School of Medicine, Boston, MA, USA
| | - Eoghan McCarthy
- Department of Rheumatology, Beaumont Hospital, Dublin, Ireland
| | - Anna Montgumery
- Division of Rheumatology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
- VA Medical Center, Department of Health Research, San Francisco, CA, USA
| | - Sebastian Moyano
- Department of Rheumatology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Noreen Nasir
- Department of Medicine, The Aga Khan University Hospital, Section of Internal Medicine, Karachi, Pakistan
| | - Ivan Padjen
- School of Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
- Division of Immunology and Rheumatology, Department of Internal Medicine, University of Zagreb, Zagreb, Croatia
| | - Charalampos Papagoras
- First Department of Internal Medicine, Democritus University of Thrace, Alexandroupolis, Greece
| | - Naomi J Patel
- Division of Rheumatology, Massachusetts General Hospital, Allergy & Immunology, Boston, MA, USA
| | - Mariana Pera
- Department of Rheumatology, Hospital Angel C Padilla, Tucuman, Argentina
| | - Cecilia Pisoni
- Rheumatology and Immunology Section, Department of Internal Medicine, CEMIC, Buenos Aires, Argentina
| | | | - Antonio L Quiambao
- Department of Rheumatology, East Avenue Medical Center, Quezon City, Philippines
| | - Rosana Quintana
- Research Unit, Argenitine Society of Rheumatology, Buenos Aires, Argentina
| | - Eric Ruderman
- Department of Medicine/Rheumatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Sebastian Sattui
- Department of Rheumatology, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Savino Sciascia
- Osedale San Giovanni Bosco, Centro Multidisciplinare de Recerche di Immunopatologia e Documentazione su Malattie Rare (C.M.I.D.), Turin, Italy
| | - Marieta Sencarova
- Department of Rheumatology, Univerzitna Nemocnica L Pasteura, Kosice, Slovakia
| | - Rosa Serrano Morales
- Centro Regional de Enfermedades Autoinmunes y Reumaticas (GO-CREAR), Rosario, Argentina
| | - Faizah Siddique
- Department of Rheumatology, Loyola University Medical Center, Maywood, IL, USA
| | - Emily Sirotich
- Department of Health Research, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Jeffrey Sparks
- Department of Rheumatology and Clinical Immunology, Beth Isreal Deaconess Medical Center, Boston, MA, USA
- Division of Rheumatology, Inflammation and Immunity, Brigham and Women’s Hospital, Boston, MA, USA
| | - Anja Strangfeld
- Epidemiology Unit, German Rheumatism Research Centre, Berlin, Germany
| | | | - Helen Tanner
- Department of Rheumatology, Royal Brisbane and Women’s Hospital, Herston, QLD, Australia
- Royal Brisbane Clinical Unit, University of Queensland, Brisbane, QLD, Australia
| | | | - Zachary Wallace
- Division of Rheumatology, Massachusetts General Hospital, Allergy & Immunology, Boston, MA, USA
- Division of Rheumatology, Inflammation and Immunity, Brigham and Women’s Hospital, Boston, MA, USA
| | - Marina L Werner
- Department of Rheumatology, Hospital Nacional de Clinicas, Cordoba, Argentina
| | - Leanna Wise
- Keck School of Medicine, University of Southern California, Los Angelos, CA, USA
| | - Angus B Worthing
- Department of Rheumatology, Arthritis and Rheumatism Associates PC, Washington, DC, USA
- Georgetown University Medical Center, Washington, DC, USA
| | - JoAnn Zell
- Division of Rheumatology, University of Colorado Health, Aurora, Colorado, USA
| | - Julija Zepa
- Department of Rheumatology, Paul Stradins Clinical University Hospital, Latvia, Riga
- School of Medicine, Riga Stradins University, Latvia, Riga
| | - Pedro M Machado
- Centre for Rheumatology and Department of Neuromuscular Diseases, University College London, London, UK
- National Institute for Health Research (NIHR) University College London Hospitals (UCLH) Biomedical Research Centre (BRC), London, UK
- Department of Rheumatology, Northwick Park Hospital, London, UK
| | - Jinoos Yazdany
- Division of Rheumatology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Philip Robinson
- Department of Rheumatology, Royal Brisbane and Women’s Hospital, Herston, QLD, Australia
- Royal Brisbane Clinical Unit, University of Queensland, Brisbane, QLD, Australia
- Metro North Hospital & Health Service, Herston, QLD, Australia
| | - Richard Conway
- Department of Rheumatology, St James’s Hospital, Dublin, Ireland
- School of Medicine, Trinity College Dublin, Dublin, Ireland
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8
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Muñoz CM, Goulden B, Ahmed K, Alijotas-Reig J, Giles I. Risk of adverse pregnancy outcomes prior to the onset of an autoimmune rheumatic disease: a systematic review. Rheumatology (Oxford) 2023; 62:497-511. [PMID: 35929796 PMCID: PMC9891407 DOI: 10.1093/rheumatology/keac417] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 06/17/2022] [Accepted: 07/07/2022] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVES An increased risk of adverse maternal and foetal pregnancy complications (including pre-eclampsia, intrauterine growth restriction, and small for gestational age) is well described in women with autoimmune rheumatic disease (ARD) compared with the general population (GenPop). It is less clear, however, whether this risk of adverse pregnancy outcome (APO) also exists in women with 'preclinical ARD' (pre-ARD) before they are diagnosed with an ARD many years post-partum. Therefore, we have undertaken a systematic review of the available evidence on APO in patients who subsequently were diagnosed with a rheumatic disease to identify whether there is an increased risk in pre-ARD. METHODS The present study was reported in accordance with the guidance of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standard. A systematic literature review was performed using the online PubMed database. Pre-SLE and pre-RA patients were defined as those who, over the subsequent years, developed SLE or RA according to international classification criteria. RESULTS A total of 176 articles were screened, and 27 original articles were selected for final analysis. Pre-RA was the most studied group, with 15 studies and a total of >1600 pregnancies, and pre-SLE was the second-most studied pre-ARD in pregnancy, with 14 studies and a total of >1000 pregnancies. We found that patients who subsequently developed SLE had an increased burden of poor pregnancy outcomes compared with pregnant women from the GenPop, but fewer APOs compared with pregnancies of women with SLE. In contrast, a similar rate of APOs was found when pre-RA pregnancies were compared with GenPop pregnancies. CONCLUSION Our findings of an increased risk of APO in certain pre-ARDs highlights the relevance of taking an obstetric history during the first rheumatology appointment and the need for novel screening strategies for the prediction of APOs. Further research is required to elucidate the immune basis of APOs in preclinical and clinical ARD.
