The Influence of Methotrexate Treatment on Male Fertility and Pregnancy Outcome After Paternal Exposure

Uncovering the link between inflammatory rheumatic diseases and male reproductive health: a perspective on male infertility and sexual dysfunction

Inflammatory rheumatic diseases (IRDs) refer to a range of persistent disorders that have a major influence on several physiological systems. Although there is much evidence connecting IRDs to sexual dysfunction and fertility problems, research specifically focusing on male infertility in relation to these diseases is sparse. This review addresses the complicated connection between IRDs and male infertility, emphasising the physiological, psychological, and pharmacological aspects that influence reproductive health outcomes in men with rheumatic conditions. We explore the effects of IRDs and their treatments on many facets of male reproductive well-being, encompassing sexual functionality, semen characteristics, and hormonal balance. Additionally, we present a comprehensive analysis of the present knowledge on the impact of several categories of anti-rheumatic drugs on male reproductive function. Although there is an increasing awareness of the need of addressing reproductive concerns in individuals IRDs, there is a noticeable lack of research especially dedicated to male infertility. Moving forward, more comprehensive research is needed to determine the prevalence, risk factors, and mechanisms driving reproductive difficulties in males with IRDs. We can better assist the reproductive health requirements of male IRD patients by expanding our understanding of male infertility in the setting of rheumatic disorders and implementing holistic methods to care.

Efficacy and Safety of Bimekizumab in Patients With Psoriatic Arthritis With or Without Methotrexate: 52-Week Results From Two Phase 3 Studies

OBJECTIVE

The objective of this study was to assess 52-week efficacy and safety of bimekizumab in patients with active psoriatic arthritis (PsA) with or without concomitant methotrexate (+/-MTX) treatment at baseline.

METHODS

We conducted a post hoc analysis of patients in BE OPTIMAL (NCT03895203; biologic disease-modifying antirheumatic drug [bDMARD]-naïve), BE COMPLETE (NCT03896581; prior inadequate response or intolerance to tumor necrosis factor inhibitors [TNFi-IR]), and the BE VITAL open-label extension (NCT04009499) study. Patients were randomized to one of the following treatment groups: bimekizumab 160 mg every four weeks, placebo, or a reference drug (adalimumab 40 mg every two weeks; BE OPTIMAL only). From Week 16, placebo-randomized patients received bimekizumab. Missing data were imputed using non-responder imputation, multiple imputation, or worst-category imputation.

RESULTS

Through Week 52, similar proportions of bimekizumab-treated patients achieved American College of Rheumatology 50% (ACR50) response criteria for both +MTX and -MTX (BE OPTIMAL: 54.4% +MTX, 54.7% -MTX; BE COMPLETE: 56.3% +MTX, 48.0% -MTX). Similar proportions of bimekizumab-treated patients achieved complete skin clearance (Psoriasis Area and Severity Index 100% [PASI100] response) and minimal disease activity in both +MTX and -MTX groups. Similar trends were seen in placebo/bimekizumab-treated patients. Through Week 52, the proportion of bimekizumab-treated patients with ≥1 treatment-emergent adverse event were similar between the +MTX and -MTX groups (BE OPTIMAL 325 of 410 [79.3%] vs 230 of 292 [78.8%], BE COMPLETE 105 of 168 [62.5%] vs 138 of 220 [62.7%]). The safety profile was comparable between subgroups and consistent with the prior safety profile of bimekizumab.

CONCLUSION

Treatment with bimekizumab demonstrated consistent, sustained efficacy to 52 weeks in bDMARD-naïve and TNFi-IR patients with PsA and was well tolerated, irrespective of concomitant MTX.

Testicular dysfunction and "its recovery effect" after cadmium exposure

In recent years, with the acceleration of industrialization, the decline of male fertility caused by heavy metal pollution has attracted much attention. However, whether the inhibition of testicular function after cadmium exposure is reversible remains to be studied. In this study, we constructed rat models of cadmium exposure and dis-exposure, and collected relative samples to observe the changes of related indicators. The results showed that cadmium exposure could reduce the fertility, inhibit the hypothalamic-pituitary-testis axis and activate hypothalamic-pituitary-adrenal axis function, the testicular GR/PI3K-AKT/AMPK signal was abnormal, cell proliferation was inhibited and apoptosis was enhanced. Four weeks after the exposure was stopped, the fertility was still decreased, testicular testosterone synthesis and spermatogenesis were inhibited, cell proliferation was inhibited and apoptosis was enhanced, but all of them were reversed. After eight weeks of cadmium exposure, the above indicators were observed to return to normal. At the same time, by giving different concentrations of corticosterone to spermatogonium, we confirmed that corticosterone may regulate the proliferation and apoptosis of spermatogonium through GR/PI3K-AKT/AMPK signal. In this study, the reproductive toxicity of cadmium, a metal environmental pollutant, was analyzed in depth to provide a new theoretical and experimental basis for ensuring male reproductive health.

Paternal use of selective serotonin reuptake inhibitors and adverse health outcomes: A nationwide cohort study on 13,547 exposed children

BACKGROUND

The use of selective serotonin reuptake inhibitors (SSRIs) has increased over time. Several studies indicate that paternal use of medication may adversely affect the developing fetus. Only a few studies have investigated the association between preconceptional paternal exposure to SSRIs and the risks of adverse health outcomes in children.

