1
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Flatman LK, Malhamé I, Colmegna I, Bérard A, Bernatsky S, Vinet É. Tumour necrosis factor inhibitors and serious infections in reproductive-age women and their offspring: a narrative review. Scand J Rheumatol 2024:1-12. [PMID: 38314746 DOI: 10.1080/03009742.2024.2303832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 01/08/2024] [Indexed: 02/07/2024]
Abstract
Tumour necrosis factor inhibitors (TNFi) are commonly used to treat patients with chronic inflammatory diseases, and function by inhibiting the pro-inflammatory cytokine tumour necrosis factor-α (TNF-α). Although beneficial in reducing disease activity, they are associated with an increased risk of serious infections. Data on the risk of serious infections associated with TNFi use during the reproductive years, particularly in pregnancy, are limited. For pregnant women, there is an additional risk of immunosuppression in the offspring as TNFi can be actively transported across the placenta, which increases in the second and third trimesters. Several studies have explored the risk of serious infections with TNFi exposure in non-pregnant and pregnant patients and offspring exposed in utero, indicating an increased risk in non-pregnant patients and a potentially increased risk in pregnant patients. The studies on TNFi-exposed offspring showed conflicting results between in utero TNFi exposure and serious infections during the offspring's first year. Further research is needed to understand differential risks based on TNFi subtypes. Guidelines conditionally recommend the rotavirus vaccine before 6 months of age for offspring exposed to TNFi in utero, but more data are needed to support these recommendations because of limited evidence. This narrative review provides an overview of the risk in non-pregnant patients and summarizes evidence on how pregnancy can increase vulnerability to certain infections and how TNFi may influence this susceptibility. This review focuses on the evidence regarding the risk of serious infections in pregnant patients exposed to TNFi and the risk of infections in their offspring.
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Affiliation(s)
- L K Flatman
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - I Malhamé
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- Department of Medicine, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
- Division of General Internal Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - I Colmegna
- Division of Rheumatology, McGill University Health Centre, Montreal, Quebec, Canada
| | - A Bérard
- Faculty of Pharmacy, University of Montreal, Montreal, Quebec, Canada
- Research Center, CHU Sainte-Justine, Montreal, Quebec, Canada
- Faculty of Medicine, Université Claude Bernard Lyon 1, Lyon, France
| | - S Bernatsky
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- Department of Medicine, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
- Division of Rheumatology, Division of Clinical Epidemiology, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - É Vinet
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- Department of Medicine, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
- Division of Rheumatology, Division of Clinical Epidemiology, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
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2
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Julsgaard M, Wieringa JW, Baunwall SMD, Bibby BM, Driessen GJA, Kievit L, Brodersen JB, Poulsen A, Kjeldsen J, Hansen MM, Tang HQ, Balmer CL, Glerup H, Seidelin JB, Haderslev KV, Svenningsen L, Wildt S, Juel MA, Neumann A, Fuglsang J, Jess T, Haase AM, Hvas CL, Kelsen J, Janneke van der Woude C. Infant Ustekinumab Clearance, Risk of Infection, and Development After Exposure During Pregnancy. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00083-1. [PMID: 38278191 DOI: 10.1016/j.cgh.2024.01.008] [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: 11/12/2023] [Revised: 01/11/2024] [Accepted: 01/12/2024] [Indexed: 01/28/2024]
Abstract
BACKGROUND Evidence on ustekinumab safety in pregnancy is gradually expanding, but its clearance in the postnatal period is unknown. The aim of this study was to investigate ustekinumab concentrations in umbilical cord blood and rates of clearance after birth, as well as how these correlate with maternal drug concentrations, risk of infection, and developmental milestones during the first year of life. METHODS Pregnant women with inflammatory bowel disease were prospectively recruited from 19 hospitals in Denmark and the Netherlands between 2018 and 2022. Infant infections leading to hospitalization/antibiotics and developmental milestones were assessed. Serum ustekinumab concentrations were measured at delivery and specific time points. Nonlinear regression analysis was applied to estimate clearance. RESULTS In 78 live-born infants from 76 pregnancies, we observed a low risk of adverse pregnancy outcomes and normal developmental milestones. At birth, the median infant-mother ustekinumab ratio was 2.18 (95% confidence interval, 1.69-2.81). Mean time to infant clearance was 6.7 months (95% confidence interval, 6.1-7.3 months). One in 4 infants at 6 months had an extremely low median concentration of 0.015 μg/mL (range 0.005-0.12 μg/mL). No variation in median ustekinumab concentration was noted between infants with (2.8 [range 0.4-6.9] μg/mL) and without (3.1 [range 0.7-11.0] μg/mL) infections during the first year of life (P = .41). CONCLUSIONS No adverse signals after intrauterine exposure to ustekinumab were observed with respect to pregnancy outcome, infections, or developmental milestones during the first year of life. Infant ustekinumab concentration was not associated with risk of infections. With the ustekinumab clearance profile, live attenuated vaccination from 6 months of age seems of low risk.
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Affiliation(s)
- Mette Julsgaard
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark; Center for Molecular Prediction of Inflammatory Bowel Disease, Department of Clinical Medicine, Aalborg University, Copenhagen, Denmark.
