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Prakash P, Dua A, Blumenfeld Y, Chen PH, Parian AM, Limketkai BN. Longitudinal Trends in Pregnancy Outcomes Among Women With Inflammatory Bowel Disease in the Era of Biologics: A 20-Year Nationwide Analysis. Inflamm Bowel Dis 2024; 30:1788-1795. [PMID: 37857421 PMCID: PMC11447069 DOI: 10.1093/ibd/izad250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND Many women with inflammatory bowel disease (IBD) are diagnosed by their reproductive years. Prior literature suggests that women with IBD may be at increased risk of adverse pregnancy outcomes. Biologics have revolutionized IBD treatment, and current evidence favors continuation during pregnancy. We sought to examine trends in pregnancy outcomes over 20 years with the evolution of IBD treatment. METHODS Using the National Inpatient Sample, IBD and non-IBD obstetric hospitalizations were identified between 1998 and 2018 using International Classification of Diseases 9 and 10 codes. Outcomes of interest included cesarean delivery, gestational diabetes, preeclampsia/eclampsia, premature rupture of membranes (PROM), preterm delivery, fetal growth restriction (FGR), fetal distress, and stillbirth. Stratified by Crohn's disease (CD), ulcerative colitis (UC), and non-IBD deliveries, temporal trends and multivariable logistic regression were analyzed. RESULTS There were 48 986 CD patients, 30 998 UC patients, and 69 963,805 non-IBD patients. Between 1998 and 2018, CD deliveries increased from 3.3 to 12.9 per 10 000 deliveries (P < 0.001) and UC deliveries increased from 2.3 to 8.6 per 10 000 deliveries (P < 0.001). Cesarean deliveries, gestational diabetes, preeclampsia/eclampsia, PROM, FGR, and fetal distress increased over time for IBD and non-IBD women, while preterm deliveries decreased (P < 0.001). Multivariable analyses demonstrated that IBD patients had higher risk of cesarean delivery, preeclampsia/eclampsia, PROM, and preterm delivery compared with non-IBD patients. CONCLUSION Over a 20-year period, live deliveries amongst women with IBD have increased. Trends in pregnancy outcomes have followed a similar trajectory in patients with and without IBD. However, there is still demonstrable risk of adverse pregnancy outcomes in patients with IBD.
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Affiliation(s)
- Preeti Prakash
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Anoushka Dua
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Yair Blumenfeld
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
| | - Po-Hung Chen
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Alyssa M Parian
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Berkeley N Limketkai
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Andreoli L, Andersen J, Avcin T, Chambers CD, Fazzi EM, Marlow N, Wulffraat NM, Tincani A. The outcomes of children born to mothers with autoimmune rheumatic diseases. THE LANCET. RHEUMATOLOGY 2024; 6:e573-e586. [PMID: 38876127 DOI: 10.1016/s2665-9913(24)00096-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Revised: 04/03/2024] [Accepted: 04/10/2024] [Indexed: 06/16/2024]
Abstract
Maternal autoimmune rheumatic diseases can influence the outcomes of children through several life stages. During pregnancy, maternal inflammation and autoantibodies can hinder fetal development and lead to growth restriction, preterm birth, and low birth weight; prematurity, especially at extreme gestational ages, can in turn impair future child health. Treatment with compatible immunomodulatory drugs and preventive medications aims to keep maternal disease under control and minimise the risk of adverse pregnancy outcomes. However, concerns have been raised about the effects of immunomodulatory drugs on neonatal conditions (ie, the risk of serious infections, inadequate responses to vaccinations, and organ toxicity) and long-term outcomes (metabolic and cardiovascular problems and neurodevelopmental disorders). Among the unmet needs of parents with autoimmune rheumatic diseases, there is the estimation of risk for the children to develop autoimmune disorders and the need for reassurance about parenting capacity while living with a chronic condition. This Series paper provides a comprehensive overview of the literature and guidance on discussing these topics with patients.
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Affiliation(s)
- Laura Andreoli
- Rheumatology and Clinical Immunology Unit, ERN ReCONNET, ASST Spedali Civili, Brescia, Italy; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy; Danish Centre for Expertise in Rheumatology, Danish Hospital for Rheumatic Diseases, Sonderborg, Denmark; Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | | | - Tadej Avcin
- Department of Allergology, Rheumatology and Clinical Immunology, ERN RITA, ERN ReCONNET, University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia; Department of Pediatrics, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | | | - Elisa M Fazzi
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy; Child Neurology and Psychiatry Unit, ASST Spedali Civili, Brescia, Italy
| | - Neil Marlow
- UCL Elizabeth Garret Anderson Institute for Women's Health, University College London, London, UK
| | - Nico M Wulffraat
- Department of Pediatric Rheumatology and Immunology, ERN RITA, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Angela Tincani
- Rheumatology and Clinical Immunology Unit, ERN ReCONNET, ASST Spedali Civili, Brescia, Italy; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.
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3
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Danpanichkul P, Duangsonk K, Lopimpisuth C, Ho AHY, Fangsaard P, Sukphutanan B, Pang Y, Chaisrimaneepan N, Dejvajara D, Suenghataiphorn T, Worapongpaiboon R, Chaiyakunapruk N, Lui RN, Kochhar GS, Ng SC, Farraye FA, Wijarnpreecha K. Geographical and sociodemographic epidemiology of inflammatory bowel disease in young females from 2010 to 2019. Dig Liver Dis 2024:S1590-8658(24)00872-7. [PMID: 39068136 DOI: 10.1016/j.dld.2024.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 06/14/2024] [Accepted: 07/03/2024] [Indexed: 07/30/2024]
Abstract
BACKGROUND AND AIMS Inflammatory Bowel Disease (IBD) represents a significant health threat worldwide. However, there are deficiencies in large-scale epidemiological research focusing on these issues, especially among young women. We aim to examine the trend of IBD in young females globally. METHODS We utilized data from the Global Burden of Disease (GBD) study between 2010 and 2019 to conduct a comprehensive analysis of the prevalence, mortality, and disability-adjusted life years (DALYs) from IBD in young females (15-49 years), stratified by region, nation, and sociodemographic index (SDI). RESULTS Globally, there were 1.27 million (95 % UI 1.10 to 1.45 million) cases and 314,120 (95 % UI 240,880 to 395,420) DALYs from IBD in young females in 2019. Geographically, Europe had the highest burden of IBD in young females (n = 421,320). From 2010 to 2019, the prevalence rate increased in Africa (APC 0.34 %, 95 % CI 0.25 to 0.44 %), the Eastern Mediterranean (APC 0.77 %, 95 % CI 0.74 to 0.81 %), Europe (APC 0.48 %, 95 % CI 0.44 to 0.51 %) and the Western Pacific region (APC 1.01 %, 95 % CI 0.89 to 1.14 %). Countries with lower SDI exhibited higher DALYs to prevalence ratio. Over the study period, the percentage of young women with IBD compared to young adults increased by 0.24 %. This percentage varies significantly between countries, from 26 % to 62 %. CONCLUSION The burden of IBD in young females is high and increasing. Countries with lower SDIs generate higher disability per case. This necessitates immediate and inclusive measures to tackle the rising burden of IBD in this vulnerable group. LAY SUMMARY From 2010 to 2019, in the largest global epidemiology database, prevalence rates of inflammatory bowel disease in young females increased in many regions. Countries with lower socioeconomic development, as indicated by sociodemographic index, generated a higher burden compared to countries with higher development.