OBJECTIVES

This study aimed to assess adverse birth outcomes and adverse early life events in children fathered by men using SSRIs prior to conception.

MATERIALS AND METHODS

All live-born singleton children born in Denmark from 1997 until 2019 and their parents were included. The exposed cohort comprised all children fathered by men using SSRIs 3 months prior to conception and the unexposed cohort comprised all other children. We estimated the odds ratios for adverse birth outcomes: small for gestational age (SGA), preterm birth, low Apgar score, and major congenital malformations. Furthermore, we estimated the hazard ratios for adverse early life events of infections and hospitalizations within 1 year from birth. We also examined adverse birth outcomes and the adverse early life events according to SSRI subgroups.

RESULTS

There was a statistically significantly increased odds ratio 1.15 (confidence interval, CI: 1.06-1.23) for preterm birth. No significant results were found for SGA, low Apgar score, and major congenital malformations. The adjusted hazard ratios for hospitalizations and infections were 1.06 (CI: 1.02-1.11) and 1.02 (CI: 0.97-1.07), respectively. There was a statistically significantly increased odds ratio for preterm birth with respect to the SSRI subgroups citalopram and escitalopram, and for hospitalizations with respect to citalopram.

DISCUSSION AND CONCLUSION

Although the risks of certain adverse birth and adverse early life outcomes were statistically significantly increased, the ratios were small and may have limited clinical importance. Paternal use of SSRI was in general safe in the preconceptual period.

Non-biologic immunosuppressive drugs for inflammatory and autoimmune skin diseases

Non-biologic immunosuppressive drugs, such as azathioprine, dapsone or methotrexate are fundamental treatment options for a wide range of autoimmune and chronic inflammatory skin diseases. Some of these drugs were initially used for malignancies (e.g., azathioprine or methotrexate) or infectious diseases (e.g., hydroxychloroquine or dapsone) but are nowadays mostly used for their immunosuppressive/immunomodulating action. Although dermatologists have years of clinical experience with these drugs, some of the mechanisms of action are not fully understood and are the subject of research. Although these drugs are commonly used, lack of experience or knowledge regarding their safety profiles and management leads to skepticism among physicians. Here, we summarize the mechanism of action and detailed management of adverse effects of the most commonly used immunosuppressive drugs for skin diseases. Furthermore, we discuss the management of these drugs during pregnancy and breastfeeding, as well as their interaction and handling during vaccination.

Nicht-Biologika-Immunsuppressiva bei entzündlichen und autoimmunen Hautkrankheiten: Non-biologic immunosuppressive drugs for inflammatory and autoimmune skin diseases

Nicht‐Biologika‐Immunsuppressiva wie Azathioprin, Dapson oder Methotrexat sind grundlegende Behandlungsmöglichkeiten für ein breites Spektrum von Autoimmunerkrankungen und chronisch‐entzündlichen Hauterkrankungen. Einige dieser Medikamente wurden ursprünglich bei malignen Erkrankungen (zum Beispiel Azathioprin oder Methotrexat) oder Infektionskrankheiten (zum Beispiel Hydroxychloroquin oder Dapson) eingesetzt, werden aber heute hauptsächlich wegen ihrer immunsuppressiven/immunmodulierenden Wirkung verwendet. Obwohl Dermatologen über jahrelange klinische Erfahrung mit diesen Arzneimitteln verfügen, sind einige der Wirkmechanismen noch nicht vollständig geklärt und noch Gegenstand der Forschung. Obwohl diese Medikamente häufig eingesetzt werden, führen mangelnde Erfahrung oder fehlendes Wissen über ihre Sicherheitsprofile und ihr Management zu einer skeptischen Haltung bei den Ärzten. Hier fassen wir den Wirkmechanismus und das detaillierte Management der Nebenwirkungen der am häufigsten verwendeten immunsuppressiven Medikamente für Hautkrankheiten zusammen. Darüber hinaus diskutieren wir den Umgang mit diesen Medikamenten während der Schwangerschaft und Stillzeit sowie ihre Wechselwirkung und Handhabung im Zusammenhang mit Impfungen.

The Dutch Pregnancy Drug Register: Suitable to Study Paternal Drug Exposures?

Paternal medication use around the time of conception is common, but information about its effects on pregnancy outcome and the health of the child is generally limited. The aim of this study is to examine the feasibility of studying paternal exposure in the Dutch Pregnancy Drug Register by using immunosuppressants as a proof of concept. In 113 of 15,959 pregnancies, long-term paternal immunosuppressant use was reported 3 months before conception. In total, 134 immunosuppressants were used. Pregnancy outcome was known for 54 cases and was in accordance with previous findings. Two spontaneous abortions, two premature births, six small for gestational age babies, and two major congenital malformations were reported. Time to pregnancy (TTP) was known for 9548 pregnancies, including 89 with paternal immunosuppressant use. TTP analysis did not show a difference in pregnancies with paternal immunosuppressant use compared to the control group. Moreover, the number of fertility treatments in the paternal immunosuppressant group was similar to the control group. In our opinion, it is feasible to use the Dutch Pregnancy Drug Register to study the effects of paternal exposure on pregnancy outcome. However, to study the potential effects on fertility, more information is needed, particularly since the beginning of pregnancy attempts.