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Affiliation(s)
- Candido Muñoz Muñoz
- Centre for Rheumatology, Department of Inflammation, Division of Medicine, University College London, London, UK.,Systemic Autoimmune Disease Unit, Department of Medicine, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Bethan Goulden
- Centre for Rheumatology, Department of Inflammation, Division of Medicine, University College London, London, UK
| | - Kawser Ahmed
- Centre of Inflammation, Division of Medicine, University College London, London, UK
| | - Jaume Alijotas-Reig
- Systemic Autoimmune Disease Unit, Department of Medicine, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Ian Giles
- Centre for Rheumatology, Department of Inflammation, Division of Medicine, University College London, London, UK
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9
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Rheumatic Diseases in Reproductive Age-the Possibilities and the Risks. Reprod Sci 2023; 30:111-123. [PMID: 35359225 DOI: 10.1007/s43032-022-00901-6] [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: 11/04/2021] [Accepted: 02/20/2022] [Indexed: 01/11/2023]
Abstract
The most common systemic connective tissue diseases (CTD), such as rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), antiphospholipid syndrome (APS), systemic sclerosis (SSc), and Sjögren's syndrome (SjS), affect many women of reproductive age. These diseases may strongly impact the course of pregnancy and increase the risk factors of incompatibility. A literature search was done on MEDLINE, PubMed, and Google Scholar in 2011-2021. The analysis included meta-analysis, randomized control trials, prospective and retrospective studies, and systematic reviews. The literature search allowed us to form conclusions and underline recommendations regarding pregnancy's risk and treatment possibilities in the course of rheumatic disease. Optimal control of CTD activity should be reached at least 6 months before conception. High-risk pregnancies are often accompanied by maternal-placental syndrome, which manifests as preeclampsia, eclampsia, fetal growth restriction, and prematurity. The flare of rheumatic disease can coexist with obstetrical complications, and differential diagnosis can be difficult. Medications that do not influence the risk of fetus complications should be applied before and during pregnancy. Teratogenic drugs (e.g., methotrexate, leflunomide, cyclophosphamide) must be withdrawn before pregnancy. Conventional medications such as hydroxychloroquine, sulfasalazine, colchicine, and the TNFα inhibitor certolizumab can be used safely at any stage of pregnancy. Corticosteroids should be tapered, and other biologics should be avoided due to teratogenicity or carefully administered due to the impact on the fetal immune system. Distinguishing between disease flare and obstetrical complications can be difficult in clinical practice; however, some clinical symptoms and serological markers can be helpful in the differential diagnosis.
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10
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Schreiber K, Frishman M, Russell MD, Dey M, Flint J, Allen A, Crossley A, Gayed M, Hodson K, Khamashta M, Moore L, Panchal S, Piper M, Reid C, Saxby K, Senvar N, Tosounidou S, van de Venne M, Warburton L, Williams D, Yee CS, Gordon C, Giles I, 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: comorbidity medications used in rheumatology practice. Rheumatology (Oxford) 2022; 62:e89-e104. [PMID: 36318967 PMCID: PMC10070063 DOI: 10.1093/rheumatology/keac552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 09/14/2022] [Indexed: 11/07/2022] Open
Affiliation(s)
- Karen Schreiber
- Thrombosis & Haemophilia Centre, 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, University of Southern Denmark , Odense, Denmark
| | - Margreta Frishman
- Obstetrics and Gynaecology, North Middlesex University Hospital NHS Trust , London, UK
| | - 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
| | - Alexander Allen
- Clinical Affairs, British Society for Rheumatology , London, UK
| | | | - Mary Gayed
- Rheumatology, University Hospital Birmingham NHS Foundation Trust , Birmingham, UK
| | - Kenneth Hodson
- The UK Teratology Information Service , Newcastle upon Tyne, UK
| | - Munther Khamashta
- Division of Women’s Health, Lupus Research Unit, King's College London , London, UK
| | - Louise Moore
- Rheumatic and Musculoskeletal Disease Unit, Our Lady’s Hospice and Care Service , Dublin, Ireland
| | - Sonia Panchal
- Rheumatology, South Warwickshire NHS Foundation Trust , Warwickshire, UK
| | - Madeleine Piper
- Royal National Hospital for Rheumatic Diseases, Royal United Hospital , Bath, UK
| | | | - Katherine Saxby
- Pharmacology, University College London Hospitals NHS Foundation Trust , London, UK
| | - 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 NHS Trust , Birmingham, UK
| | | | - Louise Warburton
- Shropshire Community NHS Trust , Shropshire, UK
- Primary Care and Health Sciences, Keele University , Keele, 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, Department of Inflammation, Division of Medicine, University College London , London, UK
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11
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Leflunomide Exposure and Teriflunomide Concentrations up to the Third Trimester of Pregnancy: A Case Report. Clin Drug Investig 2022; 42:787-789. [PMID: 35896855 DOI: 10.1007/s40261-022-01185-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2022] [Indexed: 11/03/2022]