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Affiliation(s)
- Pojsakorn Danpanichkul
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA; Immunology Unit, Department of Microbiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.
| | - Kwanjit Duangsonk
- Department of Microbiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Chawin Lopimpisuth
- Department of Internal Medicine, University of Miami/ Jackson Memorial Hospital, Miami, Florida, USA
| | - Agnes Hiu-Yan Ho
- Division of Gastroenterology and Hepatology, Department of Medicine and Therapeutics, Prince of Wales Hospital, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, SAR, China
| | - Panisara Fangsaard
- Department of Internal Medicine, Bassett Medical Center, Cooperstown, New York, USA
| | | | - Yanfang Pang
- Affiliated Hospital of Youjiang Medical University for Nationalities, Baise, Guangxi 533000, China; National Immunological Laboratory of Traditional Chinese Medicine, Baise, Guangxi 533000, China; Key Laboratory of Research on Clinical Molecular Diagnosis for High Incidence Diseases in Western Guangxi, Baise, Guangxi 533000, China
| | | | | | | | | | - Nathorn Chaiyakunapruk
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, Utah, USA; IDEAS Center, Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, Utah, USA
| | - Rashid N Lui
- Division of Gastroenterology and Hepatology, Department of Medicine and Therapeutics, Prince of Wales Hospital, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, SAR, China
| | - Gursimran Singh Kochhar
- Division of Gastroenterology, Hepatology & Nutrition, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Siew C Ng
- Division of Gastroenterology and Hepatology, Department of Medicine and Therapeutics, Prince of Wales Hospital, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, SAR, China
| | - Francis A Farraye
- Inflammatory Bowel Disease Center, Division of Gastroenterology, Mayo Clinic, Jacksonville, Florida, USA
| | - Karn Wijarnpreecha
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Arizona College of Medicine, Phoenix, Arizona, USA; Division of Gastroenterology and Hepatology, Department of Internal Medicine, Banner University Medical Center, Phoenix, Arizona, USA; BIO5 Institute, University of Arizona College of Medicine-Phoenix, Phoenix, Arizona, USA.
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Zingone F, Borsato A, Maniero D, Della Loggia F, Lorenzon G, Zanini A, Canova C, Barberio B, Savarino EV. Impact of inflammatory bowel disease on women's reproductive life: a questionnaire-based study. Therap Adv Gastroenterol 2024; 17:17562848241249440. [PMID: 38766477 PMCID: PMC11102668 DOI: 10.1177/17562848241249440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 04/07/2024] [Indexed: 05/22/2024] Open
Abstract
Background Inflammatory bowel diseases (IBDs) have a peak incidence between the second and fourth decades of life and can affect women's reproductive life. Objectives Our study aimed to assess the impact of IBD on the reproductive life of female patients with this condition. Design Cross-sectional study. Methods Women with IBD followed at our IBD Unit and a group of healthy controls were enrolled. Data on reproductive life were collected using a dedicated questionnaire. Results The study included 457 women, of whom 228 had IBD, and 229 age-matched healthy controls. No differences were found in the use of contraceptives, infertility, and endometriosis. The risk of spontaneous and voluntary abortions was significantly higher in IBD patients than in healthy controls [odds ratio (OR) 2 and 3.62, respectively]. The risk of obstetrical complications in the IBD population was more than six times higher in patients who experienced disease reactivations during pregnancy than in those with persistent remission [OR 6.9, 95% confidence interval (CI) 1.51-31.28]. Finally, we found that the chances of breastfeeding were 66% lower in patients with IBD than in controls (OR 0.44, 95% CI 0.22-0.91). Conclusion Our study underlines the negative impact of IBD on women's reproductive life, supporting the need for proactive preconception counseling.
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Affiliation(s)
- Fabiana Zingone
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Via Giustiniani 2, Padua 235128, Italy
- Gastroenterology Unit, Azienda Ospedale Università Padova, Padova, Italy
| | - Alessandro Borsato
- Gastroenterology Unit, Azienda Ospedale Università Padova, Padova, Italy
| | - Daria Maniero
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | | | - Greta Lorenzon
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Annalisa Zanini
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
- Gastroenterology Unit, Azienda Ospedale Università Padova, Padova, Italy
| | - Cristina Canova
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Brigida Barberio
- Gastroenterology Unit, Azienda Ospedale Università Padova, Padova, Italy
| | - Edoardo Vincenzo Savarino
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
- Gastroenterology Unit, Azienda Ospedale Università Padova, Padova, Italy
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Andreoli L, Guadagni I, Picarelli G, Principi M. Comprehensive reproductive healthcare for women with immune-mediated inflammatory diseases: Addressing rheumatoid arthritis, spondyloarthritis and inflammatory bowel disease through life's stages. Autoimmun Rev 2024; 23:103507. [PMID: 38142899 DOI: 10.1016/j.autrev.2023.103507] [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: 11/30/2023] [Accepted: 12/19/2023] [Indexed: 12/26/2023]
Abstract
Immuno-mediated inflammatory diseases (IMIDs) such as rheumatoid arthritis, spondyloarthritis, and inflammatory bowel disease are characterised by pathophysiological mechanisms wherein the immune system erroneously targets the body's own tissues. This review explores the heightened vulnerability of women with IMIDs, influenced by hormonal modulators like estrogen and progesterone. The challenges this poses are multifaceted, encompassing the impact of active disease and medical treatments throughout life stages, including family planning, fertility, and menopause. From the perspectives of rheumatologists and gastroenterologists, we review current management strategies and underscore the need for a multidisciplinary and life-cycle approach to healthcare for women with IMIDs.