Paternal preconception exposure to non-steroid anti-inflammatory drugs or opioids and adverse birth outcomes: A nationwide registry-based cohort study

BACKGROUND AND AIM

Paternal use of analgesics during the time of conception and adverse birth outcomes are poorly studied. We investigated the association between paternal exposure to non-steroid anti-inflammatory drugs and opioids within 3 months before the date of conception and the risk of adverse birth outcomes (preterm birth, small for gestational age, low Apgar score, and major congenital malformations).

METHODS

We used nationwide data from the Danish health registers. We included information on all singleton live births, and their fathers and mothers from 1997 to 2018. We created two exposed cohorts, children with preconception paternal exposure to (1) non-steroid anti-inflammatory drugs and (2) opioids. The unexposed cohort was children without preconception paternal exposure to non-steroid anti-inflammatory drugs or opioids, and we performed a sub-analysis against paternal use of acetaminophen (paracetamol). We used logistic regression models to estimate the odds ratios of adverse birth outcomes including 95% confidence intervals.

RESULTS

We identified 1,260,934 children, 45,667 children with paternal exposure to non-steroid anti-inflammatory drugs, 10,086 children with paternal exposure to opioids, and 1,205,181 unexposed children. The adjusted odds ratio for preterm birth was 1.08 (95% confidence interval, 1.03-1.13) after paternal exposure to non-steroid anti-inflammatory drugs and 1.21 (95% confidence interval, 1.08-1.35) after paternal exposure to opioids. The adjusted odds ratio for small for gestational age was 1.09 (95% confidence interval, 1.03-1.17) after paternal exposure to non-steroid anti-inflammatory drugs, and 1.03 (95% confidence interval, 0.88-1.21) after paternal exposure to opioids. We found null-associations for a low Apgar score and major congenital malformations. Estimates were attenuated when compared against paternal paracetamol exposure.

CONCLUSIONS

Overall, we found null-associations across the comparisons made. Weak associations were found for paternal exposure to non-steroid anti-inflammatory drugs or opioids and preterm birth and small for gestational age, but not with low Apgar score or major congenital malformation. All associations were attenuated when compared against an active comparator of paternal paracetamol exposure. The effect sizes were small and less likely to be of clinical relevance.

Methotrexate use among men-association with fertility and the perinatal health of their children: a Swedish nationwide register study

OBJECTIVE

To study the effect of methotrexate on male fertility and subsequent effects on their children, for which data are scarce and contradictory.

DESIGN

Nationwide multiregister cohort study.

SETTING

Not applicable.

SUBJECT(S)

All children born alive in Sweden between 2006 and 2014 and their fathers. Three cohorts were defined: children to fathers with periconceptional methotrexate exposure (exposed cohort), children whose fathers stopped methotrexate intake ≥2 years before conception (previously exposed cohort), and children to fathers with no methotrexate exposure (control cohort).

EXPOSURE(S)

The father having at least one dispensed methotrexate prescription from pharmacies 0-3 months before conception, along with at least one more dispensed methotrexate prescription 0-12 months before conception (periconceptional exposure). Previously exposed cohort: the father having no dispensed methotrexate prescriptions in the 2 years before conception, but having at least two dispensed prescriptions before that.

MAIN OUTCOME MEASURES

Congenital anomalies (major and any; primary outcomes), preterm birth (PTB) and being small for gestational age (SGA; secondary outcomes), as well as need of intracytoplasmic sperm injection (ICSI) to achieve pregnancy (primary outcome in exposed cohort vs. controls, exploratory outcome in previously exposed cohort vs. controls). Outcomes were analyzed using logistic regression.

RESULTS

A total of 223 children to fathers with periconceptional methotrexate exposure were identified, along with 356 children whose fathers stopped methotrexate intake ≥2 years before conception and 809,706 not methotrexate-treated controls. In children with fathers periconceptionally exposed to methotrexate, the adjusted and unadjusted odds ratios (95% confidence intervals) for major congenital anomalies were 1.1 (0.4-2.6) and 1.1 (0.4-2.4), any congenital anomalies 1.3 (0.7-2.4) and 1.4 (0.7-2.3), PTB 1.0 (0.5-1.8) and 1.0 (0.5-1.8), SGA 1.1 (0.4-2.6) and 1.0 (0.4-2.2), and conception by use of ICSI 3.9 (2.2-7.1) and 4.6 (2.5-7.7). Use of ICSI was not increased among fathers who stopped methotrexate intake ≥2 years before conception, having adjusted and unadjusted odds ratios 0.9 (0.4-1.9) and 1.5 (0.6-2.9).

CONCLUSION

This study suggests that paternal periconceptional methotrexate use does not increase risk of congenital anomalies, PTB, or SGA in the offspring but may temporarily reduce fertility.

Real-World Experience of Methotrexate in the Treatment of Skin Diseases: an Italian Delphi Consensus

BACKGROUND

After decades of use, methotrexate displays an established safety and efficacy profile in both in-hospital and outpatient settings. Despite its widespread use, there is surprisingly little clinical evidence to guide daily practice with methotrexate in dermatology.

OBJECTIVES

To provide guidance for clinicians in daily practice for areas in which there is limited guidance.

METHODS

A Delphi consensus exercise on 23 statements was carried out on the use of methotrexate in dermatological routine settings.