| | - Jantien W Wieringa
- Department of Pediatrics, Haaglanden Medical Center, The Hague, the Netherlands; Division of Paediatric Infectious Diseases and Immunology, Department of Pediatrics, Sophia Children's Hospital, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Simon M D Baunwall
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Bo M Bibby
- Department of Biostatistics, University of Aarhus, Aarhus, Denmark
| | - Gertjan J A Driessen
- Department of Pediatrics, MosaKids Children's Hospital, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Linda Kievit
- Department of Medicine, Gjødstrup Hospital, Gjødstrup, Denmark
| | - Jacob B Brodersen
- Department of Gastroenterology, Esbjerg Hospital, University Hospital of Southern Denmark, Esbjerg, Denmark; Department of Regional Health Science, University of Southern Denmark, Esbjerg, Denmark
| | - Anja Poulsen
- Digestive Disease Center, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Jens Kjeldsen
- Department of Medical Gastrointestinal Diseases, Odense University Hospital, Odense, Denmark
| | - Mette M Hansen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Hai Q Tang
- Department of Obstetrics and Gynaecology, Aarhus University Hospital, Denmark
| | - Christina L Balmer
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Henning Glerup
- Diagnostic Centre, University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Silkeborg, Denmark
| | - Jakob B Seidelin
- Department of Gastroenterology and Hepatology, Herlev Hospital, University of Copenhagen, Herlev, Denmark
| | - Kent V Haderslev
- Department of Gastroenterology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Lise Svenningsen
- Department of Internal Medicine, Horsens Regional Hospital, Horsens, Denmark
| | - Signe Wildt
- Unit of Medical and Surgical Gastroenterology, Hvidovre University Hospital, Hvidovre, Denmark
| | - Mie A Juel
- Department of Gastroenterology, Esbjerg Hospital, University Hospital of Southern Denmark, Esbjerg, Denmark; Department of Internal Medicine, Vejle Hospital, Vejle, Denmark
| | - Anders Neumann
- Department of Internal Medicine, Viborg Regional Hospital, Viborg, Denmark
| | - Jens Fuglsang
- Department of Obstetrics and Gynaecology, Aarhus University Hospital, Denmark
| | - Tine Jess
- Center for Molecular Prediction of Inflammatory Bowel Disease, Department of Clinical Medicine, Aalborg University, Copenhagen, Denmark; Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Anne-Mette Haase
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Christian L Hvas
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark; Institute of Clinical Medicine, Health, Aarhus University, Aarhus, Denmark
| | - Jens Kelsen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark; Institute of Clinical Medicine, Health, Aarhus University, Aarhus, Denmark
| | - C Janneke van der Woude
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
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3
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Guo P, Cao W. Case report: A pregnant woman with Crohn disease who used ustekinumab to the 3rd trimester developed severe infection. Medicine (Baltimore) 2023; 102:e36253. [PMID: 38050250 PMCID: PMC10695489 DOI: 10.1097/md.0000000000036253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 11/01/2023] [Indexed: 12/06/2023] Open
Abstract
RATIONALE Crohn disease (CD) and pregnancy often impact each other, which poses challenges for women with CD to successfully give birth to a healthy baby. The latest guideline recommends that patients with active inflammatory bowel disease delay pregnancy to induce remission and optimize disease control. Research data has showed that the incidence of infection and severe infection in patients treated with ustekinumab (UST) did not increase compared to those treated with a placebo. PATIENT CONCERNS This report describes the entire process of a pregnant woman with CD who has undergone ileostomy and long-term enteral nutrition and requires biological agents to control the disease, from conception to delivery. This case was pregnant during CD period and regularly treated with UST to the third trimester, with the onset of sepsis and septic shock at 38 weeks gestation. DIAGNOSES The patient was pathologically diagnosed with CD 16 years ago and admitted to our department at 38 weeks gestation. INTERVENTIONS After admission to our department, fetal heart monitoring indicated fetal distress, so we immediately terminated the pregnancy by cesarean section. After the diagnosis of septic shock, the patient was transferred to intensive care unit for active anti-infection and symptomatic supportive treatment. OUTCOMES The mother only experienced an infection in the third trimester, and cured by active treatment. The newborn was delivered at full term and confirmed to be low birth weight. LESSONS Her experience suggests that although pregnant during Crohn active period, a good outcome can be achieved through positively controlling with medication and closely monitoring it. The use of UST during pregnancy appears to be safe for both the mother and fetus but may be associated with severe infections.
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Affiliation(s)
- Peng Guo
- Department of Obstetrics and Gynecology, Zhongshan City People’s Hospital, Zhongshan, China
| | - Wulan Cao
- Department of Obstetrics and Gynecology, Zhongshan City People’s Hospital, Zhongshan, China
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4
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Yuan S, Wang KS, Meng H, Hou XT, Xue JC, Liu BH, Cheng WW, Li J, Zhang HM, Nan JX, Zhang QG. The gut microbes in inflammatory bowel disease: Future novel target option for pharmacotherapy. Biomed Pharmacother 2023; 165:114893. [PMID: 37352702 DOI: 10.1016/j.biopha.2023.114893] [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: 03/16/2023] [Revised: 05/09/2023] [Accepted: 05/13/2023] [Indexed: 06/25/2023] Open
Abstract
Gut microbes constitute the main microbiota in the human body, which can regulate biological processes such as immunity, cell proliferation, and differentiation, hence playing a specific function in intestinal diseases. In recent years, gut microbes have become a research hotspot in the pharmaceutical field. Because of their enormous number, diversity, and functional complexity, gut microbes have essential functions in the development of many digestive diseases. Inflammatory bowel disease (IBD) is a chronic non-specific inflammatory disease with a complex etiology, the exact cause and pathogenesis are unclear. There are no medicines that can cure IBD, and more research on therapeutic drugs is urgently needed. It has been reported that gut microbes play a critical role in pathogenesis, and there is a tight and complex association between gut microbes and IBD. The dysregulation of gut microbes may be a predisposing factor for IBD, and at the same time, IBD may exacerbate gut microbes' disorders, but the mechanism of interaction between the two is still not well defined. The study of the relationship between gut microbes and IBD is not only important to elucidate the pathogenesis but also has a positive effect on the treatment based on the regimen of regulating gut microbes. This review describes the latest research progress on the functions of gut microbes and their relationship with IBD, which can provide reference and assistance for further research. It may provide a theoretical basis for the application of probiotics, fecal microbiota transplantation, and other therapeutic methods to regulate gut microbes in IBD.
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Affiliation(s)
- Shuo Yuan
- Key Laboratory of Natural Medicines of the Changbai Mountain, Ministry of Education, College of Pharmacy, Yanbian University, Yanji, Jilin Province 133002, China
| | - Ke-Si Wang
- Chronic diseases research center, Dalian University College of Medicine, Dalian, Liaoning, 116622, China
| | - Huan Meng
- Chronic diseases research center, Dalian University College of Medicine, Dalian, Liaoning, 116622, China
| | - Xiao-Ting Hou
- Chronic diseases research center, Dalian University College of Medicine, Dalian, Liaoning, 116622, China
| | - Jia-Chen Xue
- Chronic diseases research center, Dalian University College of Medicine, Dalian, Liaoning, 116622, China; Affiliated Zhongshan Hospital of Dalian University, Dalian, Liaoning, 116001, China
| | - Bao-Hong Liu
- Chronic diseases research center, Dalian University College of Medicine, Dalian, Liaoning, 116622, China
| | - Wen-Wen Cheng
- Chronic diseases research center, Dalian University College of Medicine, Dalian, Liaoning, 116622, China
| | - Jiao Li
- Chronic diseases research center, Dalian University College of Medicine, Dalian, Liaoning, 116622, China
| | - Hua-Min Zhang
- Chronic diseases research center, Dalian University College of Medicine, Dalian, Liaoning, 116622, China
| | - Ji-Xing Nan
- Key Laboratory of Natural Medicines of the Changbai Mountain, Ministry of Education, College of Pharmacy, Yanbian University, Yanji, Jilin Province 133002, China.
| | - Qing-Gao Zhang
- Key Laboratory of Natural Medicines of the Changbai Mountain, Ministry of Education, College of Pharmacy, Yanbian University, Yanji, Jilin Province 133002, China; Chronic diseases research center, Dalian University College of Medicine, Dalian, Liaoning, 116622, China.