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12
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Luo L, Li X, Yan R, Zhang H, Li C. Risk factors for adverse pregnancy outcomes in women with rheumatoid arthritis and follow-up of their offspring. Clin Rheumatol 2022; 41:3135-3141. [PMID: 35698010 DOI: 10.1007/s10067-022-06233-9] [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: 02/09/2022] [Revised: 05/05/2022] [Accepted: 06/01/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To explore the risk factors for adverse pregnancy outcomes (APOs) in women with rheumatoid arthritis (RA) and the influence on their offspring health. METHODS Pregnant women with RA (n = 67) who were hospitalized in the Department of Obstetrics, Peking University People's Hospital between January 2007 and September 2021 were included in this study. Participants were evaluated at least once in each trimester and postpartum. Fetal outcomes and RA disease activity were extracted from medical records, and the offspring of enrolled patients were followed up. Associations between RA disease activity, medication use, and pregnancy outcomes were analyzed. RESULTS The incidence of APOs in our cohort was 43.3%. Postpartum hemorrhage (20.9%) was the commonest complication, followed by premature delivery (11.9%). Previous miscarriages [odds ratio (OR): 1.869, 95% confidence interval (CI): 1.053-3.318, P = 0.033] and antinuclear antibody (ANA) positivity (OR:3.168, 95% CI: 1.068-9.768, P = 0.045) were risk factors for APOs. Compared to patients with APOs, the remission rate of disease activity during pregnancy was higher in patients without APOs (P = 0.027). There were no significant differences between patients with and without APOs with respect to daily and cumulative doses of prednisone (P > 0.05). The average age of the offspring was 4.9 years (range 0.3-14 years). Long-term follow-up showed no significant differences in offspring health between the two groups (P > 0.05). CONCLUSION Previous miscarriages and ANA positivity are independent risk factors for APOs in RA patients, while adverse pregnancy outcomes and low-dose prednisone have no effect on offspring health. Key points • Previous miscarriages and ANA positivity are risk factors for APOs in RA patients. • Adverse pregnancy outcomes and low-dose prednisone during pregnancy have no effect on offspring health.
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Affiliation(s)
- Liang Luo
- Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing, China.,Department of Rehabilitation, Chongqing Rehabilitation Hospital of Integrated Traditional Chinese and Western Medicine, Chongqing, China
| | - Xuerong Li
- Department of Rheumatology and Immunology, Chongqing University Three Gorges Hospital, Chongqing, China
| | - Rui Yan
- Department of Rheumatology and Immunology, Beijing Shunyi Hospital, Beijing, China
| | - Huijuan Zhang
- Department of Rheumatology, Shexian Hospital, Handan, China
| | - Chun Li
- Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing, China.
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13
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Systemic sclerosis and pregnancy outcomes: a retrospective study from a single center. Arthritis Res Ther 2022; 24:91. [PMID: 35477585 PMCID: PMC9044598 DOI: 10.1186/s13075-022-02783-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 04/19/2022] [Indexed: 11/23/2022] Open
Abstract
Background Pregnancy in systemic sclerosis (SSc) patients is no more an infrequent event as it used to be, but literature data on pregnancy outcomes in women with SSc are scarce. The rate of preterm deliveries and intrauterine growth restriction (IUGR) seems to be increased, while the risk of miscarriages is controversial. Moreover, no study compared pregnancy outcomes in SSc with antiphospholipid syndrome (APS) and systemic lupus erythematosus (SLE). We performed a retrospective study to compare the pregnancy and disease outcomes of women with SSc with a cohort of age-matched women with systemic lupus erythematosus (SLE), antiphospholipid syndrome (APS), and healthy controls (HC). Methods A total of 154 pregnancies from SSc, SLE, APS patients, and HC were prospectively followed at the High-Risk Pregnancy Unit of our center from 2008 to 2019. The primary outcome was a composite endpoint of miscarriages, fetal deaths, intrauterine growth restriction (IUGR), preeclampsia, neonatal deaths, preterm birth, and small-for-gestational-age (SGA) newborns. Single adverse pregnancy outcomes (APO) represented secondary endpoints. SSc activity variations in relation to pregnancy were assessed. Results The risk of APO was significantly higher in SSc patients compared to HC (60.6% vs 10.0%; OR = 14.42; 95% CI 3.70–56.18, p = 0.001) and SLE patients (60.6% vs 37.5%; OR = 3.56; 95% CI 1.29–9.83, p = 0.014). Compared to HC, women with SSc had an increased frequency of first trimester miscarriage (15% vs 0 %; p = 0.016), preeclampsia (12% vs 0%, p = 0.038), and SGA newborns (21.2% vs 0%; p = 0.003). Preterm deliveries were more frequent in SSc pregnancies in comparison with HC (24.2% vs 5%; OR = 6.08; 95% CI 1.19–31.02, p = 0.036) and SLE patients (24.2% vs 7.5%, OR = 5.68; 95% CI 1.1–29.38, p = 0.038). Disease remained stable in all SSc patients during pregnancy and up to 1 year after delivery. Conclusions We found an increased risk of APO in our SSc cohort in comparison with HC (with higher rates of miscarriages, preeclampsia, SGA newborns, and preterm deliveries) and SLE patients (presenting a higher rate of preterm deliveries). High-risk multidisciplinary management of SSc pregnant women is highly recommended.