RESULTS

Consensus was reached on statements that cover six main areas: (1) pre-screening exams and monitoring of therapy; (2) dosing and administration in patients naïve to methotrexate; (3) optimal strategy for patients in remission; (4) use of folic acid; (5) safety; and (6) predictors of toxicity and efficacy. Specific recommendations are provided for all 23 statements.

CONCLUSIONS

In order to optimize methotrexate efficacy, it is essential to optimize treatment using appropriate dosages, carrying out a rapid drug-based step-up on a treat-to-target strategy and preferably using the subcutaneous formulation. To manage safety aspects appropriately, it is essential to evaluate patients' risk factors and carry out proper monitoring during the course of treatment.

Australian inflammatory bowel disease consensus statements for preconception, pregnancy and breast feeding

OBJECTIVE

Because pregnancy outcomes tend to be worse in women with inflammatory bowel disease (IBD) than in those without, we aimed to update consensus statements that guide the clinical management of pregnancy in patients with IBD.

DESIGN

A multidisciplinary working group was established to formulate these consensus statements. A modified RAND/UCLA appropriateness method was used, consisting of a literature review, online voting, discussion meeting and a second round of voting. The overall agreement among the delegates and appropriateness of the statement are reported.

RESULTS

Agreement was reached for 38/39 statements which provide guidance on management of pregnancy in patients with IBD. Most medications can and should be continued throughout pregnancy, except for methotrexate, allopurinol and new small molecules, such as tofacitinib. Due to limited data, no conclusion was reached on the use of tioguanine during pregnancy. Achieving and maintaining IBD remission before conception and throughout pregnancy is crucial to optimise maternofetal outcomes. This requires a multidisciplinary approach to engage patients, allay anxieties and maximise adherence tomedication. Intestinal ultrasound can be used for disease monitoring during pregnancy, and flexible sigmoidoscopy or MRI where clinically necessary.

CONCLUSION

These consensus statements provide up-to-date, comprehensive recommendations for the management of pregnancy in patients with IBD. This will enable a high standard of care for patients with IBD across all clinical settings.

Pregnancy in Patients with Inflammatory Bowel Diseases-A Literature Review

In recent years, we have faced an increasing incidence of inflammatory bowel disease (IBD), especially among young people, affecting them during their reproductive years. The paucity of data and reduced knowledge regarding the evolution of the disease during pregnancy and the adverse effects of the therapy on the mother and infant increase voluntary childlessness in this group of patients. Depending on the type of IBD, severity and surgical or medical management, this can negatively affect the pregnancy. C-sections and the risk of low-birth-weight babies are higher in women with IBD, independent of active/inactive disease, while preterm birth, stillbirth and miscarriage are associated with disease activity. In the last period, medicinal therapy has evolved, and new molecules have been developed for better control of the lesions, but the effect on pregnancy and breastfeeding is still controversial. We conducted this review by studying the literature and recent research in order to have a better image of the practical management of IBD during pregnancy.

Adverse Birth and Child Outcomes in Children Fathered by Men Treated with Antidiabetics Prior to Conception: A Nationwide Cohort Study

BACKGROUND

The safety of fathers' use of antidiabetic drugs in terms of child outcomes is an important clinical question. We aimed to assess the risk of adverse birth and early childhood outcomes after fathers' use of antidiabetics prior to conception.

METHODS

A nationwide cohort study based on Danish health registries. The study comprised all live born singleton children in Denmark (1997 through 2018). Children were categorized according to fathers' filled prescriptions for antidiabetic drugs three months prior to conception. Exposed cohorts: children born after paternal use of insulin or non-insulin anti-hyperglycemic agents. The unexposed constituted children born by fathers not treated with antidiabetics prior to conception. We examined adverse birth outcomes (preterm birth, small for gestational age (SGA)), and adverse childhood outcomes in the first year of life (major congenital malformations (MCMs), and infections diagnosed at a hospital).

RESULTS

A total of 1,318,684 children were included. In all, 5527 children were born after paternal use of insulin, 2121 after use of non-insulin anti-hyperglycemic agents, and 1,311,036 were unexposed. After fathers' use of insulin we did not find increased risk of adverse outcomes. After fathers' use of metformin, the adjusted OR of MCMs was 1.40 (95% CI 1.11-1.76). After fathers' use of sulfonylureas, the adjusted OR of SGA was 1.80 (95% CI 1.11-2.93), and for child gastrointestinal infections the adjusted HR was 1.76 (95% CI 1.04-2.99).

CONCLUSIONS

Fathers' use of insulin was reassuring. Metformin and sulfonylureas were associated with selected adverse outcomes. Our findings suggest an additional 14 MCMs per 1000 fathers exposed to metformin prior to conception. As there is no meaningful supporting biological rationale, these findings should be confirmed in a different population prior to clinical consequences being drawn.

Low-dose Methotrexate Therapy Does Not Affect Semen Parameters and Sperm DNA

BACKGROUND

Methotrexate is widely used in inflammatory diseases during the patients' reproductive years. The effect on male fertility and sperm DNA integrity is largely unknown. We evaluated sperm DNA integrity and basic semen parameters according to the World Health Organization (WHO) in male patients with inflammatory diseases treated with methotrexate.