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5
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Laube R, Selinger CP, Seow CH, Christensen B, Flanagan E, Kennedy D, Mountifield R, Seeho S, Shand A, Williams AJ, Leong RW. Australian inflammatory bowel disease consensus statements for preconception, pregnancy and breast feeding. Gut 2023; 72:1040-1053. [PMID: 36944479 DOI: 10.1136/gutjnl-2022-329304] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 02/21/2023] [Indexed: 03/23/2023]
Abstract
OBJECTIVE Because pregnancy outcomes tend to be worse in women with inflammatory bowel disease (IBD) than in those without, we aimed to update consensus statements that guide the clinical management of pregnancy in patients with IBD. DESIGN A multidisciplinary working group was established to formulate these consensus statements. A modified RAND/UCLA appropriateness method was used, consisting of a literature review, online voting, discussion meeting and a second round of voting. The overall agreement among the delegates and appropriateness of the statement are reported. RESULTS Agreement was reached for 38/39 statements which provide guidance on management of pregnancy in patients with IBD. Most medications can and should be continued throughout pregnancy, except for methotrexate, allopurinol and new small molecules, such as tofacitinib. Due to limited data, no conclusion was reached on the use of tioguanine during pregnancy. Achieving and maintaining IBD remission before conception and throughout pregnancy is crucial to optimise maternofetal outcomes. This requires a multidisciplinary approach to engage patients, allay anxieties and maximise adherence tomedication. Intestinal ultrasound can be used for disease monitoring during pregnancy, and flexible sigmoidoscopy or MRI where clinically necessary. CONCLUSION These consensus statements provide up-to-date, comprehensive recommendations for the management of pregnancy in patients with IBD. This will enable a high standard of care for patients with IBD across all clinical settings.
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Affiliation(s)
- Robyn Laube
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
- Department of Gastroenterology, Macquarie University Hospital, Sydney, New South Wales, Australia
| | | | - Cynthia H Seow
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Britt Christensen
- Gastroenterology Department, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Emma Flanagan
- Department of Gastroenterology, University of Melbourne, Melbourne, Victoria, Australia
| | - Debra Kennedy
- MotherSafe, Royal Hospital for Women, Sydney, New South Wales, Australia
| | - Reme Mountifield
- Department of Gastroenterology, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Sean Seeho
- Department of Obstetrics and Gynaecology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Antonia Shand
- Department of Maternal Foetal Medicine, Royal Hospital for Women, Sydney, New South Wales, Australia
| | - Astrid-Jane Williams
- Department of Gastroenterology, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Rupert W Leong
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
- Department of Gastroenterology, Macquarie University Hospital, Sydney, New South Wales, Australia
- Gastroenterology and Liver Services, Concord Repatriation General Hospital, Concord, New South Wales, Australia
- The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia
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6
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Torres J, Chaparro M, Julsgaard M, Katsanos K, Zelinkova Z, Agrawal M, Ardizzone S, Campmans-Kuijpers M, Dragoni G, Ferrante M, Fiorino G, Flanagan E, Gomes CF, Hart A, Hedin CR, Juillerat P, Mulders A, Myrelid P, O'Toole A, Rivière P, Scharl M, Selinger CP, Sonnenberg E, Toruner M, Wieringa J, Van der Woude CJ. European Crohn's and Colitis Guidelines on Sexuality, Fertility, Pregnancy, and Lactation. J Crohns Colitis 2023; 17:1-27. [PMID: 36005814 DOI: 10.1093/ecco-jcc/jjac115] [Citation(s) in RCA: 77] [Impact Index Per Article: 77.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Indexed: 02/02/2023]
Affiliation(s)
- Joana Torres
- Division of Gastroenterology, Hospital Beatriz Ângelo, Loures, Portugal.,Division of Gastroenterology, Hospital da Luz, Lisboa, Portugal.,Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - María Chaparro
- Department of Gastroenterology, Hospital Universitario de La Princesa, IIS-Princesa, UAM, CIBEREHD, Madrid, Spain
| | - Mette Julsgaard
- Department of Hepatology & Gastroenterology, Aarhus University Hospital, Aarhus, Denmark.,Center for Molecular Prediction of Inflammatory Bowel Disease [PREDICT], Department of Clinical Medicine, Aalborg University, Copenhagen, Denmark
| | - Konstantinos Katsanos
- Department of Gastroenterology and Hepatology, University and Medical School of Ioannina, Ioannina, Greece
| | - Zuzana Zelinkova
- Department of Internal Medicine, Svet zdravia, Nemocnica Dunajska Streda, Slovakia.,Firstst Department of Internal Medicine of University Hospital and Slovak Medical University in Bratislava, Bratislava, Slovakia
| | - Manasi Agrawal
- Dr Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Center for Molecular Prediction of Inflammatory Bowel Disease [PREDICT], Department of Clinical Medicine, Aalborg University, Copenhagen, Denmark
| | - Sandro Ardizzone
- Gastrointestinal Unit, Department of Biomedical and Clinical Sciences. University of Milan, Milan, Italy
| | - Marjo Campmans-Kuijpers
- Department of Gastroenterology and Hepatology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Gabriele Dragoni
- Gastroenterology Research Unit, Department of Experimental and Clinical Biomedical Sciences 'Mario Serio', University of Florence, Florence, Italy.,Gastroenterology Department, Careggi University Hospital, Florence, Italy
| | - Marc Ferrante
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - Gionata Fiorino
- Department of Gastroenterology and Digestive Endoscopy, IRCCS San Raffaele Hospital and Vita-Salute San Raffaele University, Milan, Italy
| | - Emma Flanagan
- Department of Gastroenterology, St Vincent's Hospital Melbourne, Fitzroy, VIC, Australia
| | | | - Ailsa Hart
- Inflammatory Bowel Diseases Unit, St Mark's Hospital, Harrow, UK
| | - Charlotte Rose Hedin
- Karolinska Institutet, Department of Medicine Solna, Stockholm, Sweden.,Karolinska University Hospital, Department of Gastroenterology, Dermatovenereology and Rheumatology, Stockholm, Sweden
| | - Pascal Juillerat
- Clinic for Visceral Surgery and Medicine, Bern University Hospital, Bern, Switzerland.,Crohn's and Colitis Center, Gastroenterology Beaulieu SA, Lausanne, Switzerland
| | - Annemarie Mulders
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Fetal Medicine Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Pär Myrelid
- Department of Surgery, Linköping University Hospital, Linköping, Sweden.,Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Aoibhlinn O'Toole
- Beaumont Hospital, Department of Gastroenterology, Royal College of Surgeons, Dublin, Ireland
