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Siegel CH, Sammaritano LR. Safety of Medications Used to Treat Autoimmune Rheumatic Diseases During Pregnancy and Lactation. J Clin Rheumatol 2024; 30:S25-S33. [PMID: 39325122 DOI: 10.1097/rhu.0000000000002123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/27/2024]
Abstract
ABSTRACT Autoimmune rheumatic diseases (ARDs) often affect women during their reproductive years, and early studies of pregnancy in these patients reported high rates of adverse outcomes. Continuation or initiation of safe and effective medications in the preconception period is beneficial for maintaining or achieving disease quiescence throughout pregnancy thereby improving both maternal and pregnancy outcomes. The European Alliance of Associations for Rheumatology, the American College of Rheumatology, and the British Society for Rheumatology have published recommendations and guidelines regarding management of ARDs during pregnancy. The American College of Obstetricians and Gynecologists and the American Gastroenterological Association have also provided guidance statements with relevant recommendations. This review provides an overview of available recommendations for medication use in ARD pregnancy, with discussion of safety considerations for maternal and fetal well-being. Medications considered compatible with pregnancy include hydroxychloroquine, sulfasalazine, azathioprine, cyclosporine, tacrolimus, and TNF inhibitors. Methotrexate, mycophenolate, leflunomide, and cyclophosphamide should be avoided before and during pregnancy. Other medications, most of them newer, are largely discouraged for use in pregnancy due to inadequate data or concerns for neonatal immunosuppression, including non-TNF biologics and small molecule therapies. Further investigation is needed regarding effects of non-TNF biologics, biosimilars, and small molecules in pregnancy. Important efforts for the future will include improved methodologies to gather critical safety data, with consideration of inclusion of pregnant women in clinical trials, a complex and controversial issue. Long-term information on outcomes in offspring of treated women is lacking for many of these medications.
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Giles I, Thorne I, Schmidt NS, Reid C, Crossley A, Panca M, Freemantle N, Tower C, Dass S, Sharma SK, Williams D, O'Neill S, Dolhain RJEM, Toplak N, Hodson K, Nelson-Piercy C, Clowse MEB. The time of equipoise on the use of biological DMARDs in for inflammatory arthritis during pregnancy is finally over: a reappraisal of evidence to optimise pregnancy management. THE LANCET. RHEUMATOLOGY 2024; 6:e546-e559. [PMID: 38876126 DOI: 10.1016/s2665-9913(24)00097-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 11/22/2023] [Accepted: 04/10/2024] [Indexed: 06/16/2024]
Abstract
Active inflammatory arthritis in pregnancy is associated with an increased risk of adverse pregnancy outcomes. Treatment of active inflammation and maintenance of low disease activity with medication reduces these risks. Therapeutic decisions on disease-modifying antirheumatic drugs (DMARDs) in pregnancy are complicated by safety concerns, which have led to inappropriate withdrawal of treatment and consequential harm to mother and fetus. Studies of inflammatory arthritis in pregnancy have consistently shown minimal safety concerns with the use of biological DMARDs and an increased risk of disease flare with discontinuation of biological DMARDs. It is our opinion that during pregnancy, the benefits of disease control with biological DMARDs, when required in addition to conventional synthetic DMARDs, outweigh the risks. In this Series paper, we review the reasons for reconsideration of equipoise and propose an agenda for future research to optimise the use of biological DMARDs in inflammatory arthritis during pregnancy.
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Affiliation(s)
- Ian Giles
- Centre for Rheumatology, Division of Medicine, University College London, London, UK.