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14
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Hum RM, David T, Lau YJ, Iftikhar H, Thornber S, Simcox L, Bruce I, Tower C, Ho P. Pregnancy outcomes of a joint obstetric and rheumatology clinic in a tertiary centre: a 2-year retrospective study of 98 pregnancies. Rheumatol Adv Pract 2022; 6:rkac026. [PMID: 35474882 PMCID: PMC9034115 DOI: 10.1093/rap/rkac026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 03/24/2022] [Indexed: 11/14/2022] Open
Abstract
Objectives The purpose of this study was to describe the maternal and fetal outcomes in patients with inflammatory rheumatic diseases attending a joint rheumatology and obstetric clinic in the UK. Methods Electronic records of 98 patients attending the joint rheumatology and obstetric clinic between January 2018 and January 2020 were analysed. Data on patient demographics, characteristics (including age, ethnicity, diagnosis, and medications taken during pregnancy), pregnancy outcomes (miscarriage, stillbirth or live birth), maternal complications [infection, post-partum haemorrhage (PPH) or pre-eclampsia] and fetal complications (sepsis, congenital heart block, prematurity and low birth weight) were tabulated. Subgroups of patients based on maternal diagnosis, medications and Ro/La antibody status were described in a similar manner. Results The cohort was found to be predominantly Caucasian women >30 years of age, diagnosed with a CTD. Of 98 pregnancies, 97% (n = 95) resulted in a live birth, with only 2% resulting in miscarriage (n = 2) and 1% in stillbirth (n = 1). The median duration of gestation was 38 (interquartile range 37-39) weeks, and the majority of patients had a normal vaginal delivery (35%, n = 34), whereas 30% had emergency Caesarean sections (n = 29). The median birth weight was 3120 (interquartile range 2690-3410) g. The most common maternal complications were PPH (56%, n = 54) and infection (22%, n = 21). The most common fetal complications were prematurity (23%, n = 22) and low birth weight (17%, n = 16). Conclusion We report favourable outcomes from this service model, including a high live birth rate, a low miscarriage rate and a high median birth weight. With limited reported data of pregnancy outcomes from joint obstetric/rheumatology clinics, this service model might be beneficial in other centres.
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Affiliation(s)
- Ryan Malcolm Hum
- The Kellgren Centre for Rheumatology, Manchester Royal Infirmary, Manchester University NHS Foundation Trust.,NIHR Manchester Biomedical Research Centre.,Centre for Musculoskeletal Research, The University of Manchester
| | - Trixy David
- The Kellgren Centre for Rheumatology, Manchester Royal Infirmary, Manchester University NHS Foundation Trust.,NIHR Manchester Biomedical Research Centre.,Centre for Musculoskeletal Research, The University of Manchester
| | - Yen June Lau
- The Kellgren Centre for Rheumatology, Manchester Royal Infirmary, Manchester University NHS Foundation Trust
| | - Hajira Iftikhar
- The Kellgren Centre for Rheumatology, Manchester Royal Infirmary, Manchester University NHS Foundation Trust
| | - Sue Thornber
- Saint Mary's Hospital, Manchester University NHS Foundation Trust
| | - Louise Simcox
- Saint Mary's Hospital, Manchester University NHS Foundation Trust
| | - Ian Bruce
- The Kellgren Centre for Rheumatology, Manchester Royal Infirmary, Manchester University NHS Foundation Trust.,NIHR Manchester Biomedical Research Centre.,Centre for Musculoskeletal Research, The University of Manchester
| | - Clare Tower
- Saint Mary's Hospital, Manchester University NHS Foundation Trust.,Maternal and Fetal Health Research Centre, The University of Manchester, Manchester, UK
| | - Pauline Ho
- The Kellgren Centre for Rheumatology, Manchester Royal Infirmary, Manchester University NHS Foundation Trust.,NIHR Manchester Biomedical Research Centre.,Centre for Musculoskeletal Research, The University of Manchester
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15
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Scott R, Parker H, Mccartney S, Harrow P, Williams D, Giles I. Outcomes following biosimilar TNF inhibitors use for inflammatory-mediated immune disorders in pregnancy. Obstet Med 2021; 15:104-107. [PMID: 35845229 PMCID: PMC9277732 DOI: 10.1177/1753495x211028779] [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: 03/08/2021] [Revised: 05/15/2021] [Accepted: 06/09/2021] [Indexed: 12/03/2022] Open
Abstract
Background Biosimilar tumour necrosis factor inhibitors (TNFi) are increasingly used to
treat inflammatory immune-mediated disorders as they cost less than the
originator biologic drug. More women are therefore becoming pregnant on
biosimilar TNFi. This is the first paper to explore the safety and efficacy
of biosimilar therapies in pregnancy. Methods A retrospective review of clinical data reviewed pregnancy outcomes and
inflammatory disease activity in 18 pregnancies where the mother was using a
biosimilar TNFi at conception. Results Biosimilar therapy was not associated with congenital abnormalities, preterm
birth or other adverse pregnancy outcomes. Stopping biosimilar TNFi in
pregnancy was associated with childbirth at an earlier gestation, as well as
a flare of inflammatory disease in pregnancy or post-partum. Conclusions Women and clinicians should feel confident in using biosimilar TNFi in early
pregnancy, and continuing them through pregnancy to prevent flares in late
pregnancy or the early post-partum.