| | - Pauline Rivière
- Gastroenterology Unit, Bordeaux University Hospital, Pessac, France
| | - Michael Scharl
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | | | - Elena Sonnenberg
- Charité-Universitätsmedizin Berlin, Department of Gastroenterology, Infectious Diseases and Rheumatology, Germany
| | - Murat Toruner
- Department of Gastroenterology, Ankara University School of Medicine, Ankara, Turkey
| | - Jantien Wieringa
- Department of Paediatrics, Haaglanden Medical Center, The Hague, The Netherlands.,Department of Paediatrics, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - C Janneke Van der Woude
- Department of Gastroenterology & Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
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7
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Shitrit ABG, Avni-Biron I. Editorial: ustekinumab during pregnancy-reassuring but still not enough. Authors' reply. Aliment Pharmacol Ther 2023; 57:160. [PMID: 36468216 DOI: 10.1111/apt.17282] [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)
| | - Irit Avni-Biron
- IBD Center, Division of Gastroenterology, Rabin Medical Center, Petah-Tikva, Israel
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8
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Liu Z, Julsgaard M, Zhu X, Martin J, Barclay ML, Cranswick N, Gibson PR, Gearry RB, van der Giessen J, Connor SJ, Rosella O, Grosen A, Toong C, Flanagan E, Wieringa JW, Janneke van der Woude C, Bell SJ. Timing of Live Attenuated Vaccination in Infants Exposed to Infliximab or Adalimumab in Utero: A Prospective Cohort Study in 107 Children. J Crohns Colitis 2022; 16:1835-1844. [PMID: 35779236 DOI: 10.1093/ecco-jcc/jjac093] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIMS For infants exposed in utero to anti-tumour necrosis factor-α [TNF] medications, it is advised that live-attenuated vaccinations be postponed until the drug is cleared, but little is known about time to clearance. To minimize delays before live-attenuated vaccination can be given, we aimed to develop a pharmacokinetic model to predict time-to-clearance in infants exposed during pregnancy. METHODS We prospectively followed in utero infliximab/adalimumab-exposed infants of mothers with inflammatory bowel disease across four countries between 2011 and 2018. Infants with a detectable anti-TNF umbilical-cord level and at least one other blood sample during the first year of life were included. RESULTS Overall, 107 infants were enrolled, including 166 blood samples from 71 infliximab-exposed infants and 77 samples from 36 adalimumab-exposed infants. Anti-TNF was detectable in 23% [n = 25] of infants at 6 months. At 12 months, adalimumab was not detected but 4% [n = 3] had detectable infliximab. A Bayesian forecasting method was developed using a one-compartment pharmacokinetic model. Model validation showed that the predicted clearing time was in accordance with the measured observations. A clinician-friendly online calculator was developed for calculating full anti-TNF clearing time: https://xiaozhu.shinyapps.io/antiTNFcalculator2/. CONCLUSIONS Almost one-quarter of infants born to mothers receiving anti-TNF during pregnancy have detectable anti-TNF at 6 months. To limit the time to live-attenuated vaccination in infants of mothers receiving anti-TNF during pregnancy, the results of a cord drug level at birth and a second sample ≥ 1 month thereafter can be used to estimate the time for full anti-TNF clearance in these children.
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Affiliation(s)
- Zheng Liu
- Clinical Pharmacology, School of Medicine and Public Health, University of Newcastle, Hunter Medical Research Institute, Kookaburra Circuit, Australia.,Clinical Pharmacology, Department of Medicine, The Royal Children's Hospital Melbourne, Australia.,Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Mette Julsgaard
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark.,Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Gastroenterology, St Vincent's Hospital, and University of Melbourne, Melbourne, Australia
| | - Xiao Zhu
- Department of Clinical Pharmacy and Pharmacy Administration, School of Pharmacy, Fudan University, China.,School of Pharmacy, University of Otago, Dunedin, New Zealand
| | - Jennifer Martin
- Clinical Pharmacology, School of Medicine and Public Health, University of Newcastle, Hunter Medical Research Institute, Kookaburra Circuit, Australia
| | - Murray L Barclay
- Departments of Gastroenterology & Clinical Pharmacology, Christchurch Hospital, Christchurch, New Zealand
| | - Noel Cranswick
- Clinical Pharmacology, Department of Medicine, The Royal Children's Hospital Melbourne, Australia
| | - Peter R Gibson
- Department of Gastroenterology, Alfred Hospital, and Monash University, Melbourne, VIC, Australia
| | - Richard B Gearry
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Janine van der Giessen
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Susan J Connor
- Department of Gastroenterology, Liverpool Hospital, Sydney.,South Western Sydney Clinical, University of NSW Sydney.,Ingham Institute of Applied Medical Research, Sydney, Australia
| | - Ourania Rosella
- Department of Gastroenterology, Alfred Hospital, and Monash University, Melbourne, VIC, Australia
| | - Anne Grosen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Catherine Toong
- South Western Sydney Clinical, University of NSW Sydney.,Sydney South West Pathology Service, Liverpool Hospital, University of NSW, Sydney, Australia
| | - Emma Flanagan
- Department of Gastroenterology, St Vincent's Hospital, and University of Melbourne, Melbourne, Australia
| | - Jantien W Wieringa
- Department of Pediatrics, Haaglanden Medical Center, the Hague, The Netherlands.,Department of Pediatrics, Division of Paediatric Infectious Diseases and Immunology, Erasmus MC University Medical Centre-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - C Janneke van der Woude
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Sally J Bell
- Department of Gastroenterology, St Vincent's Hospital, and University of Melbourne, Melbourne, Australia.,Department of Gastroenterology, Monash Health, and School of Clinical Sciences Monash University, Melbourne, VIC, Australia
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9
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Russell MD, Dey M, Flint J, Davie P, Allen A, Crossley A, Frishman M, Gayed M, Hodson K, Khamashta M, Moore L, Panchal S, Piper M, Reid C, Saxby K, Schreiber K, Senvar N, Tosounidou S, van de Venne M, Warburton L, Williams D, Yee CS, Gordon C, Giles I, Roddy E, Armon K, Astell L, Cotton C, Davidson A, Fordham S, Jones C, Joyce C, Kuttikat A, McLaren Z, Merrison K, Mewar D, Mootoo A, Williams E. British Society for Rheumatology guideline on prescribing drugs in pregnancy and breastfeeding: immunomodulatory anti-rheumatic drugs and corticosteroids. Rheumatology (Oxford) 2022; 62:e48-e88. [PMID: 36318966 PMCID: PMC10070073 DOI: 10.1093/rheumatology/keac551] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 09/15/2022] [Indexed: 11/07/2022] Open