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Affiliation(s)
- Laura Andreoli
- Unit of Rheumatology and Clinical Immunology, ASST Spedali Civili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.
| | | | | | - Mariabeatrice Principi
- Emergency and Organ Transplantation Department, Section of Gastroenterology, AOU Policlinico, Bari, Italy
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6
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Azzam NA, Almutairdi A, Almudaiheem HY, AlAmeel T, Bakkari SA, Alharbi OR, Alenzi KA, AlMolaiki MA, Al-Omari BA, Albarakati RG, Al-Jedai AH, Saadah OI, Almadi MA, Al-Bawardy B, Mosli MH. Saudi consensus guidance for the management of inflammatory bowel disease during pregnancy. Saudi J Gastroenterol 2023:00936815-990000000-00066. [PMID: 38099556 PMCID: PMC11379253 DOI: 10.4103/sjg.sjg_318_23] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 11/08/2023] [Indexed: 09/10/2024] Open
Abstract
ABSTRACT The management of inflammatory bowel disease (IBD) in pregnant women is challenging and must be addressed on a patient-by-patient basis. Optimal patient management requires a multidisciplinary team and clear evidence-based recommendations that cater to this subset of patients. In this article, we provide concise guidelines and clinical care pathway for the management of IBD in pregnant women. Our recommendations were developed by a multidisciplinary working group that includes experts from the Saudi Ministry of Health in collaboration with the Saudi Gastroenterology Association and the Saudi Society of Clinical Pharmacology. All recommendations are based on up-to-date information following an extensive literature review. A total of 23 evidence-based expert opinion recommendations for the management of IBD in pregnant women are herein provided.
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Affiliation(s)
- Nahla A Azzam
- Division of Gastroenterology, Department of Medicine, College of Medicine, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Abdulelah Almutairdi
- Department of Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | | | - Turki AlAmeel
- Department of Medicine, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Shakir A Bakkari
- Department of Gastroenterology, King Saud Medical City, Riyadh, Saudi Arabia
| | - Othman R Alharbi
- Division of Gastroenterology, Department of Medicine, College of Medicine, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Khalidah A Alenzi
- Executive Director of Transformation, Planning, and Business Development, Tabuk Health Cluster, Tabuk, Saudi Arabia
| | - Maha A AlMolaiki
- Department of Pharmaceutical Care Services, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Bedor A Al-Omari
- Department of Pharmaceutical Care Services, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Rayan G Albarakati
- Department of Obstetrics and Gynecology, Majmaah University, Riyadh, Saudi Arabia
| | - Ahmed H Al-Jedai
- Deputyship of Therapeutic Affairs, Ministry of Health, Riyadh, Saudi Arabia
- Professor, Colleges of Medicine and Pharmacy, Alfaisal University, Riyadh, Saudi Arabia
| | - Omar I Saadah
- Department of Pediatrics, Faculty of Medicine, King Abdulaziz University, Inflammatory Bowel Disease Unit, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Majid A Almadi
- Division of Gastroenterology, Department of Medicine, College of Medicine, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Badr Al-Bawardy
- Department of Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
- Department of Internal Medicine, Section of Digestive Diseases, Yale School of Medicine, New Haven, CT, USA
| | - Mahmoud H Mosli
- Department of Internal Medicine, King Abdulaziz University, Inflammatory Bowel Disease Unit, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
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Al-jabri R, Wetwittayakhlang P, Lakatos PL. Monitoring of Inflammatory Bowel Disease in Pregnancy: A Review of the Different Modalities. J Clin Med 2023; 12:7343. [PMID: 38068395 PMCID: PMC10707304 DOI: 10.3390/jcm12237343] [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: 09/27/2023] [Revised: 11/23/2023] [Accepted: 11/23/2023] [Indexed: 09/14/2024] Open
Abstract
Inflammatory Bowel Disease (IBD) significantly affects women in their reproductive years. Understanding the relationship between IBD and pregnancy is crucial, given its impact across pre-gestational, gestational, and postpartum phases. Monitoring IBD activity during pregnancy involves various modalities. This review discusses these modalities, focusing on the efficacy and safety of Small Intestine Ultrasound (IUS) as a noninvasive and reliable option. While IUS has gained popularity, its technique-sensitive nature necessitates trained staff for optimal usage.
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Affiliation(s)
- Reem Al-jabri
- Division of Gastroenterology and Hepatology, McGill University Health Center, Montreal, QC H3G 1Y6, Canada;
| | - Panu Wetwittayakhlang
- Gastroenterology and Hepatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla 90110, Thailand
| | - Peter L. Lakatos
- Division of Gastroenterology and Hepatology, McGill University Health Center, Montreal, QC H3G 1Y6, Canada;
- Department of Oncology and Medicine, Semmelweis University, 1085 Budapest, Hungary
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Yeaman F, Stritzke A, Kuret V, Sharifi N, Seow CH, Metcalfe A, Leung Y. Thiopurine Exposure During Pregnancy is Not Associated With Anemia in Infants Born to Mothers With IBD. CROHN'S & COLITIS 360 2023; 5:otad066. [PMID: 37941596 PMCID: PMC10629965 DOI: 10.1093/crocol/otad066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Indexed: 11/10/2023] Open
Abstract
Background Thiopurines are commonly used to treat inflammatory bowel disease (IBD). Thiopurines are considered safe throughout pregnancy. However, a published study suggested the risk of neonatal anemia was increased if exposed to thiopurines in utero. This prospective cohort study aimed to determine if there is an increased risk of cytopenia among infants born to pregnant people with IBD, exposed or unexposed to thiopurines, compared to infants born to those without IBD. Methods Pregnant IBD patients, with and without thiopurine exposure, and one cohort of control individuals were recruited over a 5-year period. Consenting individuals completed a questionnaire and infants had a complete blood cell count at the newborn heel prick. Anemia was defined as hemoglobin (Hb) < 140g/L. Descriptive statistics were used to characterize the study population. Fisher exact tests were used to examine differences in outcomes between groups, a P-value of < 0.05 was deemed significant. Results Three cohorts were recruited: 19 IBD patients on thiopurines, 50 IBD patients not on thiopurines, and 37 controls (total of 106). Neonatal median Hb was not different with 177g/L (IQR 38g/L) for the IBD thiopurine group, 180.5g/L (IQR 40g/L) for the IBD non-thiopurine group, and 181g/L (IQR 37g/L) for the controls. Nineteen infants (18%) were cytopenic with 12 (11%) anemic, 6 (5.6%) thrombocytopenic, and 1 (0.94%) lymphopenic. Thiopurine exposure was only in one, mildly anemic, infant. Conclusions These findings further support physicians and IBD patients contemplating pregnancy that current guidelines recommending thiopurine adherence do not lead to increased perinatal risk of anemia or cytopenia.