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Affiliation(s)
- R Scott
- Department of Obstetrics, University College London Hospital NHS Foundation Trust, London, UK
| | - H Parker
- Department of Gastroenterology, University College London Hospital NHS Foundation Trust, London, UK
| | - S Mccartney
- Department of Gastroenterology, University College London Hospital NHS Foundation Trust, London, UK
| | - P Harrow
- Department of Gastroenterology, University College London Hospital NHS Foundation Trust, London, UK
| | - D Williams
- Department of Obstetrics, University College London Hospital NHS Foundation Trust, London, UK
- The Institute for Women’s Health, University College London, London, UK
| | - I Giles
- Department for Rheumatology, University College London Hospital NHS Foundation Trust, London, UK
- Centre for Rheumatology, University College London, University College London Hospitals NHS Foundation Trust, London, UK
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16
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Giles I, Allen A, Crossley A, Flint J, Frishman M, Gayed M, Kamashta M, Moore L, Panchal S, Piper M, Reid C, Saxby K, Schreiber K, Senvar N, Tosounidou S, van de Venne M, Warburton L, Wiliams D, Yee CS, Gordon C. Prescribing anti-rheumatic drugs in pregnancy and breastfeeding-the British Society for Rheumatology guideline scope. Rheumatology (Oxford) 2021; 60:3565-3569. [PMID: 33848327 DOI: 10.1093/rheumatology/keab334] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 03/08/2021] [Accepted: 04/01/2021] [Indexed: 11/14/2022] Open
Affiliation(s)
- Ian Giles
- Centre For Rheumatology Research, UCL Division of Medicine, University College, London, UK
| | - Alexander Allen
- Clinical Affairs, British Society for Rheumatology, London, UK
| | | | - Julia Flint
- Rheumatology, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Margreta Frishman
- Rheumatology, North Middlesex University Hospital NHS Trust, London, UK
| | - Mary Gayed
- Rheumatology, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Munther Kamashta
- Division of Women's Health, Lupus Research Unit, King's College London, London, UK
| | - Louise Moore
- Rheumatic and Musculoskeletal Disease Unit, Our Lady's Hospice and Care Service, Dublin, Ireland
| | - Sonia Panchal
- Rheumatology, University Hospitals of Leicester, Leicester, UK
| | | | | | - Katherine Saxby
- Pharmacy, University College London Hospitals NHS Foundation Trust, London, UK
| | - Karen Schreiber
- Thrombosis and Haemophilia Centre, Guy's and Saint Thomas' NHS Foundation Trust, London, UK
| | - 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 Wiliams
- Maternal and Fetal Medicine, UCL EGA Institute for Womens Health, University College London, London, UK
| | - Chee-Seng Yee
- Department of Rheumatology, Doncaster and Bassetlaw Hospitals NHS Foundation Trust, Doncaster Royal Infirmary, Doncaster, UK
| | - Caroline Gordon
- Rheumatology Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
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17
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Fernández-Sánchez M, Ribes-Artero H, Romá-Sánchez E, Gómez-Portero MR, Guerrero-Hurtado E, García-Pellicer J, Poveda-Andrés JL. Fetal exposure to tofacitinib during the first trimester: A healthy newborn case report. Birth Defects Res 2021; 113:1275-1279. [PMID: 34309233 DOI: 10.1002/bdr2.1942] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 07/09/2021] [Accepted: 07/12/2021] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Preclinical studies with tofacitinib demonstrated teratogenic effects. Data about effects on human fetuses are limited and current recommendations are to immediately discontinue the treatment. Our purpose is to report a case of exposure to tofacitinib during the first trimester of pregnancy. CASE SUMMARY A 40-year-old woman with psoriatic arthritis became pregnant during the first month of treatment with tofacitinib. Tofacitinib was interrupted immediately, and parents were informed about the possible risks of teratogenicity. At the end of pregnancy, our patient gave birth to a healthy newborn. CONCLUSION All the available evidence of tofacitinib exposure during pregnancy in humans belongs to outcomes of unexpected pregnancies in the context of clinical trials and post-marketing cases. This case may contribute to enriching available data about teratogenic risks of tofacitinib exposure during pregnancy.
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Affiliation(s)
| | - Hugo Ribes-Artero
- Pharmacy Service, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Eva Romá-Sánchez
- Pharmacy Service, Hospital Universitario y Politécnico La Fe, Valencia, Spain
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18
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Pazmino S, Westhovens R, De Cock D, Verschueren P. Editorial commentary on: Prescribing anti-rheumatic drugs in pregnancy and breastfeeding-the BSR guideline scope. Rheumatology (Oxford) 2021; 61:480-481. [PMID: 34302477 DOI: 10.1093/rheumatology/keab600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 06/30/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Sofia Pazmino
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Centre, KU Leuven, Leuven, Belgium
| | - Rene Westhovens
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Centre, KU Leuven, Leuven, Belgium.,Department of Rheumatology, University Hospitals Leuven, Leuven, Belgium
| | - Diederik De Cock
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Centre, KU Leuven, Leuven, Belgium
| | - Patrick Verschueren
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Centre, KU Leuven, Leuven, Belgium.,Department of Rheumatology, University Hospitals Leuven, Leuven, Belgium
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19
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Kour G, Haq SA, Bajaj BK, Gupta PN, Ahmed Z. Phytochemical add-on therapy to DMARDs therapy in rheumatoid arthritis: In vitro and in vivo bases, clinical evidence and future trends. Pharmacol Res 2021; 169:105618. [PMID: 33878447 DOI: 10.1016/j.phrs.2021.105618] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 03/25/2021] [Accepted: 04/13/2021] [Indexed: 02/07/2023]
Abstract
The use of biologically active compounds derived from plants i.e. phytochemicals, have been known for ages for their pharmacological activities in the treatment of autoimmune disorders like rheumatoid arthritis (RA). Besides enormous scientific evidence, the therapeutic potential of phytochemicals is often undervalued. The treatment in RA involves the use of synthetic and biological disease modifying anti-rheumatic drugs (DMARDs). However, the long-term treatment in RA is associated with the risk of gastrointestinal, liver, pulmonary and renal toxicities and serious infections including latent tuberculosis, pneumococcus influenza, herpes zoster and hepatitis. These adverse effects sometimes lead to discontinuation of the therapy. A relatively new vision based on the combination of DMARDs with phytochemicals exhibiting anti-inflammatory, anti-arthritic, anti-oxidant, hepatoprotective and nephroprotective properties for the treatment of RA has achieved substantial importance in the last decade. From this perspective, the present review focuses on the combination of DMARDs (primarily MTX) with phytochemicals that have shown synergistic therapeutic effects while decreasing the toxic repercussions of current RA therapy. The review covers recent evidences of such combination studies that have shown promising results both in experimental arthritic models and clinical arthritis. Few of the combinations including resveratrol, sinomenine, coenzyme Q10 exhibited considerable interest because of their efficacy as an adjuvant to the MTX/standard DMARDs therapy in clinical trials. Besides giving an overview of such combination studies the review also critically discusses the limitations with the use of phytochemicals (e.g. solubility, permeability and bioavailability) compromising their clinical application. Additionally, it stresses upon the need of novel delivery systems and pharmaceutical technologies to increase the therapeutic efficacy of the combination therapy. Overall, the review unveils the potential of phytochemicals in combination with DMARDs with increased tolerability and superior efficacy in further refining the future of the RA therapy.