Affiliation(s)
- Mark D Russell
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Mrinalini Dey
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Julia Flint
- Department of Rheumatology, Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Shropshire, UK
| | - Philippa Davie
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Alexander Allen
- Clinical Affairs, British Society for Rheumatology, London, UK
| | | | - Margreta Frishman
- Rheumatology, North Middlesex University Hospital NHS Trust, London, UK
| | - Mary Gayed
- Rheumatology, Sandwell and West Birmingham Hospitals, Birmingham, UK
| | | | - Munther Khamashta
- Lupus Research Unit, Division of Women's Health, King's College London, London, UK
| | - Louise Moore
- Rheumatic and Musculoskeletal Disease Unit, Our Lady's Hospice and Care Service, Dublin, Ireland
| | - Sonia Panchal
- Department of Rheumatology, South Warwickshire NHS Foundation Trust, Warwickshire, UK
| | - Madeleine Piper
- Royal National Hospital for Rheumatic Diseases, Royal United Hospital, Bath, UK
| | | | - Katherine Saxby
- Pharmacy, University College London Hospitals NHS Foundation Trust, London, UK
| | - Karen Schreiber
- Thrombosis and Haemostasis, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Department of Rheumatology, Danish Hospital for Rheumatic Diseases, Sonderborg, Denmark.,Department of Regional Health Research (IRS), University of Southern Denmark, Odense, Denmark
| | - Naz Senvar
- Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Sofia Tosounidou
- Lupus UK Centre of Excellence, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | | | | | - David Williams
- Obstetrics, University College London Hospitals NHS Foundation Trust, London, UK
| | - Chee-Seng Yee
- Department of Rheumatology, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, Doncaster, UK
| | - Caroline Gordon
- Rheumatology Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Ian Giles
- Centre for Rheumatology, Division of Medicine, University College London, London, UK
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10
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Kouthouridis S, Robson E, Hartung A, Raha S, Zhang B. Se(XY) matters: the importance of incorporating sex in microphysiological models. Trends Biotechnol 2022; 40:1284-1298. [PMID: 35597689 DOI: 10.1016/j.tibtech.2022.04.005] [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: 01/13/2022] [Revised: 04/06/2022] [Accepted: 04/09/2022] [Indexed: 01/21/2023]
Abstract
The development of microphysiological models is currently at the forefront of preclinical research. Although these 3D tissue models are being developed to mimic physiological organ function and diseases, which are often sexually dimorphic, sex is usually neglected as a biological variable. For decades, national research agencies have required government-funded clinical trials to include both male and female participants as a means of eliminating male bias. However, this is not the case in preclinical trials, which have been shown to favor male rodents in animal studies and male cell types in in vitro studies. In this Opinion, we highlight the importance of considering sex as a biological variable and outline five approaches for incorporating sex-specific features into current microphysiological models.
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Affiliation(s)
- Sonya Kouthouridis
- Department of Chemical Engineering, McMaster University, Hamilton, ON, L8S 4L8, Canada
| | - Eleanor Robson
- Department of Chemical Engineering, McMaster University, Hamilton, ON, L8S 4L8, Canada
| | - Alicia Hartung
- Department of Chemical Engineering, McMaster University, Hamilton, ON, L8S 4L8, Canada; School of Biomedical Engineering, McMaster University, Hamilton, ON, L8S 4L8, Canada
| | - Sandeep Raha
- Department of Pediatrics, McMaster University, Hamilton, ON, L8S 4L8, Canada; Graduate Program in Medical Sciences, McMaster University, Hamilton, ON, L8S 4L8, Canada.
| | - Boyang Zhang
- Department of Chemical Engineering, McMaster University, Hamilton, ON, L8S 4L8, Canada; School of Biomedical Engineering, McMaster University, Hamilton, ON, L8S 4L8, Canada.
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11
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Meyer A, Neumann A, Drouin J, Weill A, Carbonnel F, Dray-Spira R. Benefits and Risks Associated With Continuation of Anti-Tumor Necrosis Factor After 24 Weeks of Pregnancy in Women With Inflammatory Bowel Disease : A Nationwide Emulation Trial. Ann Intern Med 2022; 175:1374-1382. [PMID: 36162111 DOI: 10.7326/m22-0819] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Continuation of biologics for inflammatory disorders during pregnancy is still a difficult decision. Many women with inflammatory bowel diseases (IBDs) stop anti-tumor necrosis factor (anti-TNF) treatment after 24 weeks. OBJECTIVE To evaluate the benefits and risks of anti-TNF continuation after 24 weeks of pregnancy for mothers with IBD and their offspring. DESIGN Target trial emulation between 2010 and 2020. SETTING Nationwide population-based study using the Système National des Données de Santé. PATIENTS All pregnancies with birth exposed to anti-TNF between conception and 24 weeks of pregnancy in women with IBD. INTERVENTION Continuation of anti-TNF after 24 weeks of pregnancy. MEASUREMENTS Occurrence of maternal IBD relapse up to 6 months after pregnancy, adverse pregnancy outcomes, and serious infections in the offspring during the first 5 years of life was compared according to anti-TNF continuation after 24 weeks of pregnancy using inverse probability-weighted marginal models. RESULTS A total of 5293 pregnancies were included; among them, anti-TNF treatment was discontinued before 24 weeks for 2890 and continued beyond 24 weeks for 2403. Continuation of anti-TNF was associated with decreased frequencies of maternal IBD relapse (35.8% vs. 39.0%; adjusted risk ratio [aRR], 0.93 [95% CI, 0.86 to 0.99]) and prematurity (7.6% vs. 8.9%; aRR, 0.82 [CI, 0.68 to 0.99]). No difference according to anti-TNF continuation was found regarding stillbirths (0.4% vs. 0.2%; aRR, 2.16 [CI, 0.64 to 7.81]), small weight for gestational age births (13.1% vs. 12.9%; aRR, 1.01 [CI, 0.88 to 1.17]), and serious infections in the offspring (54.2 vs. 50.2 per 1000 person-years; adjusted hazard ratio, 1.08 [CI, 0.94 to 1.25]). LIMITATION Algorithms rather than clinical data were used to identify patients with IBD, pregnancies, and serious infections. CONCLUSION Continuation of anti-TNF after 24 weeks of pregnancy appears beneficial regarding IBD activity and prematurity, while not affecting neonatal outcomes and serious infections in the offspring. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
- Antoine Meyer
- EPI-PHARE, Épidémiologie des produits de santé, Saint-Denis, and Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre & Université Paris-Saclay, Le Kremlin Bicêtre, France (A.M.)