| | - Iona Thorne
- Chelsea and Westminster Hospital NHS Trust, London, UK
| | - Nanna Surlemont Schmidt
- Danish Centre for Expertise in Rheumatology (CeViG), Danish Hospital for Rheumatic Diseases, Sønderborg, Denmark; Thrombosis and Haemostasis, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Claire Reid
- Department of Rheumatology, UCLH, London, UK
| | | | - Monica Panca
- Comprehensive Clinical Trials Unit, University College London, London, UK
| | - Nick Freemantle
- Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Clare Tower
- Obstetrics and Maternal and Fetal Medicine, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester, UK
| | - Shouvik Dass
- Department of Rheumatology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Shefali K Sharma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - David Williams
- UCL Elizabeth Garrett Anderson Institute for Women's Health, London, UK
| | - Sean O'Neill
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Department of Rheumatology, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Radboud J E M Dolhain
- Department of Rheumatology, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Nataša Toplak
- Department of Allergology, Rheumatology and Clinical Immunology, University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Kenneth Hodson
- Obstetrics and Maternal Medicine, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK; UK Teratology Information Service, Newcastle, UK
| | | | - Megan E B Clowse
- Division of Rheumatology and Immunology, Duke University School of Medicine, Durham, NC, USA
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Duhig K, Hyrich KL. Annals of the Rheumatic Diseases collection on pregnancy 2018-2023: observational data-driven knowledge. Ann Rheum Dis 2024; 83:965-970. [PMID: 38331590 DOI: 10.1136/ard-2023-224861] [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: 11/23/2023] [Accepted: 01/30/2024] [Indexed: 02/10/2024]
Abstract
Pregnancy can be an exciting time but for those living with rheumatic musculoskeletal diseases (RMDs), it can also be a time fraught with concern, including what effect pregnancy will have on the underlying RMD and what effect the RMD may have on the pregnancy and the baby, including the effects of medications. Generating an evidence base in pregnancy is challenging. Few interventional trials of medications in RMD pregnancies have ever been conducted, often for concerns of safety for both the mother and the child. Therefore, observational research remains important for informing clinical practice and helping women with RMDs make decisions regarding their health preconception and during pregnancy. The Annals of the Rheumatic Diseases (ARD) continues to publish important research on pregnancy in RMDs to increase the evidence base on this subject. Here we present an overview of papers published on this topic between January 2018 and December 2023. Our focus includes papers on pregnancy and RMD outcome, the effects of drug exposure, fetal outcomes as well as fertility.
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Affiliation(s)
- Kate Duhig
- Maternal and Fetal Health Research Centre, The University of Manchester, Manchester, UK
| | - Kimme L Hyrich
- Centre for Musculoskeletal Research, The University of Manchester, Manchester, UK
- NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester, UK
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Deodhar A, Machado PM, Mørup M, Taieb V, Willems D, Orme M, Pritchett D, Gensler LS. Comparative efficacy and safety of bimekizumab in axial spondyloarthritis: a systematic literature review and network meta-analysis. Rheumatology (Oxford) 2024; 63:1195-1205. [PMID: 37947318 PMCID: PMC11065447 DOI: 10.1093/rheumatology/kead598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 09/19/2023] [Accepted: 10/17/2023] [Indexed: 11/12/2023] Open
Abstract
OBJECTIVES To compare the efficacy and safety of bimekizumab 160 mg every 4 weeks, a selective inhibitor of IL-17F and IL-17A, with those of biologic/targeted synthetic DMARDs (b/tsDMARDs) in non-radiographic axial SpA (nr-axSpA) and AS. METHODS A systematic literature review identified randomized controlled trials until January 2023 for inclusion in Bayesian network meta-analyses (NMAs), including three b/tsDMARDs exposure networks: predominantly-naïve, naïve, and experienced. Outcomes were Assessment of SpondyloArthritis international Society (ASAS)20, ASAS40 and ASAS partial remission (PR) response rates at 12-16 weeks. A safety NMA investigated discontinuations due to any reason and serious adverse events at 12-16 weeks. RESULTS The NMA included 36 trials. The predominantly-naïve network provided the most comprehensive results. In the predominantly-naïve nr-axSpA analysis, bimekizumab had significantly higher ASAS20 response rates vs secukinumab 150 mg [with loading dose (LD)/without LD], and comparable response rates vs other active comparators. In the predominantly-naïve AS analysis, bimekizumab had significantly higher ASAS40 response rates vs secukinumab 150 mg (without LD), significantly higher ASAS-PR response rates vs secukinumab 150 mg (with LD) and comparable response rates vs other active comparators. Bimekizumab demonstrated similar safety to that of other b/tsDMARDs. CONCLUSION Across ASAS outcomes, bimekizumab was comparable with most b/tsDMARDs, including ixekizumab, TNF inhibitors and upadacitinib, and achieved higher response rates vs secukinumab for some ASAS outcomes in predominantly b/tsDMARD-naïve nr-axSpA and AS patients at 12-16 weeks. In a pooled axSpA network, bimekizumab demonstrated comparable safety vs other b/tsDMARDs.