METHODS

Semen samples from 14 patients on low-dose maintenance methotrexate were compared with samples from 40 healthy volunteers. Further, 5 patients delivered samples on and off methotrexate therapy for paired comparison. Sperm DNA fragmentation index (DFI), concentration, motility, and morphology were evaluated. Blood sex hormones and methotrexate levels were measured in blood and semen.

RESULTS

DNA fragmentation index in methotrexate-treated patients was comparable with that in healthy volunteers (DFI, 11.5 vs 15.0; P = .06), and DFI did not change significantly on and off methotrexate in the paired samples (DFI, 12.0 vs 14.0; P = 0.35). Sperm concentration, motility, and morphology did not differ between men treated with methotrexate and healthy volunteers. Sperm progressive motility increased off therapy compared with on therapy (65.0% vs 45.0%, P = .04), but all fluctuations in progressive motility were within the WHO reference interval. All methotrexate polyglutamates1-5 were detected in blood, but only methotrexate polyglutamate1 in semen. Serum testosterone was unaffected by methotrexate therapy.

CONCLUSIONS

Patients treated with low-dose methotrexate have a sperm quality comparable with that of healthy volunteers, and methotrexate treatment does not increase sperm DNA fragmentation. This study does not support cryopreservation of semen before treatment initiation nor a 3-month methotrexate-free interval prior to conception.

Immunosuppressive Drugs

Immunosuppressant is a class of medicines that inhibit or decrease the intensity of the immune response in the body. Most of these medications are used to allow the body less likely to resist a transplanted organ. In solid organ transplantation, immunosuppressive agents are needed for the activation of early-stage immunosuppression, the management of late-stage immunosuppression or for the maintenance of organ rejection. The emergence of novel agents and improvements in immunosuppression regimens after transplantation are significant factors leading to this progress. However, these drugs also increase the risk of infection, cancers and specific adverse side effects specific to each agent in patients particularly in pregnant women and fertility issues. Corona virus disease being hot topic of debate is has given positive outcome to immunosuppressive drugs however need more attention in future. Transplant centers across the world utilize multiple immunosuppression protocols; nevertheless, each patient can require an individually formulated immunosuppression regimen to manage the advantages and possible damage of treatment thus eliminating the likelihood of their primary disease recurrence.

Effect of Multiple Sclerosis and Its Treatments on Male Fertility: Cues for Future Research

Multiple sclerosis is a chronic disease that may lead to different types of symptoms and disabilities. with the better quality of life and decreased disability due to early diagnosis and the availability of disease-modifying therapies (DMTs), the treating physician is increasingly asked to counsel patients on its effects on fertility and reproduction. In particular, reproductive issues are still scarcely studied and discussed in men. Among the still open questions are the following: (a) Does multiple sclerosis cause infertility per sè? (b) Is multiple sclerosis correlated with conditions that increase the risk of infertility? (c) Do DMTs or other therapies for multiple sclerosis impact gonadal function in men? The aim of this review is to provide an overview on the available literature data about the reproductive issues unique to men with multiple sclerosis, underlining the numerous areas where evidence is lacking and, therefore, the priorities for future research.

A Comprehensive Review of Sarcoidosis Treatment for Pulmonologists

Due to frequent lung involvement, the pulmonologist is often the reference physician for management of sarcoidosis, a systemic granulomatous disease with a heterogeneous course. Treatment of sarcoidosis raises some issues. The first challenge is to select patients who are likely to benefit from treatment, as sarcoidosis may be self-limiting and remit spontaneously, in which case treatment can be postponed and possibly avoided without any significant impact on quality of life, organ damage or prognosis. Systemic glucocorticosteroids (GCs) are the drug of first choice for sarcoidosis. When GCs are started, there is a > 50% chance of long-term treatment. Prolonged use of prednisone at > 10 mg/day or equivalent is often associated with severe side effects. In these and refractory cases, steroid-sparing options are advised. Antimetabolites, such as methotrexate, are the second-choice therapy. Biologics, such as anti-TNF and especially infliximab, are third-choice drugs. The three treatments can be used concomitantly. Regardless of whether treatment is started, the clinician needs to organize regular follow-up to monitor remissions, flares, progression, complications, toxicity and relapses in order to promptly adjust the drugs used.

Review of pregnancy in Crohn's disease and ulcerative colitis

Inflammatory bowel disease (IBD) frequently affects women of childbearing age and can have implications in pregnancy. Most women with IBD have comparable fertility with women in the general population. Fertility is reduced in women with active disease or previous ileal-pouch-anal anastomosis (IPAA) surgery and is temporarily reduced in men taking sulfasalazine. Women with IBD have an increased risk of preterm delivery, low birth weight, small-for-gestational-age infants and Cesarean section (CS) delivery, however, no increased risk of congenital abnormalities. These adverse outcomes are particularly prevalent for women with active IBD compared with those with quiescent disease. Conception should occur during disease remission to optimize maternal and fetal outcomes and reduce the risk of disease exacerbations during pregnancy. Pre-conception counseling is therefore pertinent to provide patient education, medication review for risk of teratogenicity and objective disease assessment. Most medications are safe during pregnancy and breastfeeding, with the exception of methotrexate, ciclosporin, allopurinol and tofacitinib. Delivery modality should be guided by obstetric factors in most cases; however, CS is recommended for women with active perianal disease and can be considered for women with inactive perianal disease or IPAA. In conclusion, most women with IBD have uncomplicated pregnancies. Active IBD is the predominant predictor of poor outcomes and disease exacerbations; therefore, maintenance of disease remission during and before pregnancy is crucial.