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Affiliation(s)
- Gurleen Kour
- Inflammation Pharmacology Division, CSIR, Indian Institute of Integrative Medicine, Canal Road, Jammu 180001, J&K, India; School of Biotechnology, University of Jammu, Baba Saheb Ambedkar Road, Jammu Tawi, 180006 J&K, India
| | - Syed Assim Haq
- Formulation & Drug Delivery Division, CSIR, Indian Institute of Integrative Medicine, Canal Road, Jammu 180001, J&K, India; Academy of Scientific and Innovative Research (AcSIR), Ghaziabad 201002, India
| | - Bijender Kumar Bajaj
- School of Biotechnology, University of Jammu, Baba Saheb Ambedkar Road, Jammu Tawi, 180006 J&K, India
| | - Prem N Gupta
- Formulation & Drug Delivery Division, CSIR, Indian Institute of Integrative Medicine, Canal Road, Jammu 180001, J&K, India; Academy of Scientific and Innovative Research (AcSIR), Ghaziabad 201002, India.
| | - Zabeer Ahmed
- Inflammation Pharmacology Division, CSIR, Indian Institute of Integrative Medicine, Canal Road, Jammu 180001, J&K, India; Academy of Scientific and Innovative Research (AcSIR), Ghaziabad 201002, India.
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20
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Duan J, Ma D, Wen X, Guo Q, Gao J, Zhang G, Xu K, Zhang L. Hydroxychloroquine prophylaxis for preeclampsia, hypertension and prematurity in pregnant patients with systemic lupus erythematosus: A meta-analysis. Lupus 2021; 30:1163-1174. [PMID: 33853420 DOI: 10.1177/09612033211007199] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES This meta-analysis aimed to evaluate the effectiveness of HCQ in improving the maternal and fetal outcomes in pregnancies with SLE. METHODS A literature search was conducted using PubMed, MEDLINE, EMBASE, and the Cochrane database for relevant English language articles, and Wanfang, CNKI and VIP for Chinese articles, from the databases' inception to April 30, 2020. These studies compared the maternal and/or fetal outcomes between pregnant patients with SLE who were administered HCQ during pregnancy (HCQ+ group) and those who were not administered HCQ (HCQ- group). Two investigators extracted the data and assessed the quality using the Newcastle-Ottawa Scale (NOS) and GRADE criteria independently. Odds ratio (OR) and 95% confidence intervals (CIs) were calculated. All statistical analyses were conducted using the Stata 12.0 software. RESULTS Nine studies involving 1132 pregnancies were included in the study (3 case controls, 2 prospective cohorts, 4 retrospective cohorts). Preeclampsia, gestational hypertension, and prematurity were significantly lower in the HCQ+ group than in the HCQ- group (OR 0.35, 95% CI 0.21-0.59), (OR 0.41, 95% CI 0.19-0.89) and (OR 0.55, 95% CI 0.36-0.86), respectively. There were no significant differences in the rates of HELLP Syndrome (OR 0.88, 95% CI 0.19-3.96), gestational diabetes (OR 2.3, 95% CI 0.44-12.12), thrombotic events (OR 0.26, 95% CI 0.05-1.51), spontaneous abortion (OR 1.77, 95% CI 0.96-3.26), premature rupture of membranes (OR 0.58, 95% CI 0.24-1.39), oligohydramnios (OR 0.90, 95% CI 0.38-2.14), live birth (OR 1.22, 95% CI 0.60-2.47), stillbirth (OR 1.00, 95% CI 0.50-2.00), congenital malformation (OR 0.53, 95% CI 0.14-2.04), low birth weight (OR 0.77, 95% CI 0.43-1.39), intrauterine distress (OR 1.07, 95% CI 0.41-2.76,), intrauterine growth restriction (OR 0.57, 95% CI 0.06-5.43), or five-minute APGAR score <7 (OR 0.72, 95% CI 0.20-2.58) between the two groups. CONCLUSIONS HCQ treatment during pregnancy could reduce the risk of preeclampsia, pregnancy hypertension and prematurity in SLE patients. The certainty of evidence is high but majority of the studies included are retrospective studies and not randomized controlled trials. Therefore, the multidisciplinary management of pregnant patients with SLE should promote HCQ use, irrespective of disease activity or severity.
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Affiliation(s)
- Jiaoniu Duan
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Taiyuan, China
| | - Dan Ma
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Taiyuan, China.,Tongji Shanxi Hospital, Tongji Medical College, Huazhong University of Science and Technology, Taiyuan, China
| | - Xiaoting Wen
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Taiyuan, China
| | - Qianyu Guo
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Taiyuan, China.,Tongji Shanxi Hospital, Tongji Medical College, Huazhong University of Science and Technology, Taiyuan, China
| | - Jinfang Gao
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Taiyuan, China.,Tongji Shanxi Hospital, Tongji Medical College, Huazhong University of Science and Technology, Taiyuan, China
| | - Gailian Zhang
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Taiyuan, China
| | - Ke Xu
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Taiyuan, China
| | - Liyun Zhang
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Taiyuan, China
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21
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Akiyama C, Shirai T, Sato H, Fujii H, Ishii T, Harigae H. Association of various myositis-specific autoantibodies with dermatomyositis and polymyositis triggered by pregnancy. Rheumatol Int 2021; 42:1271-1280. [PMID: 33837447 DOI: 10.1007/s00296-021-04851-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 03/27/2021] [Indexed: 01/05/2023]
Abstract
Although pregnancy is an important risk factor for autoimmune rheumatic diseases, little is known regarding the association between pregnancy and dermatomyositis (DM) or polymyositis (PM). Herein, we present two patients with DM that developed during the perinatal period. The first patient was positive for anti-aminoacyl synthetase (ARS) antibody and developed DM in the 14th week of pregnancy. Despite treatment, her foetus died of intrauterine growth restriction in the 27th week. The second patient was positive for anti-melanoma differentiation-associated gene 5 (MDA-5) antibody and developed DM 1 week after miscarriage at 9 weeks of gestation. The patient developed severe interstitial pneumonia, and intensive therapy including tofacitinib and rituximab administration was required. Our cases and a literature review revealed that various myositis-specific autoantibodies, including anti-ARS, anti-Mi-2, anti-TIF-1γ, and anti-MDA-5, are associated with DM and PM triggered by pregnancy. We also found that delay in commencing treatment in case of active disease including myositis and interstitial pneumonia, and poor response to corticosteroids were related to poor foetal outcomes in DM and PM. Although rare in pregnant women, it is critical to consider the possibility of DM and PM in patients presenting with rash, fever, weakness, and cough, and testing for myositis-specific autoantibodies is recommended.