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Affiliation(s)
- Atul Deodhar
- Division of Arthritis and Rheumatic Diseases, Oregon Health & Science University, Portland, OR, USA
| | - Pedro M Machado
- Centre for Rheumatology & Department of Neuromuscular Diseases, University College London, London, UK
| | | | | | | | | | | | - Lianne S Gensler
- Department of Medicine/Division of Rheumatology, University of California, San Francisco, San Francisco, CA, USA
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5
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Eke AC, Gebreyohannes RD, Fernandes MFS, Pillai VC. Physiologic Changes During Pregnancy and Impact on Small-Molecule Drugs, Biologic (Monoclonal Antibody) Disposition, and Response. J Clin Pharmacol 2023; 63 Suppl 1:S34-S50. [PMID: 37317492 PMCID: PMC10365893 DOI: 10.1002/jcph.2227] [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: 10/26/2022] [Accepted: 02/17/2023] [Indexed: 06/16/2023]
Abstract
Pregnancy is a unique physiological state that results in many changes in bodily function, including cellular, metabolic, and hormonal changes. These changes can have a significant impact on the way small-molecule drugs and monoclonal antibodies (biologics) function and are metabolized, including efficacy, safety, potency, and adverse effects. In this article, we review the various physiologic changes that occur during pregnancy and their effects on drug and biologic metabolism, including changes in the coagulation, gastrointestinal, renal, endocrine, hepatic, respiratory, and cardiovascular systems. Additionally, we discuss how these changes can affect the processes of drug and biologic absorption, distribution, metabolism, and elimination (pharmacokinetics), and how drugs and biologics interact with biological systems, including mechanisms of drug action and effect (pharmacodynamics) during pregnancy, as well as the potential for drug-induced toxicity and adverse effects in the mother and developing fetus. The article also examines the implications of these changes for the use of drugs and biologics during pregnancy, including consequences of suboptimal plasma drug concentrations, effect of pregnancy on the pharmacokinetics and pharmacodynamics of biologics, and the need for careful monitoring and individualized drug dosing. Overall, this article aims to provide a comprehensive understanding of the physiologic changes during pregnancy and their effects on drug and biologic metabolism to improve the safe and effective use of drugs.
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Affiliation(s)
- Ahizechukwu C Eke
- Division of Maternal Fetal Medicine, Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Rahel D Gebreyohannes
- Department of Obstetrics and Gynecology, Addis Ababa University College of Medicine, Addis Ababa, Ethiopia
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Andreoli L, Chighizola CB, Iaccarino L, Botta A, Gerosa M, Ramoni V, Tani C, Bermas B, Brucato A, Buyon J, Cetin I, Chambers CD, Clowse MEB, Costedoat-Chalumeau N, Cutolo M, De Carolis S, Dolhain R, Fazzi EM, Förger F, Giles I, Haase I, Khamashta M, Levy RA, Meroni PL, Mosca M, Nelson-Piercy C, Raio L, Salmon J, Villiger P, Wahren-Herlenius M, Wallenius M, Zanardini C, Shoenfeld Y, Tincani A. Immunology of pregnancy and reproductive health in autoimmune rheumatic diseases. Update from the 11 th International Conference on Reproduction, Pregnancy and Rheumatic Diseases. Autoimmun Rev 2023; 22:103259. [PMID: 36549355 DOI: 10.1016/j.autrev.2022.103259] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 12/18/2022] [Indexed: 12/24/2022]
Abstract
Autoimmune rheumatic diseases (ARD) can affect women and men during fertile age, therefore reproductive health is a priority issue in rheumatology. Many topics need to be considered during preconception counselling: fertility, the impact of disease-related factors on pregnancy outcomes, the influence of pregnancy on disease activity, the compatibility of medications with pregnancy and breastfeeding. Risk stratification and individualized treatment approach elaborated by a multidisciplinary team minimize the risk of adverse pregnancy outcomes (APO). Research has been focused on identifying biomarkers that can be predictive of APO. Specifically, preeclampsia and hypertensive disorders of pregnancy tend to develop more frequently in women with ARD. Placental insufficiency can lead to intrauterine growth restriction and small-for-gestational age newborns. Such APO have been shown to be associated with maternal disease activity in different ARD. Therefore, a key message to be addressed to the woman wishing for a pregnancy and to her family is that treatment with compatible drugs is the best way to ensure maternal and fetal wellbeing. An increasing number of medications have entered the management of ARD, but data about their use in pregnancy and lactation are scarce. More information is needed for most biologic drugs and their biosimilars, and for the so-called small molecules, while there is sufficient evidence to recommend the use of TNF inhibitors if needed for keeping maternal disease under control. Other issues related to the reproductive journey have emerged as "unmet needs", such as sexual dysfunction, contraception, medically assisted reproduction techniques, long-term outcome of children, and they will be addressed in this review paper. Collaborative research has been instrumental to reach current knowledge and the future will bring novel insights thanks to pregnancy registries and prospective studies that have been established in several Countries and to their joint efforts in merging data.