The effect of paternal exposure to immunosuppressive drugs on sexual function, reproductive hormones, fertility, pregnancy and offspring outcomes: a systematic review

BACKGROUND

Information regarding the possible influence of immunosuppressive drugs on male sexual function and reproductive outcomes is scarce. Men diagnosed with immune-mediated diseases and a wish to become a father represent an important neglected population since they lack vital information to make balanced decisions about their treatment.

OBJECTIVE AND RATIONALE

The aim of this research was to systematically review the literature for the influence of paternal immunosuppressive drug use on many aspects of male sexual health, such as sexual function, fertility, pregnancy outcomes and offspring health outcomes.

SEARCH METHODS

A systematic literature search was performed in the bibliographic databases: Embase (via Elsevier embase.com), MEDLINE ALL via Ovid, Cochrane Central Register of Trials (via Wiley) and Web of Science Core Collection. Additionally, Google Scholar and the Clinical trial registries of Europe and the USA were searched. The databases were searched from inception until 31 August 2019. The searches combined keywords regarding male sexual function and fertility, pregnancy outcomes and offspring health with a list of immunosuppressive drugs. Studies were included if they were published in English and if they included original data on male human exposure to immunosuppressive drugs. A meta-analysis was not possible to perform due to the heterogeneity of the data.

OUTCOMES

A total of 5867 references were identified, amongst which we identified 161 articles fulfilling the eligibility criteria. Amongst these articles, 50 included pregnancy and offspring outcomes and 130 included sexual health outcomes. Except for large Scandinavian cohorts, most of the identified articles included a small number of participants. While a clear negative effect on sperm quality was evident for sulfasalazine and cyclophosphamide, a dubious effect was identified for colchicine, methotrexate and sirolimus. In three articles, exposure to tumour necrosis factor-α inhibitors in patients diagnosed with ankylosing spondylitis resulted in improved sperm quality. The information regarding pregnancy and offspring outcomes was scant but no large negative effect associated with paternal immunosuppressive drug exposure was reported.

WIDER IMPLICATIONS

Evidence regarding the safety of immunosuppressive drugs in men with a wish to become a father is inconclusive. The lack of standardisation on how to evaluate and report male sexual function, fertility and reproduction as study outcomes in men exposed to immunosuppressive drugs is an important contributor to this result. Future research on this topic is needed and should be preferably done using standardised methods.

[Recommendations when switching therapy from immunosuppressive drugs to dupilumab in patients with atopic dermatitis]

Based on new insights into the molecular pathogenesis of atopic dermatitis, a targeted anti-inflammatory therapy-dupilumab-has recently been approved as treatment alongside glucocorticoids and ciclosporin. Due to their pharmacology, neither glucocorticoids nor ciclosporin nor the off label used substances methotrexate, azathioprine and mycophenolic acid derivatives are suitable for long-term therapy. When switching therapy from small molecular substances to dupilumab, various factors should be considered. Both the specific cause of the change (ineffectiveness, adverse effects or contraindications) as well as the pharmacological conditions should be taken into account. Since there have been no specific clinical studies on this subject so far, the authors relied mainly on a literature search to draw up recommendations for practical everyday use.

Use of medications during pregnancy and breastfeeding for Crohn's disease and ulcerative colitis

Introduction: The peak age of diagnosis of inflammatory bowel disease (IBD) occurs during childbearing years, therefore management of IBD during pregnancy is a frequent occurrence. Maintenance of disease remission is crucial to optimize pregnancy outcomes, and potential maternal or fetal toxicity from medications must be balanced against the risks of untreated IBD.Areas covered: This review summarizes the literature on safety and use of medications for IBD during pregnancy and lactation.Expert opinion: 5-aminosalicylates, corticosteroids and thiopurines are safe for use during pregnancy, while methotrexate and tofacitinib should only be used with extreme caution. Anti-TNF agents (except certolizumab), vedolizumab, ustekinumab and tofacitinib readily traverse the placenta via active transport, therefore theoretically may affect fetal development. Certolizumab only undergoes passive transfer across the placenta, thus has markedly lower cord blood levels making it likely the safest biologic agent for infants. There is reasonable evidence to support the safety of anti-TNF monotherapy and combination therapy during pregnancy and lactation. Vedolizumab and ustekinumab are also thought to be safe in pregnancy and lactation, while tofacitinib is generally avoided due to teratogenic effects in animal studies.

Acute anejaculation, hypogonadism, and fertility preservation in the setting of neurosarcoidosis: case report and literature review

Objective

To examine fertility preservation techniques in the setting of neurosarcoidosis, and to review the impact of corticosteroid and methotrexate therapy on fertility.

Design

Case report of a patient with infertility secondary to anejaculation associated with spinal neurosarcoidosis, treated with systemic corticosteroids and methotrexate.

Setting

Academic tertiary-care hospital.

Patient(s)

A 39-year-old man presented with neurosarcoidosis complicated by acute anejaculation, erectile dysfunction, and hypogonadism. He underwent fertility consultation and sperm cryopreservation before initiating methotrexate therapy. His pretreatment total testosterone was low, at 157 ng/dL.