| | - Anke Neumann
- EPI-PHARE, Épidémiologie des produits de santé, Saint-Denis, France (A.N., J.D., A.W., R.D.)
| | - Jérôme Drouin
- EPI-PHARE, Épidémiologie des produits de santé, Saint-Denis, France (A.N., J.D., A.W., R.D.)
| | - Alain Weill
- EPI-PHARE, Épidémiologie des produits de santé, Saint-Denis, France (A.N., J.D., A.W., R.D.)
| | - Franck Carbonnel
- Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre & Université Paris-Saclay, Le Kremlin Bicêtre, France (F.C.)
| | - Rosemary Dray-Spira
- EPI-PHARE, Épidémiologie des produits de santé, Saint-Denis, France (A.N., J.D., A.W., R.D.)
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12
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Mahadevan U, Naureckas S, Tikhonov I, Wang Y, Lin CB, Geldhof A, van der Woude CJ. Pregnancy outcomes following periconceptional or gestational exposure to ustekinumab: Review of cases reported to the manufacturer's global safety database. Aliment Pharmacol Ther 2022; 56:477-490. [PMID: 35560249 DOI: 10.1111/apt.16960] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 01/17/2022] [Accepted: 04/22/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Ustekinumab, a human immunoglobulin G1 monoclonal antibody that binds to and inhibits interleukin (IL)-12/IL-23, is indicated for multiple immune-mediated diseases. Ustekinumab is actively transported across the placenta and theoretically could impact pregnancy outcomes. Limited data on pregnancy outcomes with ustekinumab exposure are available. AIM To assess pregnancy outcomes in patients exposed to ustekinumab during pregnancy METHODS: Cumulative data on medically confirmed ustekinumab-exposed pregnancies from the manufacturer's Global Safety Database were summarised. Descriptive data for pregnancy outcomes were presented overall and by patient subgroups. RESULTS As of 31 August 2020, 408 medically confirmed, prospective, maternal ustekinumab-exposed pregnancies with reported outcomes were identified. The mean maternal age was 31 years. Of the 420 pregnancy outcomes (including 4 sets of twins),a , b 340 (81%) were live births, 51 (12.1%) spontaneous abortions, 25 (6%) elective/induced abortions, 3 (0.7%) stillbirths and 1 (0.2%) ongoing pregnancy with foetal congenital anomaly (CA). Among 340 live births, 33 (9.7%) were born pre-term. The rate of major CAs was similar by indication (Crohn's disease vs psoriasis), ustekinumab dose (45 mg vs 90 mg) and timing and duration of maternal exposure to ustekinumab. Prospective outcomes of pregnancies with paternal periconceptional ustekinumab exposure (n = 87) included 92% live births (1.2% major CA), 5.7% spontaneous abortions and 2.3% elective/induced abortions. CONCLUSIONS Rates of adverse pregnancy outcomes or CAs with ustekinumab exposure were consistent with rates reported for the US general population and do not suggest a higher risk associated with maternal or paternal exposure to ustekinumab.
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Affiliation(s)
- Uma Mahadevan
- University of California San Francisco, San Francisco, California, USA
| | - Saule Naureckas
- Janssen Research and Development, LLC, Raritan, New Jersey, USA
| | - Ilia Tikhonov
- Janssen Research and Development, LLC, Raritan, New Jersey, USA
| | - Yiting Wang
- Janssen Research and Development, LLC, Spring House, Pennsylvania, USA
| | - Connie B Lin
- Janssen Research and Development, LLC, Horsham, Pennsylvania, USA
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13
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Malhi G, Tandon P, Perlmutter JW, Nguyen G, Huang V. Risk Factors for Postpartum Disease Activity in Women With Inflammatory Bowel Disease: A Systematic Review and Meta-analysis. Inflamm Bowel Dis 2022; 28:1090-1099. [PMID: 34427643 DOI: 10.1093/ibd/izab206] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND Women with inflammatory bowel disease (IBD) have an increased risk of postpartum disease activity. We aimed to systematically determine the effect of various risk factors on postpartum IBD disease activity. METHODS Electronic databases were searched through January 2021 for studies that reported risk of postpartum disease activity in women with IBD. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated for the impact of IBD phenotype, disease activity, therapy de-escalation, mode of delivery, and breastfeeding on postpartum disease activity. Study bias was determined using the Quality in Prognostic Studies tool. RESULTS Twenty-seven observational studies (3825 patients) were included, 15 of which had a high risk of confounding bias. The pooled incidence of women with postpartum active IBD was 31.9% (95% CI, 25.6-38.1). Similar results were seen with ulcerative colitis and Crohn's disease (CD; OR, 0.96; 95% CI, 0.58-1.59). Those with stricturing (OR, 3.64; 95% CI, 1.31-10.08) and penetrating (OR, 4.25; 95% CI, 1.11-16.26) CD had higher odds of postpartum active IBD. Active disease at conception (OR, 10.59; 95% CI, 1.48-76.02) and during pregnancy (OR, 4.91; 95% CI, 1.82-13.23) increased the odds of postpartum disease activity. Similarly, biologic discontinuation in the third trimester (OR, 1.77; 95% CI, 1.01-3.10) and therapy de-escalation after delivery (OR, 7.36; 95% CI, 3.38-16.0) was associated with postpartum disease activity. CONCLUSIONS Complicated Crohn's disease, disease activity at conception and during pregnancy, and de-escalation of biologics during pregnancy or after delivery are associated with postpartum disease activity in women with IBD.