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Affiliation(s)
- Laura Andreoli
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili, Brescia, Italy; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Cecilia B Chighizola
- Paediatric Rheumatology Unit, ASST G. Pini & CTO, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Luca Iaccarino
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Angela Botta
- Department of Obstetrics, Gynaecology and Pediatrics, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Maria Gerosa
- Division of Clinical Rheumatology, ASST Gaetano Pini-CTO, Research Center for Adult and Pediatric Rheumatic Diseases, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Véronique Ramoni
- Medicina Generale Lodi, ASST Lodi-Ospedale Maggiore, Lodi, Italy
| | - Chiara Tani
- Rheumatology Unit, Azienda Ospedaliero Universitaria Pisana and Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Antonio Brucato
- Internal Medicine, Fatebenefratelli Hospital, Milan, Italy; Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Jill Buyon
- Division of Rheumatology, New York University Grossman School of Medicine, New York, NY, USA
| | - Irene Cetin
- Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy; Department of Woman, Mother and Child, Luigi Sacco and Vittore Buzzi Children Hospitals, ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Christina D Chambers
- Department of Pediatrics, University of California, Herbert Wertheim School of Public Health and Longevity Science, University of California, San Diego, La Jolla, CA, USA
| | - Megan E B Clowse
- Division of Rheumatology & Immunology, Duke University School of Medicine, Durham, NC, USA
| | - Nathalie Costedoat-Chalumeau
- Internal Medicine Department, Cochin Hospital, Referral center for rare autoimmune and systemic diseases, Université de Paris, CRESS, INSERM, INRA, Paris, France
| | - Maurizio Cutolo
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal M edicine, University of Genoa, IRCSS San Martino Polyclinic, Genoa, Italy
| | - Sara De Carolis
- Department of Obstetrics, Gynaecology and Pediatrics, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Radboud Dolhain
- Department of Rheumatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Elisa M Fazzi
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy; Child Neurology and Psychiatry Unit, ASST Spedali Civili, Brescia, Italy
| | - Frauke Förger
- Department of Rheumatology and Immunology, University Hospital (Inselspitaland University of Bern, Bern, Switzerland
| | - Ian Giles
- Centre for Rheumatology, Department of Inflammation, Division of Medicine, University College London, Department of rheumatology, University College London Hospital, London, UK
| | - Isabell Haase
- Department for Rheumatology and Hiller Research Institute, Heinrich-Heine-University, Düsseldorf, Germany
| | - Munther Khamashta
- Women & Children's Health, King's College, London, UK; GlaxoSmithKline Global Medical Expert, Dubai, United Arab Emirates
| | - Roger A Levy
- Universidade do Estado de Rio de Janeiro, Rio de Janeiro, Brazil; GlaxoSmithKline Global Medical Expert, Collegeville, PA, USA
| | - Pier Luigi Meroni
- IRCCS Istituto Auxologico Italiano, Immunorheumatology Research Laboratory, Milan, Italy
| | - Marta Mosca
- Rheumatology Unit, Azienda Ospedaliero Universitaria Pisana and Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Luigi Raio
- Department of Obstetrics and Gynaecology, University Hospital (Inselspitaland University of Bern, Bern, Switzerland
| | - Jane Salmon
- Division of Rheumatology, Department of Medicine, Hospital for Special Surgery and Weill Cornell Medicine, New York, NY, USA
| | - Peter Villiger
- Rheumatology and Clinical Immunology, Medical Center Monbijou, Bern, Switzerland
| | - Marie Wahren-Herlenius
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Marianne Wallenius
- National Advisory Unit on Pregnancy and Rheumatic Diseases, St Olavs Hospital, Trondheim, University Hospital and Institute of Neuromedicine and Movement Science, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
| | - Cristina Zanardini
- Department of Obstetrics and Gynecology, ASST Spedali Civili, Brescia, Italy
| | - Yehuda Shoenfeld
- Sackler Faculty of Medicine, Ariel University, Ariel, Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel
| | - Angela Tincani
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili, Brescia, Italy; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.