Intervention(s)

Unsuccessful pharmacologic therapy and penile vibratory stimulation (PVS) were followed by microdissection testicular sperm extraction (microTESE). Clomiphene was administered for optimization of spermatogenesis before microTESE.

Main Outcome Measure(s)

Vials of cryopreserved sperm, testis histopathology, and serum testosterone levels.

Result(s)

Eight vials of viable sperm were harvested by means of micro-TESE and cryopreserved. Despite intraoperative appearance of hypospermatogenesis, 90% of seminiferous tubules had active germ cell sloughing. Total testosterone increased to 278 ng/dL 2 months after initiating clomiphene.

Conclusion(s)

Conventional fertility preservation techniques may be effective in the setting of neurosarcoidosis-induced infertility owing to largely intact spermatogenesis. PVS, though not effective for this patient, should be considered along with electroejaculation, given high success rates in other patients with neurogenic anejaculation. Corticosteroid-mediated hypogonadism also must be considered in these patients, because it can negatively affect downstream spermatogenesis. In addition, evidence for the impact of paternal methotrexate exposure on fertility is limited and requires further investigation. As such, fertility consultation before initiating methotrexate is highly recommended.

Rheumatologic Medication Use During Pregnancy

Chronic rheumatic diseases often occur in women of reproductive age, and the effect rheumatic disease has on pregnancy varies depending on the condition. Medical management of rheumatic diseases during pregnancy may prevent joint or organ damage and minimize the adverse effects of the disease itself on pregnancy outcomes. Each patient requires individual assessment to control disease activity while minimizing or avoiding medications with potential maternal or fetal toxicity. An open discussion with shared decision making between patients, obstetricians, rheumatologists, and pharmacists is imperative to create an individualized treatment plan that meets patients' goals. This article will review the current literature for use of disease modifying antirheumatic drugs and biologics during pregnancy and lactation, providing health care professionals with the most up-to-date information available.

Does Abatacept Induce Testicular Toxicity?

OBJECTIVES

This study aims to demonstrate the effect of subcutaneous injections of abatacept on the histology of testes in mice.

MATERIALS AND METHODS

The study included 20 male BALB/c mice (average weight, 25 g; aged 12-14 weeks). Ten mice received subcutaneous (SC) injections of abatacept [0.25 mg per 25 g body weight per 0.03 mL normal saline (NS)] at zero, two, four and eight weeks. As the control group, 10 mice received SC injections of NS (0.03 mL). At the post-injection 10th week, the mice were sacrificed, and histopathological studies were conducted.

RESULTS

The results showed that 3/10 mice died of the abatacept-treated group. Testicular histology for the abatacept-treated group showed that 7/7 displayed no histopathological changes.

CONCLUSION

To our knowledge, this is the first control-blinded study of BALB/c mice suggesting that abatacept may not have testicular toxicity. Further fertility and testicular toxicology evaluations including semen analysis and gonadal hormones should be performed to clarify our findings.

Management of psoriasis in pregnancy - a review of the evidence to date

The onset of psoriasis collides with women’s reproductive timeframe, and pregnancy brings challenges to its treatment. Indeed, the health of both mother and foetus must be considered. When choosing to treat pregnant women affected by psoriasis with pharmacological therapy, it is important to be aware of all possible options and their repercussions. Although there are several pharmacological therapies available, pregnancy brings ethical concerns and any pharmacological approach must be well thought out. The data available in humans are limited, and further investigation on this matter is needed. Within biological therapies, certolizumab pegol has recently been identified as a promising approach during pregnancy because it has been shown to have no late active placental transfer and no clear signs of foetal harm. This article aims to review the impact of psoriasis during pregnancy, how the disease can be managed pharmacologically during this period according to the available armamentarium, and the possible effects of the therapeutic options for the mother and the foetus.

Knowing when to use steroids, immunosuppressants or biologics for the treatment of sarcoidosis

Introduction: Care of patients with sarcoidosis requires familiarity with its natural history as well as of various immunosuppressants employed in its treatment. We would like to share our approach to management based on our experience and understanding of the relevant literature.Areas covered: Asymptomatic patients with pulmonary sarcoidosis ought to be managed conservatively. Systemic sarcoidosis with burdensome symptoms usually responds to corticosteroids, but one needs to consider the risk of long-term steroid toxicity as well as relapse. Rapidly tapering steroids can decrease cumulative exposure without compromising efficacy. Steroid-sparing anti-sarcoidosis (SSAS) agents take longer to act and are associated with unique but mostly reversible toxicities. Used judiciously and with careful monitoring, they effectively suppress granulomatous inflammation. Patients intolerant of or failing to improve with a particular drug can be switched to another, and occasionally combination therapy with two SSAS agents might prove effective. A small proportion of patients are refractory, but often achieve control and sometimes remission with stepping up to biologic therapy.Expert opinion: Adopting a strategy of early SSAS therapy ought to effectively control sarcoidosis and avoid harm from prolonged corticosteroid dosing.