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Affiliation(s)
- Chikaho Akiyama
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Tsuyoshi Shirai
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan.
| | - Hiroko Sato
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Hiroshi Fujii
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Tomonori Ishii
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Hideo Harigae
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
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22
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Shojaei S, Ali MS, Suresh M, Upreti T, Mogourian V, Helewa M, Labouta HI. Dynamic placenta-on-a-chip model for fetal risk assessment of nanoparticles intended to treat pregnancy-associated diseases. Biochim Biophys Acta Mol Basis Dis 2021; 1867:166131. [PMID: 33766738 DOI: 10.1016/j.bbadis.2021.166131] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 03/11/2021] [Accepted: 03/12/2021] [Indexed: 12/13/2022]
Abstract
Pregnant women often have to take medication either for pregnancy-related diseases or for previously existing medical conditions. Current maternal medications pose fetal risks due to off target accumulation in the fetus. Nanoparticles, engineered particles in the nanometer scale, have been used for targeted drug delivery to the site of action without off-target effects. This has opened new avenues for treatment of pregnancy-associated diseases while minimizing risks on the fetus. It is therefore instrumental to study the potential transfer of nanoparticles from the mother to the fetus. Due to limitations of in vivo and ex vivo models, an in vitro model mimicking the in vivo situation is essential. Placenta-on-a-chip provides a microphysiological recapitulation of the human placenta. Here, we reviewed the fetal risks associated with current therapeutic approaches during pregnancy, analyzed the advantages and limitations of current models used for nanoparticle assessment, and highlighted the current need for using dynamic placenta-on-a-chip models for assessing the safety of novel nanoparticle-based therapies during pregnancy.
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Affiliation(s)
- Shahla Shojaei
- College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada.
| | - Moustafa S Ali
- College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada; Children's Hospital Research Institute of Manitoba, University of Manitoba, Winnipeg, Canada.
| | - Madhumita Suresh
- College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada.
| | - Tushar Upreti
- College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada.
| | - Victoria Mogourian
- College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada.
| | - Michael Helewa
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Manitoba, Winnipeg, Canada.
| | - Hagar I Labouta
- College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada; Children's Hospital Research Institute of Manitoba, University of Manitoba, Winnipeg, Canada; Biomedical Engineering, University of Manitoba, Winnipeg, Canada; Faculty of Pharmacy, Alexandria University, Alexandria, Egypt.
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23
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Nalli C, Galli J, Lini D, Merlini A, Piantoni S, Lazzaroni MG, Bitsadze V, Khizroeva J, Zatti S, Andreoli L, Fazzi E, Franceschini F, Makatsariya A, Shoenfeld Y, Tincani A. The Influence of Treatment of Inflammatory Arthritis During Pregnancy on the Long-Term Children's Outcome. Front Pharmacol 2021; 12:626258. [PMID: 33815108 PMCID: PMC8013697 DOI: 10.3389/fphar.2021.626258] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 01/29/2021] [Indexed: 12/16/2022] Open
Abstract
The management of reproductive issues in women with inflammatory arthritis has greatly changed over decades. In the 1980–1990s, women with refractory forms of arthritis were either not able to get pregnant or did choose not to get pregnant because of their disabling disease. Hence, the traditional belief that pregnancy can induce a remission of arthritis. The availability of biologic agents has allowed a good control of aggressive forms of arthritis. The main topic of discussion during preconception counselling is the use of drugs during pregnancy and breastfeeding. Physicians are now supported by international recommendations released by the European League Against Rheumatism and the American College of Rheumatology, but still they must face with cultural reluctance in accepting that a pregnant woman can take medications. Patient-physician communication should be centered on the message that active maternal disease during pregnancy is detrimental to fetal health. Keeping maternal disease under control with drugs which are not harmful to the fetus is the best way to ensure the best possible outcome for both the mother and the baby. However, there might be concerns about the influence of the in utero exposure to medications on the newborn’s health conditions. Particularly, studies suggesting an increased risk of autism-spectrum-disorders in children born to women with rheumatoid arthritis has raised questions about neuropsychological impairment in the offspring of women with chronic arthritis. As a multidisciplinary group of rheumatologists and child neuropsychiatrists, we conducted a study on 16 women with chronic forms of arthritis whose diagnosis was determined before pregnancy and their 18 school-age children. The children underwent a complete neurological examination and validated tests/questionnaires. Behavioral aspects of somatization and anxiety/depression (internalizing problem) or an “adult profile” were found in nearly one third of children. Children at a high risk of neurodevelopmental problems were born to mothers with a longer history of arthritis and were breastfeed for less than 6 months of age or were not breastfeed at all. No association was found with other maternal characteristics such as autoantibody existence and disease activity during and after the pregnancy.