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Affiliation(s)
- Fiona Yeaman
- Department of Medicine, University of Calgary, Calgary, AB, Canada
- Internal Medicine, University of Western Australia, Perth, WA, Australia
| | - Amelie Stritzke
- Department of Pediatrics University of Calgary, Calgary, AB, Canada
| | - Verena Kuret
- Department of Obstetrics and Gynecology, University of Calgary, Calgary, AB, Canada
| | - Nastaran Sharifi
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Cynthia H Seow
- Department of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences; University of Calgary, Calgary, AB, Canada
| | - Amy Metcalfe
- Department of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Obstetrics and Gynecology, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences; University of Calgary, Calgary, AB, Canada
| | - Yvette Leung
- Department of Medicine and Division of Gastroenterology, University of British Columbia, Vancouver, BC, Canada
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Selinger CP, Steed H, Purewal S, Homer R, Brookes M. Factors Associated with Family Planning Status and Voluntary Childlessness in Women of Childbearing Age with Inflammatory Bowel Diseases. J Clin Med 2023; 12:4267. [PMID: 37445302 DOI: 10.3390/jcm12134267] [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: 05/26/2023] [Revised: 06/16/2023] [Accepted: 06/23/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND Women with Inflammatory Bowel Diseases (IBD) have fewer children and stay childless more often. The decision-making process around family planning choices remains incompletely understood. METHODS We examined family status in women who at recruitment to the UK IBD Bioresource had not had children yet via an electronic survey. The primary outcome was the proportion of women with voluntary childlessness. Secondary outcomes were factors associated with family planning status. RESULTS Of 326 responders, 10.7% had either given birth, were currently pregnant or were currently trying to conceive; 12.6% were planning to conceive within 12 months; 54.4% were contemplating conception in the distant future (vague plans); and 22.3% were voluntarily childless. Factors associated with family planning status fell into three areas: general background (age, household income, perceived support to raise a child), relationship status (sexual orientation, being single, not cohabiting, perception of being 'in the right relationship to raise a child', perception of a good sex life) and the expression of having a child as a goal in life. On binary logistics regression analysis with voluntary childlessness versus vague family plans as the outcomes of choice, having a household income of <£30,000 (p = 0.046), not seeing a child as a life goal (p < 0.0001) and identifying as lesbian or bisexual (p = 0.047) were independent predictors of voluntary childlessness. CONCLUSIONS Clinicians should consider sexual orientation, income, younger age, current relationship and lack of expression of having a child as a life goal as important factors for family planning when providing care. Pre-pregnancy advice should be made widely available for women with IBD.
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Affiliation(s)
- Christian P Selinger
- Leeds Gastroenterology Institute, Leeds Teaching Hospitals, Leeds LS9 7TF, UK
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds LS9 7TF, UK
| | - Helen Steed
- Department of Gastroenterology, Royal Wolverhampton Hospital, Wolverhampton WV10 0QP, UK
- Gastroenterology, University of Wolverhampton, Wolverhampton WV1 1SG, UK
| | - Satvinder Purewal
- Gastroenterology, University of Wolverhampton, Wolverhampton WV1 1SG, UK
| | - Rebecca Homer
- Gastroenterology, University of Wolverhampton, Wolverhampton WV1 1SG, UK
| | - Matthew Brookes
- Department of Gastroenterology, Royal Wolverhampton Hospital, Wolverhampton WV10 0QP, UK
- Gastroenterology, University of Wolverhampton, Wolverhampton WV1 1SG, UK
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10
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M’Koma AE, Ware JN, Nabaweesi RK, Chirwa SS. Managing Pregnancy and Nursing Affecting African American Women with Inflammatory Bowel Disease: Clinical Outcomes and Parenthood. MEDICAL RESEARCH ARCHIVES 2023; 11:3784. [PMID: 37492395 PMCID: PMC10367541 DOI: 10.18103/mra.v11i6.3784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
Inflammatory bowel disease (IBD) is a term for two autoimmune diseases encompassing Crohn's disease (CD) and ulcerative colitis (UC) which are lifelong diseases affecting more than 3 million adults (1.3%) in the United States. IBD is characterized by chronic inflammation of the whole digestive system which results in damage to the gastrointestinal (GI) tract. IBD often emerges during adolescence and young adulthood. Maternal morbidity includes physical and psychological conditions that result from or are aggravated by pregnancy and have an adverse effect on a woman's health, the baby's health or both. Some women have health challenges that arise before or during pregnancy that could lead to complications. It is recommended for women to receive health care counseling before and during pregnancy. Compared to other developed countries, the United States has the highest rate of women dying of pregnancy related complications. During the past 25 years maternal mortality has been getting worse. African American women (AAW) with and/or without IBD are dying at significantly higher rates than other groups. This is linked to several factors, i.e., systemic, institutionalized, and structural racism in health-care delivery and subsequent toxic stress from people's lived experiences of racism, limited knowledge about healthcare system function, lack of access to healthcare, (inclusiveness and insurance policies) all of which negatively impact these patients. African Americans (AAs) are also up to three times as likely to experience severe maternal morbidity: unexpected outcomes of labor and delivery, deficient or lacking prenatal care and social determinants of health like lack of transportation, adequate employment, limited literacy, and limited healthcare access contribute to poor health outcomes. Studies on IBD patients indicate Medicaid expansion is associated with reduced rates of maternal morbidity, particularly for African American Women (AAW) and increased access to preconception and prenatal services that make pregnancy and childbirth safer for parent and baby. Herein we examine the physiological changes of pregnancy in patients diagnosed with inflammatory bowel disease and their relationship perinatal outcomes and parenthood.
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Affiliation(s)
- Amosy E. M’Koma
- Departments of Biochemistry, Cancer Biology, Neuroscience and Pharmacology
| | | | | | - Sanika S. Chirwa
- Departments of Biochemistry, Cancer Biology, Neuroscience and Pharmacology
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11
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Herrera-deGuise C, Serra-Ruiz X, Lastiri E, Borruel N. JAK inhibitors: A new dawn for oral therapies in inflammatory bowel diseases. Front Med (Lausanne) 2023; 10:1089099. [PMID: 36936239 PMCID: PMC10017532 DOI: 10.3389/fmed.2023.1089099] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 02/09/2023] [Indexed: 03/06/2023] Open
Abstract
Inflammatory bowel disease (IBD) is a chronic immune-mediated condition of the gastrointestinal tract that requires chronic treatment and strict surveillance. Development of new monoclonal antibodies targeting one or a few single cytokines, including anti-tumor necrosis factor agents, anti-IL 12/23 inhibitors, and anti-α4β7 integrin inhibitors, have dominated the pharmacological armamentarium in IBD in the last 20 years. Still, many patients experience incomplete or loss of response or develop serious adverse events and drug discontinuation. Janus kinase (JAK) is key to modulating the signal transduction pathway of several proinflammatory cytokines directly involved in gastrointestinal inflammation and, thus, probably IBD pathogenesis. Targeting the JAK-STAT pathway offers excellent potential for the treatment of IBD. The European Medical Agency has approved three JAK inhibitors for treating adults with moderate to severe Ulcerative Colitis when other treatments, including biological agents, have failed or no longer work or if the patient cannot take them. Although there are currently no approved JAK inhibitors for Crohn's disease, upadacitinib and filgotinib have shown increased remission rates in these patients. Other JAK inhibitors, including gut-selective molecules, are currently being studied IBD. This review will discuss the JAK-STAT pathway, its implication in the pathogenesis of IBD, and the most recent evidence from clinical trials regarding the use of JAK inhibitors and their safety in IBD patients.