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Fetal and Neonatal Adverse Drug Reactions Associated with Biologics Taken During Pregnancy by Women with Autoimmune Diseases: Insights from an Analysis of the World Health Organization Pharmacovigilance Database (VigiBase ®). BioDrugs 2023; 37:73-87. [PMID: 36401769 PMCID: PMC9676840 DOI: 10.1007/s40259-022-00564-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/25/2022] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Published data on the safety of biologics other than tumor necrosis factor (TNF) inhibitors during pregnancy are limited. OBJECTIVE The aim was to detect pharmacovigilance signals for fetal and neonatal adverse drug reactions (ADRs) to biologics taken by pregnant women with autoimmune diseases. METHODS We performed a disproportionality analysis of the World Health Organization's VigiBase® pharmacovigilance database from 1968 to June 1, 2021. Data were collected in June 2021. By using terms for different hierarchical levels of the Medical Dictionary for Regulatory Activities, we selected the following fetal or neonatal ADRs: stillbirth, premature birth, low birth weight, small for gestational age, and congenital malformations. The frequency of all identified ADRs for biologics of interest (adalimumab, infliximab, golimumab, certolizumab, etanercept, anakinra, canakinumab, tocilizumab, sarilumab, ustekinumab, guselkumab, secukinumab, ixekizumab, belimumab, abatacept, and rituximab) was compared with that of all other reports for all other drugs and quoted as the reporting odds ratio (ROR) [95% confidence interval]. Reports with known concomitant use of teratogenic drugs were excluded from the main analysis. Other analyses included ROR stratifications by therapeutic indication in the periods 1968-2021 and 2001-2021, and an analysis after excluding reports with steroids. RESULTS In the main analysis, the RORs were particularly high for musculoskeletal malformations with anakinra (7.18 [3.50-14.73]), canakinumab (19.54 [12.82-29.79]), and abatacept (5.09 [2.77-9.33]), and for immune system disorders with canakinumab (347.88 [217.9-555.50]) and rituximab (9.27 [2.95-29.15]). After the exclusion of reports with steroids, the ROR was significant for neonatal infections with belimumab (28.49 [5.75-141.25]). CONCLUSION We identified possible associations with some adverse fetal and neonatal outcomes, suggesting that vigilance is required when prescribing certain biologics during pregnancy.
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Clowse M, Fischer-Betz R, Nelson-Piercy C, Scheuerle AE, Stephan B, Dubinsky M, Kumke T, Kasliwal R, Lauwerys B, Förger F. Pharmacovigilance pregnancy data in a large population of patients with chronic inflammatory disease exposed to certolizumab pegol. Ther Adv Musculoskelet Dis 2022; 14:1759720X221087650. [PMID: 35464812 PMCID: PMC9023886 DOI: 10.1177/1759720x221087650] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 02/15/2022] [Indexed: 12/29/2022] Open
Abstract
Introduction: Chronic inflammatory diseases (CIDs), including rheumatic diseases and other inflammatory conditions, often affect women of reproductive age. Tumor necrosis factor inhibitors (TNFi) are widely used to treat CID, but there is limited information on outcomes of TNFi-exposed pregnancies. We evaluated pregnancy outcomes from 1392 prospectively reported pregnancies exposed to certolizumab pegol (CZP), a PEGylated, Fc-free TNFi with no to minimal placental transfer. Methods: CZP-exposed pregnancies in patients with CID from the UCB Pharmacovigilance global safety database were reviewed from the start of CZP clinical development (July 2001) to 1 November 2020. To limit bias, the analysis focused on prospectively reported cases with known pregnancy outcomes. Results: In total, 1392 prospective pregnancies with maternal CZP exposure and known pregnancy outcomes (n = 1425) were reported; 1021 had at least first-trimester CZP exposure. Live birth was reported in 1259/1425 (88.4%) of all prospective outcomes. There were 150/1425 (10.5%) pregnancy losses before 20 weeks (miscarriage/induced abortion), 11/1425 (0.8%) stillbirths, and 5/1392 (0.4%) ectopic pregnancies. Congenital malformations were present in 30/1259 (2.4%) live-born infants, of which 26 (2.1%) were considered major according to the Metropolitan Atlanta Congenital Defects Program criteria. There was no pattern of congenital malformations. Discussion and conclusion: No signal for adverse pregnancy outcomes or congenital malformations was observed in CZP-exposed pregnancies. Although the limitations of data collected through this methodology (including underreporting, missing information, and absence of a comparator group) should be considered, these data provide reassurance for women with CID who require CZP treatment during pregnancy, and their treating physicians.