New advances in the management of pulmonary sarcoidosis

Sarcoidosis is a highly variable granulomatous multisystem syndrome. It affects individuals in the prime years of life; both the frequency and severity of sarcoidosis are greater in economically disadvantaged populations. The diagnosis, assessment, and management of pulmonary sarcoidosis have evolved as new technologies and therapies have been adopted. Transbronchial needle aspiration guided by endobronchial ultrasound has replaced mediastinoscopy in many centers. Advanced imaging modalities, such as fluorodeoxyglucose positron emission tomography scanning, and the widespread availability of magnetic resonance imaging have led to more sensitive assessment of organ involvement and disease activity. Although several new insights about the pathogenesis of sarcoidosis exist, no new therapies have been specifically developed for use in the disease. The current or proposed use of immunosuppressive medications for sarcoidosis has been extrapolated from other disease states; various novel pathways are currently under investigation as therapeutic targets. Coupled with the growing recognition of corticosteroid toxicities for managing sarcoidosis, the use of corticosteroid sparing anti-sarcoidosis medications is likely to increase. Besides treatment of granulomatous inflammation, recognition and management of the non-granulomatous complications of pulmonary sarcoidosis are needed for optimal outcomes in patients with advanced disease.

Sex Differences in Treatment Strategies Among Patients With Ulcerative Colitis: A Retrospective Cohort Analysis of Privately Insured Patients

BACKGROUND

Sex-based treatment disparities occur in many diseases. Women undergo fewer procedural interventions, and their care is less consistent with guideline-based therapy. There is limited research exploring sex-based differences in ulcerative colitis treatment. We hypothesized that women are less likely to be treated with strategies consistent with long-term disease remission, including surgery and maintenance medications.

OBJECTIVE

The aim of this study was to determine if patient sex is associated with choice of treatment strategy for ulcerative colitis.

DESIGN

This is a retrospective cohort analysis.

SETTING

Data were gathered from a large commercial insurance claims database from 2007 to 2015.

PATIENTS

We identified a cohort of 38,851 patients newly diagnosed with ulcerative colitis, aged 12 to 64 years with at least 1 year of follow-up.

MAIN OUTCOME MEASURES

The primary outcomes measured were the differences between male and female patients in 1) rates and types of index ulcerative colitis operations, 2) rates and types of ulcerative colitis medication prescriptions, and 3) rates of opioid prescriptions.

RESULTS

Men were more likely to undergo surgical treatment for ulcerative colitis (2.94% vs 1.97%, p < 0.001, OR 1.51, p < 0.001). The type of index operation performed did not vary by sex. Men were more likely to undergo treatment with maintenance medications, including biologic (12.4% vs 10.2%, p < 0.001, OR 1.22, p < 0.001), immunomodulatory (16.3% vs 14.9%, p < 0.001, OR 1.08, p = 0.006), and 5-aminosalicylate medications (67.0% vs 63.2%, p < 0.001, OR 1.18, p < 0.001). Women were more likely to undergo treatment with rescue therapies and symptomatic control with corticosteroids (55.5% vs 54.0%, p = 0.002, OR 1.07, p = 0.002) and opioids (50.2% vs 45.9%, p < 0.001, OR 1.17, p < 0.001).

LIMITATIONS

Claims data lack clinical characteristics acting as confounders.

CONCLUSIONS

Men with ulcerative colitis were more likely to undergo treatment consistent with long-term remission or cure, including maintenance medications and definitive surgery. Women were more likely to undergo treatment consistent with short-term symptom management. Further studies to explore underlying mechanisms of sex-related differences in ulcerative colitis treatment strategies and disease trajectories are warranted. See Video Abstract at http://links.lww.com/DCR/A943.

[What's new in internal medicine?]

As it is practiced in France, internal medicine meets the Anglo-Saxon definition of the specialty, ie doctors "equipped to handle the broad and comprehensive spectrum of illnesses that affect adults, and are recognized as experts in diagnosis, in treatment of chronic illness, and in health promotion and disease prevention - they are not limited to one type of medical problem or organ system". This 2017 "What's new in internal medicine" will consist of 2 parts, a first part on significant publications in the field of systemic and autoimmune diseases and a second part on more diverse publications (HIV, cancer, pregnancy, well-being...) important for medicine in general and its different specialties.

Updates on Women's Health Issues in Patients with Inflammatory Bowel Disease

PURPOSE OF REVIEW

Inflammatory bowel disease affects approximately 800,000 women in the USA with the peak incidence between ages 15 to 40. Thus for many females, IBD can impact nearly every stage of their life from menarche to pregnancy, menopause, and beyond. This paper will review the most recent updates on the topics of sexual health, cervical cancer screening, menstruation, fertility, contraception, and menopause.

RECENT FINDINGS

Menarche can be delayed in females especially those who are underweight, malnourished, or with active inflammatory bowel disease. Cyclical GI symptoms during a menstrual cycle are very common in women with IBD and should not be confused with flares. Overall fertility is similar to the general population unless females with IBD have had significant abdominal surgery but reassuringly this infertility appears to be restored with the use of in vitro fertilization. Discussion regarding family planning is imperative in women with IBD with a strong recommendation to consider long-acting highly effective contraceptives such as intrauterine devices or implants. Cervical cancer screening should be tailored in women on immunosuppressive medications and all women under 26 years of age should be advised to receive the human papilloma virus vaccination. As gastroenterologists will have longitudinal relationships with their female IBD patients, they must be knowledgeable about sex-specific issues during each stage of life from puberty to after menopause to optimize their patient's care.