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Affiliation(s)
| | | | | | - Natalia Borruel
- Unitat d’Atenció Crohn-Colitis, Digestive System Research Unit, Hospital Universitari Vall d’Hebrón, Barcelona, Spain
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Davies A, Mullin S, Chapman S, Barnard K, Bakhbakhi D, Ion R, Neuberger F, Standing J, Merriel A, Fraser A, Burden C. Interventions to enhance medication adherence in pregnancy- a systematic review. BMC Pregnancy Childbirth 2023; 23:135. [PMID: 36864375 PMCID: PMC9979410 DOI: 10.1186/s12884-022-05218-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 11/15/2022] [Indexed: 03/04/2023] Open
Abstract
BACKGROUND Sub-optimal medication adherence in pregnant women with chronic disease and pregnancy-related indications has the potential to adversely affect maternal and perinatal outcomes. Adherence to appropriate medications is advocated during and when planning pregnancy to reduce risk of adverse perinatal outcomes relating to chronic disease and pregnancy-related indications. We aimed to systematically identify effective interventions to promote medication adherence in women who are pregnant or planning to conceive and impact on perinatal, maternal disease-related and adherence outcomes. METHODS Six bibliographic databases and two trial registries were searched from inception to 28th April 2022. We included quantitative studies evaluating medication adherence interventions in pregnant women and women planning pregnancy. Two reviewers selected studies and extracted data on study characteristics, outcomes, effectiveness, intervention description (TIDieR) and risk of bias (EPOC). Narrative synthesis was performed due to study population, intervention and outcome heterogeneity. RESULTS Of 5614 citations, 13 were included. Five were RCTs, and eight non-randomised comparative studies. Participants had asthma (n = 2), HIV (n = 6), inflammatory bowel disease (IBD; n = 2), diabetes (n = 2) and risk of pre-eclampsia (n = 1). Interventions included education +/- counselling, financial incentives, text messaging, action plans, structured discussion and psychosocial support. One RCT found an effect of the tested intervention on self-reported antiretroviral adherence but not objective adherence. Clinical outcomes were not evaluated. Seven non-randomised comparative studies found an association between the tested intervention and at least one outcome of interest: four found an association between receiving the intervention and both improved clinical or perinatal outcomes and adherence in women with IBD, gestational diabetes mellitus (GDM), and asthma. One study in women with IBD reported an association between receiving the intervention and maternal outcomes but not for self-reported adherence. Two studies measured only adherence outcomes and reported an association between receiving the intervention and self-reported and/or objective adherence in women with HIV and risk of pre-eclampsia. All studies had high or unclear risk of bias. Intervention reporting was adequate for replication in two studies according to the TIDieR checklist. CONCLUSIONS There is a need for high-quality RCTs reporting replicable interventions to evaluate medication adherence interventions in pregnant women and those planning pregnancy. These should assess both clinical and adherence outcomes.
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Affiliation(s)
- Anna Davies
- Academic Women's Health Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 1QU, UK.
| | - Sadie Mullin
- grid.5337.20000 0004 1936 7603Academic Women’s Health Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 1QU UK
| | - Sarah Chapman
- grid.7340.00000 0001 2162 1699Department of Pharmacy and Pharmacology, University of Bath, Bath, BA2 7AY UK
| | - Katie Barnard
- grid.416201.00000 0004 0417 1173North Bristol NHS Trust, Southmead Hospital, Southmead Road, Bristol, BS10 5NB UK
| | - Danya Bakhbakhi
- grid.5337.20000 0004 1936 7603Academic Women’s Health Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 1QU UK
| | - Rachel Ion
- grid.416201.00000 0004 0417 1173North Bristol NHS Trust, Southmead Hospital, Southmead Road, Bristol, BS10 5NB UK
| | - Francesca Neuberger
- grid.416201.00000 0004 0417 1173North Bristol NHS Trust, Southmead Hospital, Southmead Road, Bristol, BS10 5NB UK
| | - Judith Standing
- grid.416201.00000 0004 0417 1173North Bristol NHS Trust, Southmead Hospital, Southmead Road, Bristol, BS10 5NB UK
| | - Abi Merriel
- grid.5337.20000 0004 1936 7603Academic Women’s Health Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 1QU UK ,grid.5337.20000 0004 1936 7603Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 1QU UK
| | - Abigail Fraser
- grid.5337.20000 0004 1936 7603Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 1QU UK ,grid.410421.20000 0004 0380 7336National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Oakfield House, Oakfield Grove, Bristol, BS8 2BN UK
| | - Christy Burden
- grid.5337.20000 0004 1936 7603Academic Women’s Health Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 1QU UK
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Grigorescu RR, Husar-Sburlan IA, Rosulescu G, Bobirca A, Cerban R, Bobirca F, Florescu MM. Pregnancy in Patients with Inflammatory Bowel Diseases-A Literature Review. Life (Basel) 2023; 13:475. [PMID: 36836832 PMCID: PMC9961380 DOI: 10.3390/life13020475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 02/03/2023] [Accepted: 02/04/2023] [Indexed: 02/11/2023] Open
Abstract
In recent years, we have faced an increasing incidence of inflammatory bowel disease (IBD), especially among young people, affecting them during their reproductive years. The paucity of data and reduced knowledge regarding the evolution of the disease during pregnancy and the adverse effects of the therapy on the mother and infant increase voluntary childlessness in this group of patients. Depending on the type of IBD, severity and surgical or medical management, this can negatively affect the pregnancy. C-sections and the risk of low-birth-weight babies are higher in women with IBD, independent of active/inactive disease, while preterm birth, stillbirth and miscarriage are associated with disease activity. In the last period, medicinal therapy has evolved, and new molecules have been developed for better control of the lesions, but the effect on pregnancy and breastfeeding is still controversial. We conducted this review by studying the literature and recent research in order to have a better image of the practical management of IBD during pregnancy.