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Affiliation(s)
- Megan Clowse
- Division of Rheumatology, Duke University Medical Center, 3535, Durham, NC 27710, USA
| | - Rebecca Fischer-Betz
- Department for Rheumatology and Hiller Research Institute, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | | | - Angela E. Scheuerle
- Department of Pediatrics, Division of Genetics and Metabolism, UT Southwestern Medical Center, Dallas, TX, USA
| | - Brigitte Stephan
- Institute for Health Services Research in Dermatology and Nursing (IVDP), University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Marla Dubinsky
- The Susan and Leonard Feinstein IBD Center, Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
| | | | | | | | - Frauke Förger
- Department of Rheumatology and Immunology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
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Nishide M, Yagita M, Kumanogoh A. Continuous Use of Etanercept During Pregnancy Does Not Affect TNF-Alpha Levels in Umbilical Cord Blood. Biologics 2022; 16:17-19. [PMID: 35386275 PMCID: PMC8979416 DOI: 10.2147/btt.s358449] [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: 01/21/2022] [Accepted: 03/02/2022] [Indexed: 11/23/2022]
Abstract
TNF-alpha-targeted therapies during pregnancy is a topic of interest in rheumatology. Etanercept (ETN) is expected to have lower transplacental transfer, however, clinical evidence is lacking on the usefulness and safeness of continuing etanercept throughout pregnancy. We here described the first reported case of relapsing polychondritis where continuous use of ETN throughout pregnancy was required. The patient was a pregnant Japanese woman who presented with bilateral ear cartilage redness, swelling, saddle nose and severe subglottic oedema. Due to severe systemic and life-threatened disease, we decided to continue using ETN throughout pregnancy and resulted in successful vaginal delivery. The treatment with ETN was successful and TNF-alpha levels in umbilical cord blood were not affected. The infant did not have any signs of chondritis although levels of anti-type 2 collagen antibodies in maternal and umbilical cord blood were similar, suggesting that anti-type 2 collagen antibodies crossed the placenta. This case is an important clinical experience that strengthens the safety to continue ETN during the entire pregnancy if necessary.
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Affiliation(s)
- Masayuki Nishide
- Department of Respiratory Medicine and Clinical Immunology, Graduate School of Medicine, Osaka University, Osaka, Japan
- Correspondence: Masayuki Nishide, Department of Respiratory Medicine and Clinical Immunology, Graduate School of Medicine, Osaka University, 2-2 Yamada-oka, Suita, Osaka, 565-0871, Japan, Tel +81-6-6879-3831, Fax +81-6-6879-3839, Email
| | - Mayu Yagita
- Department of Respiratory Medicine and Clinical Immunology, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Atsushi Kumanogoh
- Department of Respiratory Medicine and Clinical Immunology, Graduate School of Medicine, Osaka University, Osaka, Japan
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Araujo GG, dos Passos Junior RR, Lunardi RR, Volpato GT, Soares TS, Giachini FR, Lima VV. Maternal and Fetal-Placental Effects of Etanercept Treatment During Rats’ Pregnancy. Front Physiol 2022; 12:787369. [PMID: 35185598 PMCID: PMC8851240 DOI: 10.3389/fphys.2021.787369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 12/17/2021] [Indexed: 11/29/2022] Open
Abstract
Etanercept is a tumor necrosis factor alpha (TNF-α) inhibitor chronically used to treat autoimmune diseases. However, the use of etanercept during pregnancy still needs to be further investigated. The aim of this study is to evaluate the etanercept treatment during pregnancy, analyzing maternal reproductive performance, fetal outcomes, and placental repercussions. Wistar rats (200–250 g) were mated and randomly distributed into two experimental groups: control and etanercept (n = 10 animals/group). Treatments with etanercept (0.8 mg/kg, s.c.), or saline (control group) were carried out on days 0, 6, 12, and 18 of gestation. On the morning of the 21st day of pregnancy, rats were euthanized in a CO2 chamber and submitted to laparotomy to remove the fetuses, placentas, ovaries, and maternal organs. There were no differences between groups in the following parameters: water and food consumption; placental efficiency; reproductive parameters, including number of corpora lutea and implants, reabsorption, and pre- and post-implantation losses. However, etanercept treatment increased liver weight, reduced fetal and placental weight, decreased the placental junction zone, reduced the percentage of normal fetuses, and increased visceral or skeletal fetal abnormalities. Therefore, etanercept resulted in damages more related to fetus and placenta. However, more studies with different doses are required to better predict possible injuries elicited using etanercept during pregnancy.