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Affiliation(s)
- Cecilia Nalli
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili and University of Brescia, Brescia, Italy
| | - Jessica Galli
- Child Neurology and Psychiatry Unit, Department of Clinical and Experimental Sciences, ASST Spedali Civili and University of Brescia, Brescia, Italy
| | - Daniele Lini
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili and University of Brescia, Brescia, Italy.,Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Angela Merlini
- Child Neurology and Psychiatry Unit, Department of Clinical and Experimental Sciences, ASST Spedali Civili and University of Brescia, Brescia, Italy
| | - Silvia Piantoni
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili and University of Brescia, Brescia, Italy.,Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Maria Grazia Lazzaroni
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili and University of Brescia, Brescia, Italy.,Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Victoria Bitsadze
- Department of Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - Jamilya Khizroeva
- Department of Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - Sonia Zatti
- Obstetric and Gynecology Unit, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Laura Andreoli
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili and University of Brescia, Brescia, Italy.,Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Elisa Fazzi
- Child Neurology and Psychiatry Unit, Department of Clinical and Experimental Sciences, ASST Spedali Civili and University of Brescia, Brescia, Italy
| | - Franco Franceschini
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili and University of Brescia, Brescia, Italy.,Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Alexander Makatsariya
- Department of Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - Yehuda Shoenfeld
- Department of Medicine 'B', The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Ramat Gan, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel.,I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - Angela Tincani
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili and University of Brescia, Brescia, Italy.,Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.,I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
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24
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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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25
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Abstract
Caring for women in the postnatal period can be challenging. One of the most important aspects is ensuring disease control as there is a risk of flare in the postpartum period. Other aspects of care also need to be addressed with the mother in mind such as breastfeeding or with the neonate in mind such as vaccinations or complications of the maternal condition affecting the neonate. This article highlights aspects of care that need to be addressed in the postpartum period such as flare rates, maternal wellbeing, thromboembolism, vaccinations, contraception and breast feeding.
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Affiliation(s)
- Maria Mouyis
- Rheumatology Department, West Middlesex University Hospital, London, UK.
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26
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Brites L, Silva S, Andreoli L, Inês L. Effectiveness of reproductive health counseling of women with systemic lupus erythematosus: observational cross-sectional study at an academic lupus clinic. Rheumatol Int 2020; 41:403-408. [PMID: 32770270 DOI: 10.1007/s00296-020-04671-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 07/30/2020] [Indexed: 12/12/2022]
Abstract
Systemic lupus erythematosus (SLE) affects women of childbearing age. To optimize fetal and maternal outcomes, effective reproductive health counseling is crucial. To analyze the effectiveness of reproductive health counseling in women with SLE and identify gaps in patient educational needs. Cross-sectional study including women aged 18-45 years fulfilling ACR'97 and/or SLICC criteria, followed at an academic lupus clinic. Participants fulfilled a questionnaire evaluating brief obstetric history, knowledge about impact of SLE in pregnancy outcomes, recall of reproductive health counseling, contraception use and reproductive healthcare received. Effectiveness of reproductive health counseling was analyzed, and potential predictors of contraceptive use (age, previous spontaneous abortion, level of knowledge about SLE and reproductive planning) were tested by multiple regression analysis. We enrolled 108 women (mean age: 34.4 ± 7.1 years; mean disease duration: 10.3 ± 7.3 years). 64.8% of the patients recalled receiving information about family planning, and 81% about contraception. Only 38% declared to be well informed about the impact of SLE on pregnancy. In this cohort, 23.2% wanted a pregnancy in the future; the remainder already had the children they wanted or planned a subsequent pregnancy. Contraceptive use was reported by 79.6% of the patients (oral contraceptives by 39.8% and intrauterine device by 20.4%), while 11.1% reported unprotected intercourses. No statistically significant predictors of contraceptive use were identified. In this academic Lupus Clinic, most SLE women of childbearing age received effective reproductive health counseling and use contraceptive methods. Their unmet needs were identified to guide optimization of patient counseling.
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Affiliation(s)
- Luisa Brites
- Rheumatology Department, Centro Hospitalar Universitário de Coimbra, Praceta Professor Mota Pinto, 3000-075, Coimbra, Portugal
| | - Stefanie Silva
- Rheumatology Department, Centro Hospitalar Universitário de Coimbra, Praceta Professor Mota Pinto, 3000-075, Coimbra, Portugal
| | - Laura Andreoli
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.,Unit of Rheumatology and Clinical Immunology, ASST Spedali Civili, Brescia, Italy
| | - Luis Inês
- Rheumatology Department, Centro Hospitalar Universitário de Coimbra, Praceta Professor Mota Pinto, 3000-075, Coimbra, Portugal. .,School of Health Sciences, University of Beira Interior, Covilhã, Portugal.
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27
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Scioscia M, Praino E, Scioscia C. Rheumatic diseases during pregnancy and SARS‐CoV‐2: An appeal for medication adherence. Int J Gynaecol Obstet 2020; 150:269-270. [PMID: 32502303 PMCID: PMC9087663 DOI: 10.1002/ijgo.13255] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 05/22/2020] [Accepted: 06/01/2020] [Indexed: 11/22/2022]
Abstract
The novel SARS‐CoV‐2 outbreak has raised concerns among patients with rheumatic diseases receiving chronic immunosuppressive therapy. Patient concerns regarding immune response to the virus have fueled non‐adherence behavior.
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Affiliation(s)
- Marco Scioscia
- Department of Obstetrics and Gynecology Policlinico Hospital Abano Terme Padua Italy
| | - Emanuela Praino
- Rheumatology Unit DSS4 Barletta ASL BT Andria Barletta Italy
| | - Crescenzio Scioscia
- Rheumatology Unit Department of Emergence Medicine and Transplantation (DETO) University of Bari "Aldo Moro" Bari Italy
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28
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Tosounidou S, Gordon C. Medications in pregnancy and breastfeeding. Best Pract Res Clin Obstet Gynaecol 2020; 64:68-76. [DOI: 10.1016/j.bpobgyn.2019.10.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Accepted: 10/24/2019] [Indexed: 11/30/2022]
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