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Affiliation(s)
| | | | - Georgiana Rosulescu
- Gastroenterology Department, “Sfanta Maria” Hospital, 011172 Bucharest, Romania
| | - Anca Bobirca
- Department of Internal Medicine and Rheumatology, Dr. I. Cantacuzino Clinical Hospital, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Razvan Cerban
- Center for Digestive Disease and Liver Transplantation, Fundeni Clinical Institute, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Florin Bobirca
- Surgery Department, Dr. Ion Cantacuzino Clinical Hospital, 011437 Bucharest, Romania
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Addison P, Keshinro AO, Schwartzberg DM. The Benefits and Drawbacks of Staging Pelvic Pouches. Clin Colon Rectal Surg 2022; 35:445-452. [PMID: 36591400 PMCID: PMC9797283 DOI: 10.1055/s-0042-1758217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Since the mid-20th century, physicians have searched for way to improve the lives of patients with ulcerative colitis (UC). Early attempts of curative resection left the patients with a permanent stoma with only primitive stoma appliances available. Gradually, stoma care improved and operations were devised to give the patient bowel continuity without the need for a permanent ostomy. As these operations were evolving, benefits and drawbacks related to fertility, ease of small bowel reach to the pelvis, and postoperative pelvic sepsis were observed. In this article, we will elucidate the various ways pelvic pouches are used to treat UC and the rationale for the timing of surgery as well as the evolution of stoma care.
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Affiliation(s)
- Poppy Addison
- Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, Lenox Hill Hospital, New York, New York
| | - Ajaratu O. Keshinro
- Division of Colon and Rectal Surgery, University of Minnesota, Minneapolis, Minnesota
| | - David M. Schwartzberg
- Division of Colorectal Surgery and Inflammatory Bowel Disease, Department of Surgery, New York–Presbyterian/Columbia University Medical Center, New York, New York
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Selinger CP, Bel Kok K, Limdi JK, Kent A, Cooney R, Nelson-Piercy C. Live vaccinations for infants exposed to maternal infliximab in utero and via breast milk - the need for nuanced decision making. BMJ Open Gastroenterol 2022; 9:bmjgast-2022-001029. [PMID: 36216381 PMCID: PMC9557327 DOI: 10.1136/bmjgast-2022-001029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Affiliation(s)
| | - Klaartje Bel Kok
- Department of Gastroenterology, Barts Health NHS Trust, London, UK
| | - Jimmy K Limdi
- The Pennine Acute Hospitals NHS Trust Gastroenterology, Manchester, UK,The University of Manchester, Manchester, UK
| | - Alexandra Kent
- Gastroenterology, King's College Hospital NHS Foundation Trust, London, London, UK
| | - Rachel Cooney
- Department of Gastroenterology, University Hospitals Birmingham NHS Trust, Birmingham, West Midlands, UK
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Lahat A, Klang E. US supreme court decision: the gastroenterological perspective. Therap Adv Gastroenterol 2022; 15:17562848221116935. [PMID: 36035307 PMCID: PMC9403450 DOI: 10.1177/17562848221116935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
| | - Eyal Klang
- DeepVision Lab, Sheba Medical Center, Tel HaShomer,
Israel,Department of Diagnostic Imaging, Sheba Medical Center,
Tel HaShomer, Israel,Sackler Medical School, Tel Aviv University, Tel Aviv,
Israel
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Pregnancy outcomes after stoma surgery for inflammatory bowel disease: The results of a retrospective multicentre audit. Colorectal Dis 2022; 24:838-844. [PMID: 35184349 PMCID: PMC9543912 DOI: 10.1111/codi.16098] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 02/09/2022] [Accepted: 02/12/2022] [Indexed: 12/13/2022]
Abstract
AIM There is a paucity of data on pregnancies in women with stomas due to inflammatory bowel disease (IBD). The aim of this study was to assess stoma, IBD, obstetric and neonatal outcomes in pregnant patients with IBD and a stoma. METHOD Multicentre retrospective audit in 15 UK hospitals. Pregnancy, stoma and neonatal outcomes were elicited from routinely collected hospital records. RESULTS Data on 82 pregnancies from 77 patients (mean age 31.4 years, 60.9% Crohn's disease, 35.4% ulcerative colitis, 3.6% IBD-U) were included. Stoma types included ileostomy in 72 (88%) and colostomy in 10 (12%) women. There was one reported miscarriage, one still birth and 80 live births. Delivery occurred in 58 cases by caesarean section (CS), of which 44 were performed electively and 14 as emergency CS. The overall CS rate was 73%. Premature delivery before week 37 occurred in 19% and birth weight <2,500 g in 17%. Significant stoma related complications occurred during 20 (24%) pregnancies and included stoma prolapse in nine cases (2 required surgery), parastomal hernias in three cases (2 required surgery) and small bowel obstructions in seven cases (3 required surgery). CONCLUSIONS Pregnancy for women who previously had stoma formation for IBD is associated with higher rates of caesarean section and stoma complications. Future prospective studies should capture data, including patient reported outcomes, to gather a full picture on the impact of pregnancy after stoma surgery for IBD.
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Liu E, Laube R, Leong RW, Fraser A, Selinger C, Limdi JK. Managing Inflammatory Bowel Disease in Pregnancy: Health Care Professionals' Involvement, Knowledge, and Decision Making. Inflamm Bowel Dis 2022; 29:522-530. [PMID: 35713620 DOI: 10.1093/ibd/izac101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND The management of pregnant women with inflammatory bowel disease (IBD) is complex. We aimed to assess health care professionals' (HCPs) theoretical and applied knowledge of pregnancy-related IBD issues. METHODS A cross-sectional international survey was distributed to HCPs providing IBD care between October 2020 and March 2021. Knowledge was assessed using the validated Crohn's and Colitis Pregnancy Knowledge Score (CCPKnow; range, 0-17). Decision-making was assessed by free text responses to 3 clinical scenarios scored against predetermined scoring criteria (maximum score 70). RESULTS Among 81 participants, median CCPKnow score was 16 (range, 8-17), and median total scenario score was 29 (range, 9-51). Health care professionals who treat >10 IBD patients per week (CCPKnow P = .03; scenarios P = .003) and are more regularly involved in pregnancy care (CCPKnow P = .005; scenarios P = .005) had significantly better scores. Although CCPKnow scoring was consistently high (median score ≥15) across all groups, consultants scored better than trainees and IBD nurses (P = .008 and P = .031). Median scenario scores were higher for consultants (32) and IBD nurses (33) compared with trainees (24; P = .018 and P = .022). There was a significant positive correlation between caring for greater numbers of pregnant IBD patients and higher CCPKnow (P = .001, r = .358) and scenario scores (P = .001, r = .377). There was a modest correlation between CCPKnow and scenario scores (r = .356; P < 0.001). CONCLUSIONS Despite "good" theoretical pregnancy-related IBD knowledge as assessed by CCPKnow, applied knowledge in the scenarios was less consistent. There is need for further HCP education and clinical experience to achieve optimal standardized care for IBD in pregnancy.