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Affiliation(s)
- Gabriel Gomes Araujo
- Institute of Biological Sciences and Health, Federal University of Mato Grosso, Barra do Garças, Brazil
| | | | - Rosaline Rocha Lunardi
- Institute of Biological Sciences and Health, Federal University of Mato Grosso, Barra do Garças, Brazil
| | - Gustavo Tadeu Volpato
- Institute of Biological Sciences and Health, Federal University of Mato Grosso, Barra do Garças, Brazil
| | - Thaigra Sousa Soares
- Institute of Biological Sciences and Health, Federal University of Mato Grosso, Barra do Garças, Brazil
| | - Fernanda Regina Giachini
- Institute of Biological Sciences and Health, Federal University of Mato Grosso, Barra do Garças, Brazil
- Institute of Biological Sciences, Federal University of Goias, Goiânia, Brazil
- *Correspondence: Fernanda Regina Giachini,
| | - Victor Vitorino Lima
- Institute of Biological Sciences and Health, Federal University of Mato Grosso, Barra do Garças, Brazil
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OUP accepted manuscript. Rheumatology (Oxford) 2022; 61:3902-3906. [DOI: 10.1093/rheumatology/keac141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 02/15/2022] [Accepted: 03/01/2022] [Indexed: 11/13/2022] Open
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Häfeli C, Förger F. [Current aspects of antirheumatic therapy in pregnancy planning, during pregnancy and breastfeeding]. Z Rheumatol 2021; 80:716-725. [PMID: 34581874 PMCID: PMC8477645 DOI: 10.1007/s00393-021-01095-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/01/2021] [Indexed: 11/25/2022]
Abstract
Active rheumatic disease is a known factor for increased fetomaternal risks during pregnancy. Remission or inactive disease should therefore be targeted to reduce these risks by using pregnancy-compatible antirheumatic drugs as recommended by international guidelines. Teratogenic antirheumatic drugs, such as mycophenolate, methotrexate, cyclophosphamide and thalidomide should be stopped about 3 months prior to conception. Leflunomide is a weak human teratogen that should be stopped and eliminated with cholestyramine prior to conception. Furthermore, drugs with limited data, such as apremilast and JAK inhibitors as well as new biologics should be avoided during gestation. Pregnancy-compatible drugs are the antirheumatic drugs hydroxychloroquine, sulfasalazine, azathioprine, cyclosporine, tacrolimus, colchicine, non-selective NSAIDs, low-dose prednisone/prednisolone and TNF inhibitors. These drugs as well as other biologics, such as rituximab can be used during lactation. In a preconception counselling visit, the benefits and the international recommendations of pregnancy-compatible antirheumatic drugs should be discussed with the patient and be weighed against the possible fetomaternal risks of an active disease to enable a shared decision-making.
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Affiliation(s)
- Celine Häfeli
- Universitätsklinik für Rheumatologie und Immunologie, Inselspital Bern, Freiburgstraße 18, 3010, Bern, Schweiz
| | - Frauke Förger
- Universitätsklinik für Rheumatologie und Immunologie, Inselspital Bern, Freiburgstraße 18, 3010, Bern, Schweiz.
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