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Affiliation(s)
- Gurpreet Malhi
- Department of Medicine, Western University, London, Ontario, Canada
| | - Parul Tandon
- Division of Gastroenterology and Hepatology, University of Toronto, Toronto, Ontario, Canada
| | | | - Geoffrey Nguyen
- Division of Gastroenterology and Hepatology, University of Toronto, Toronto, Ontario, Canada
| | - Vivian Huang
- Division of Gastroenterology and Hepatology, University of Toronto, Toronto, Ontario, Canada
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14
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O'Byrne LJ, Alqatari SG, Maher GM, O'Sullivan AM, Khashan AS, Murphy GP, McCarthy FP. Fetal and maternal outcomes after maternal biologic use during conception and pregnancy: A systematic review and meta-analysis. BJOG 2022; 129:1236-1246. [PMID: 35014759 PMCID: PMC9306977 DOI: 10.1111/1471-0528.17093] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 11/26/2021] [Accepted: 12/01/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Biologic medications, specifically tumour necrosis factor-α (TNF-α) inhibitors, have become increasingly prevalent in the treatment of chronic inflammatory disease (CID) in pregnancy. OBJECTIVE To determine pregnancy outcomes in women with CID exposed to biologics during pregnancy. SEARCH STRATEGY PubMed and EMBASE databases were searched through January 1998-July 2021. SELECTION CRITERIA Peer-reviewed, English-language cohort, case-control, cross-sectional studies, and case series that contained original data. DATA COLLECTION AND ANALYSIS Two authors independently conducted data extraction. A meta-analysis of proportions using a random-effects model was used to pool outcomes. Linear regression analysis was used to compare the mean of proportions of outcomes across exposure groups using the 'treated' group as the reference category. All studies were evaluated using an appropriate quality assessment tool. The GRADE approach was used to assess the overall certainty of evidence. MAIN RESULTS Thirty-five studies, describing 11 172 pregnancies, were eligible for inclusion. Analysis showed pooled proportions for congenital malformations as follows: treated 0.04 (95% CI 0.03-0.04; I2 = 77) versus disease-matched 0.04 (95% CI 0.03-0.05. I2 = 86; p = 0.238); preterm delivery treated 0.04 (95% CI 0.10-0.14; I2 = 88) versus disease-matched 0.10 (95% CI 0.09-0.12; I2 = 87; p = 0.250); severe neonatal infection: treated 0.05 (95% CI 0.03-0.07; I2 = 88) versus disease-matched 0.05 (95% CI 0.02-0.07; I2 = 94; p = 0.970); low birthweight: treated 0.10 (95% CI 0.07-0.12; I2 = 93) versus disease-matched 0.08 (95% CI 0.07-0.09; I2 = 0; p = 0.241); pooled miscarriage: treated 0.13 (95% CI 0.10-0.15; I2 = 77) versus disease-matched 0.08 (95% CI 0.04-0.11; I2 = 5; p = 0.078); pre-eclampsia; treated 0.01 (95% CI 0.01-0.02; I2 = 0) versus disease-matched 0.01 (95% CI 0.00-0.01; I2 = 0; p = 0.193). No statistical differences in proportions were observed. GRADE certainty of findings was low to very low. CONCLUSION We demonstrated comparable pregnancy outcomes in pregnancies exposed to biologics, disease-matched controls and CID-free pregnancies using the GRADE approach.
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Affiliation(s)
- Laura J. O'Byrne
- INFANT Research CentreUniversity College CorkCorkIreland
- Department of Obstetrics and GynaecologyCork University Maternity HospitalCorkIreland
| | | | - Gillian M. Maher
- INFANT Research CentreUniversity College CorkCorkIreland
- School of Public Health, Western Gateway BuildingUniversity College CorkCorkIreland
| | | | - Ali S. Khashan
- INFANT Research CentreUniversity College CorkCorkIreland
- School of Public Health, Western Gateway BuildingUniversity College CorkCorkIreland
| | | | - Fergus P. McCarthy
- INFANT Research CentreUniversity College CorkCorkIreland
- Department of Obstetrics and GynaecologyCork University Maternity HospitalCorkIreland
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15
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Abstract
Pregnancy is a complex biological process. The establishment and maintenance of foetal-maternal interface are pivotal events. Decidual immune cells and inflammatory cytokines play indispensable roles in the foetal-maternal interface. The disfunction of decidual immune cells leads to adverse pregnancy outcome. Tumour necrosis factor (TNF)-α, a common inflammatory cytokine, has critical roles in different stages of normal pregnancy process. However, the relationship between the disorder of TNF-α and adverse pregnancy outcomes, including preeclampsia (PE), intrauterine growth restriction (IUGR), spontaneous abortion (SA), preterm birth and so on, is still indefinite. In this review, we thoroughly reviewed the effect of TNF-α disorder on pathological conditions. Moreover, we summarized the reports about the adverse pregnancy outcomes (PE, IUGR, SA and preterm birth) of using anti-TNF-α drugs (infliximab, etanercept and adalimumab, certolizumab and golimumab) currently in the clinical studies. Overall, IUGR, SA and preterm birth are the most common adverse pregnancy outcomes of anti-TNF-α drugs. Our review may provide insight for the immunological treatment of pregnancy-related complication, and help practitioners make informed decisions based on the current evidences.
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16
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The impact of gender and sex in psoriasis: What to be aware of when treating women with psoriasis. Int J Womens Dermatol 2022; 8:e010. [PMID: 35619672 PMCID: PMC9112394 DOI: 10.1097/jw9.0000000000000010] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 02/02/2022] [Indexed: 12/25/2022] Open
Abstract
Psoriasis is a common chronic inflammatory skin disease with an exceptionally high burden for women.