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Affiliation(s)
- Eleanor Liu
- Section of IBD, Division of Gastroenterology, Northern Care Alliance NHS Foundation Trust, Manchester, United Kingdom
| | - Robyn Laube
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia.,Department of Gastroenterology, Macquarie University Hospital, Sydney, NSW, Australia
| | - Rupert W Leong
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia.,Department of Gastroenterology, Macquarie University Hospital, Sydney, NSW, Australia.,Department of Gastroenterology and Hepatology, Concord Repatriation General Hospital, Sydney, NSW, Australia
| | - Aileen Fraser
- University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom
| | | | - Jimmy K Limdi
- Section of IBD, Division of Gastroenterology, Northern Care Alliance NHS Foundation Trust, Manchester, United Kingdom.,*Faculty of Biology, Medicine & Health, University of Manchester, United Kingdom
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The Effect of Pregnancy and Inflammatory Bowel Disease on the Pharmacokinetics of Drugs Related to Inflammatory Bowel Disease-A Systematic Literature Review. Pharmaceutics 2022; 14:pharmaceutics14061241. [PMID: 35745812 PMCID: PMC9227141 DOI: 10.3390/pharmaceutics14061241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 05/27/2022] [Accepted: 06/06/2022] [Indexed: 11/19/2022] Open
Abstract
Due to ethical and practical reasons, a knowledge gap exists on the pharmacokinetics (PK) of inflammatory bowel disease (IBD)-related drugs in pregnant women with IBD. Before evidence-based dosing can be proposed, insight into the PK has to be gained to optimize drug therapy for both mother and fetus. This systematic review aimed to describe the effect of pregnancy and IBD on the PK of drugs used for IBD. One aminosalicylate study, two thiopurine studies and twelve studies with biologicals were included. Most drugs within these groups presented data over multiple moments before, during and after pregnancy, except for mesalazine, ustekinumab and golimumab. The studies for mesalazine, ustekinumab and golimumab did not provide enough data to demonstrate an effect of pregnancy on concentration and PK parameters. Therefore, no evidence-based dosing advice was given. The 6-thioguanine nucleotide levels decreased during pregnancy to 61% compared to pre-pregnancy levels. The potentially toxic metabolite 6-methylmercaptopurine (6-MMP) increased to maximal 209% of the pre-pregnancy levels. Although the PK of the thiopurines changed throughout pregnancy, no evidence-based dosing advice was provided. One study suggested that caution should be exercised when the thiopurine dose is adjusted, due to shunting 6-MMP levels. For the biologicals, infliximab levels increased, adalimumab stayed relatively stable and vedolizumab levels tended to decrease during pregnancy. Although the PK of the biologicals changed throughout pregnancy, no evidence-based dosing advice for biologicals was provided. Other drugs retrieved from the literature search were mesalazine, ustekinumab and golimumab. We conclude that limited studies have been performed on PK parameters during pregnancy for drugs used in IBD. Therefore, more extensive research to determine the values of PK parameters is warranted. After gathering the PK data, evidence-based dosing regimens can be developed.
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Gomes-Carneiro MR, de Carvalho RR, do Amaral TF, Xavier De-Oliveira ACA, Paumgartten FJR. Evaluation of the maternal and developmental toxicity of 6-methylmercaptopurine riboside in rats. Reprod Toxicol 2022; 111:158-165. [PMID: 35662571 DOI: 10.1016/j.reprotox.2022.05.015] [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: 02/23/2022] [Revised: 05/17/2022] [Accepted: 05/26/2022] [Indexed: 10/18/2022]
Abstract
Thiopurine prodrugs (azathioprine, AZA, and 6-mercaptopurine, 6MP) are embryotoxic to rodents and rabbits. Little is known about the developmental toxicity of 6-methylmercaptopurine riboside (6MMPr), a thiopurine drug metabolite that is thought to mediate its liver toxicity. A limb bud assay found that 6MMPr impairs the in vitro morphogenetic differentiation of mouse limb extremities, being more potent than 6MP in the assay. This study evaluated the embryotoxicity of 6MMPr (0, 7.5, 15, 30mg/kg bw sc) in rats after single-dose exposure in mid organogenesis (GD10). One group of pregnant rats was similarly treated with 6MP (15mg/kg bw sc). After C-section (GD21), fetuses were weighed, and examined for external abnormalities. One third of each litter was examined for soft-tissue abnormalities while the remaining fetuses were cleared and stained for skeleton evaluation. 6MMPr caused a dose-dependent maternal weight loss followed by recovery before term pregnancy. Except for a nonsignificant increase in embryolethality and slight reduction in fetal weight at 30mg/kg bw, no indication of embryotoxicity was noted at this dose or at lower doses of 6MMPr. In contrast, 6MP led to nearly 98% of post-implantation losses in the presence of slight-to-mild maternal toxicity. These results are consistent with the notion that maternal treatment with 6MMPr affects embryo development, causing a nonsignificant increase in embryolethality and a slight reduction in fetal weight at 30mg/kg bw. However, there was no increase in abnormalities at this dose, which was severely toxic to the dams, as reflected in the maternal weight gain data.
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Affiliation(s)
- Maria Regina Gomes-Carneiro
- Laboratory of Environmental Toxicology, National School of Public Health,Oswaldo Cruz Foundation, Rio de Janeiro, RJ, 21040-361, Brazil
| | - Rosângela Ribeiro de Carvalho
- Laboratory of Environmental Toxicology, National School of Public Health,Oswaldo Cruz Foundation, Rio de Janeiro, RJ, 21040-361, Brazil
| | - Thamyris Figueiredo do Amaral
- Laboratory of Environmental Toxicology, National School of Public Health,Oswaldo Cruz Foundation, Rio de Janeiro, RJ, 21040-361, Brazil
| | | | - Francisco José Roma Paumgartten
- Laboratory of Environmental Toxicology, National School of Public Health,Oswaldo Cruz Foundation, Rio de Janeiro, RJ, 21040-361, Brazil.
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Liu E, Aslam N, Nigam G, Limdi JK. Tofacitinib and newer JAK inhibitors in inflammatory bowel disease-where we are and where we are going. Drugs Context 2022; 11:2021-11-4. [PMID: 35462642 PMCID: PMC9007061 DOI: 10.7573/dic.2021-11-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 03/04/2022] [Indexed: 11/21/2022] Open
Abstract
Inflammatory bowel diseases, comprising ulcerative colitis (UC) and Crohn's disease, are chronic, immune-mediated and progressive inflammatory disorders affecting the gastrointestinal tract. Tofacitinib is the first oral small-molecule Janus kinase (JAK) inhibitor licensed and approved by the National Institute for Health and Care Excellence (NICE) for use in moderately-to-severely active UC after intolerance, inadequate response, or loss of response to conventional treatment or biologic therapy. The pivotal OCTAVE studies demonstrated the efficacy and safety of tofacitinib for the induction and maintenance of remission in UC. A growing body of evidence from real-world data supports the positive clinical and endoscopic benefits observed with tofacitinib treatment in the OCTAVE trials. This narrative review summarizes the current literature regarding the mechanism of action of tofacitinib, data from registrational trials, emerging real-world evidence, and an overview of the most recent safety evidence. We explore evolving treatment paradigms, including the use of tofacitinib in the COVID-19 era, pregnancy and extraintestinal manifestations, as well as the emerging concept of combining tofacitinib with biological therapy. We will also present a brief overview of the next generation of JAK inhibitors in the pipeline.
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Affiliation(s)
- Eleanor Liu
- Section of IBD – Division of Gastroenterology, Northern Care Alliance NHS Trust, Manchester, UK
| | - Nasar Aslam
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Gaurav Nigam
- Royal Berkshire Hospital NHS Foundation Trust, Reading, UK
- Oxford University Clinical Academic Graduate School, University of Oxford, Oxford, UK
| | - Jimmy K Limdi
- Section of IBD – Division of Gastroenterology, Northern Care Alliance NHS Trust, Manchester, UK
- Manchester Academic Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
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22
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de Aragão MC, Beraldo RF, Marcondes MB, de Barros JR, Herrerias GSP, Saad-Hossne R, Baima JP, Sassaki LY. Management of inflammatory bowel disease and serum level of infliximab in newborn exposed to anti-TNF therapy during pregnancy: Case report and literature review. Medicine (Baltimore) 2021; 100:e28274. [PMID: 34941109 PMCID: PMC8702279 DOI: 10.1097/md.0000000000028274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 11/25/2021] [Indexed: 12/05/2022] Open
Abstract
RATIONALE Heightened inflammatory bowel disease (IBD) activity during pregnancy is associated with higher rates of preterm birth, miscarriage, and low birth weight. Therefore, its adequate treatment is essential, considering the risk-benefit of medication use. Although previous literature has described the management of IBD during pregnancy, few studies have assessed the pharmacokinetics of IBD drugs in the newborn. In this case report, we describe the management of ulcerative colitis during pregnancy and discuss the benefits of checking serum levels of infliximab in newborns exposed to the medication during pregnancy. PATIENT CONCERN A 37-year-old patient with ulcerative colitis in clinical and endoscopic remission had been undergoing treated with infliximab since 2008. The patient became pregnant in 2018. DIAGNOSIS AND INTERVENTION Infliximab medication was discontinued at the 29th week of pregnancy. OUTCOMES The pregnancy was uneventful, and the levels of infliximab in the umbilical cord were >20 μg/dL. Live vaccinations were postponed until the baby was 6 months old, when a new serum drug level proved to be undetectable. LESSONS Our case suggests that the use of infliximab is safe in pregnancy, and drug discontinuation could be considered from the 24th week of pregnancy onward to reduce placental transfer to the newborn in patients at low risk of relapse. Vaccines with live attenuated organisms should be delayed for at least 6 months or until the serum level of the medication is undetectable.
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Affiliation(s)
- Maria Cecília de Aragão
- Department of Internal Medicine, São Paulo State University (Unesp), Medical School, Botucatu, São Paulo, Brazil
| | - Rodrigo Fedatto Beraldo
- Department of Internal Medicine, São Paulo State University (Unesp), Medical School, Botucatu, São Paulo, Brazil
| | - Mariana Barros Marcondes
- Department of Internal Medicine, São Paulo State University (Unesp), Medical School, Botucatu, São Paulo, Brazil
| | - Jaqueline Ribeiro de Barros
- Department of Internal Medicine, São Paulo State University (Unesp), Medical School, Botucatu, São Paulo, Brazil
| | | | - Rogerio Saad-Hossne
- Department of Surgery, São Paulo State University (Unesp), Medical School, Botucatu, São Paulo, Brazil
| | - Júlio Pinheiro Baima
- Department of Internal Medicine, São Paulo State University (Unesp), Medical School, Botucatu, São Paulo, Brazil
| | - Ligia Yukie Sassaki
- Department of Internal Medicine, São Paulo State University (Unesp), Medical School, Botucatu, São Paulo, Brazil
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Story L, Rafique S, Samadi N, Mawdsley J, Singh B, Banerjee A. Lower gastrointestinal bleeding in pregnancy: Differential diagnosis, assessment and management. Obstet Med 2021; 14:129-134. [PMID: 34646340 PMCID: PMC8504301 DOI: 10.1177/1753495x20948300] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 07/15/2020] [Accepted: 07/15/2020] [Indexed: 12/16/2022] Open
Abstract
Rectal bleeding is a common symptom experienced by pregnant women. Although the majority of cases are attributable to benign conditions such as haemorrhoids and anal fissures, other more serious diagnoses such as inflammatory bowel disease and malignancy should not be overlooked. Most investigations are safe during pregnancy and these should not be withheld as significant implications on both fetal and maternal morbidity may result. In these cases, a multidisciplinary team approach is essential. This review explores the differential diagnosis, investigation and management of rectal bleeding during pregnancy.
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Affiliation(s)
- L Story
- Department of Women and Children's Health King's College, London, UK.,Women's Services, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - S Rafique
- King's College London Medical School, London, UK
| | - N Samadi
- King's College London Medical School, London, UK
| | - J Mawdsley
- Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - B Singh
- Department of Surgery, University Hospitals Leicester, Leicester, UK
| | - A Banerjee
- Women's Services, Guy's and St Thomas' NHS Foundation Trust, London, UK
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Lopez RN, Day AS. Editorial: the risk of chronic diseases and congenital malformations during childhood and adolescence after in utero drug exposure to thiopurines. Aliment Pharmacol Ther 2021; 54:1088-1089. [PMID: 34564890 DOI: 10.1111/apt.16606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Robert N Lopez
- Department of Paediatric Gastroenterology and Hepatology, Starship Child Health, Auckland, New Zealand.,Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Andrew S Day
- Department of Paediatrics, University of Otago Christchurch, Christchurch, New Zealand
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Kumar A, Nelson-Piercy C, Selinger C. Twitter debate: controversies in pregnancy in IBD and liver disease. Frontline Gastroenterol 2021; 13:355-357. [PMID: 35722600 PMCID: PMC9186033 DOI: 10.1136/flgastro-2021-101998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 09/13/2021] [Indexed: 02/04/2023] Open
Affiliation(s)
- Aditi Kumar
- Gastroenterology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
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