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17
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Balakirski G, Gerdes S, Beissert S, Ochsendorf F, von Kiedrowski R, Wilsmann-Theis D. Psoriasis-Therapie während Schwangerschaft und Stillzeit. J Dtsch Dermatol Ges 2022; 20:653-685. [PMID: 35578434 DOI: 10.1111/ddg.14789_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 03/09/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Galina Balakirski
- Zentrum für Dermatologie, Allergologie und Dermatochirurgie, HELIOS Universitätsklinikum Wuppertal, Universität Witten/Herdecke, Wuppertal
| | - Sascha Gerdes
- Psoriasis-Zentrum, Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Schleswig- Holstein - Campus Kiel
| | - Stefan Beissert
- Klinik und Poliklinik für Dermatologie, Universitätsklinikum Carl Gustav Carus Dresden
| | - Falk Ochsendorf
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Frankfurt am Main
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18
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Balakirski G, Gerdes S, Beissert S, Ochsendorf F, von Kiedrowski R, Wilsmann-Theis D. Therapy of psoriasis during pregnancy and breast-feeding. J Dtsch Dermatol Ges 2022; 20:653-683. [PMID: 35578438 DOI: 10.1111/ddg.14789] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 03/09/2022] [Indexed: 12/21/2022]
Abstract
There have been multiple systemic drugs approved for the therapy of psoriasis vulgaris and psoriasis arthritis (PsA) in the last decade. However, treatment decisions are difficult to make in women planning a pregnancy and in pregnant and lactating women due to the paucity of data for such cases. The strongest evidence for psoriasis therapy during pregnancy exists for topical corticosteroids. Medically controlled use of UVB-therapy is also considered safe. The best evidence regarding systemic therapy during pregnancy and lactation is available for the group of TNF-alpha inhibitors, which is also reflected in the respective medical product information. This is especially important in cases of psoriatic arthritis. Among traditional systemic therapeutics, the largest clinical experience exists for ciclosporin, which, if medically necessary, may be continued during gestation. However, TNF-alpha inhibitors, especially the pegylated form, should be preferred in case of pregnancy. Furthermore, an elective pregnancy termination is not necessary due to systemic therapy of psoriasis with many further substances during the first pregnancy weeks. The current work provides a comprehensive review of the scientific literature on treatment of psoriasis during pregnancy and lactation. Based on the available scientific information, severity of psoriasis and patient's comorbidities, the best possible therapeutic approach can be found in consensus with the patient.
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Affiliation(s)
- Galina Balakirski
- Center for Dermatology, Allergology and Dermatosurgery, HELIOS University Hospital Wuppertal, Witten/Herdecke University, Wuppertal, Germany
| | - Sascha Gerdes
- Psoriasis Center, Department of Dermatology, Venereology and Allergology, University Hospital Schleswig- Holstein - Campus Kiel, Germany
| | - Stefan Beissert
- Department and Clinic for Dermatology, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Falk Ochsendorf
- Department of Dermatology, Venereology and Allergology, University Hospital Frankfurt am Main, Frankfurt, Germany
| | | | - Dagmar Wilsmann-Theis
- Department and Clinic for Dermatology and Allergology, University Hospital Bonn, Germany
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19
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Nielsen OH, Gubatan JM, Juhl CB, Streett SE, Maxwell C. Biologics for Inflammatory Bowel Disease and Their Safety in Pregnancy: A Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol 2022; 20:74-87.e3. [PMID: 32931960 DOI: 10.1016/j.cgh.2020.09.021] [Citation(s) in RCA: 50] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 09/01/2020] [Accepted: 09/09/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Biologics are used routinely in pregnant women with inflammatory bowel disease (IBD), but large-scale data reporting adverse pregnancy outcomes among biologic users are lacking. We sought to estimate the prevalence of adverse pregnancy outcomes in women with IBD on biologic therapies. METHODS We searched major databases from inception to June 2020 for studies estimating the prevalence of adverse pregnancy outcomes in IBD when using biologics (anti-tumor necrosis factor [TNF], anti-integrins, and anticytokines). Prevalence and relative risk (RR) were pooled using a random-effects model. RESULTS Forty-eight studies were included in the meta-analysis comprising 6963 patients. Biologic therapy in IBD pregnancies was associated with a pooled prevalence of 8% (95% CI, 6%-10%; I2 = 87.4%) for early pregnancy loss, 9% (95% CI, 7%-11%; I2 = 89.9%) for preterm birth, 0% (95% CI, 0%-0%; I2 = 0%) for stillbirth, 8% (95% CI, 5%-10%; I2 = 87.0%) for low birth weight, and 1% (95% CI, 1%-2%; I2 = 78.3%) for congenital malformations. These rates are comparable with those published in the general population. In subgroup analyses of a small number of studies, the prevalence of early pregnancy loss and preterm birth were higher in vedolizumab vs anti-TNF users. Meta-regression did not show an association of disease activity or concomitant thiopurine on adverse outcomes. Continued TNF inhibitor use during the third trimester was not associated with risk of preterm birth (RR, 1.41; 95% CI, 0.77-2.60; I2 = 0%), low birth weight (RR, 1.32; 95% CI, 0.80-2.18; I2 = 0%), or congenital malformations (RR, 1.28; 95% CI, 0.47-3.49; I2 = 0%). CONCLUSIONS Adverse pregnancy outcomes among pregnant IBD women using biologics are comparable with that of the general population. PROSPERO protocol #CRD42019135721.
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Affiliation(s)
- Ole Haagen Nielsen
- Department of Gastroenterology, Medical Section, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark.
| | - John Mark Gubatan
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Carsten Bogh Juhl
- Research Unit for Musculoskeletal Function and Physiotherapy, University of Southern Denmark, Odense, Denmark; Department of Physiotherapy and Occupational Therapy, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Sarah Elizabeth Streett
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Cynthia Maxwell
- Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Ontario, Canada
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20
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Wang H, Chen F, Hu Y, Shen M. Adverse Pregnancy Outcomes Following Exposure to Biologics in Women With Crohn's Disease: A Systematic Review and Meta-Analysis. Front Med (Lausanne) 2021; 8:753088. [PMID: 34760901 PMCID: PMC8573108 DOI: 10.3389/fmed.2021.753088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 09/27/2021] [Indexed: 11/13/2022] Open
Abstract
Crohn's disease is a chronic disease, which commonly affects women during their reproductive years. Poorly treated Crohn's disease is associated with adverse pregnancy outcomes. Biologics, a group of therapeutic drugs targeting inflammatory mediators including anti-TNF, anti-integrins and anti-interleukins, are increasingly used in pregnant women with Crohn's disease, exposing both the women and their fetuses to treatment-related complications. At present, it is unclear which biologics are more superior. This study performed a systematic review and meta-analysis to assess the risk of adverse pregnancy outcomes in women with Crohn's disease after exposure to biologics. Bibliographic databases were searched from inception to May 2021. The outcomes of interest were preterm delivery, low birth weight, spontaneous abortion, and congenital abnormalities. A total of 11 studies comprised of 1,875 pregnancies among women with Crohn's disease were included. Of these, 1,162 received biologics and 713 received non-biologic therapy. During the remission phase of the disease, the use of biological therapy increased the risk of adverse pregnancy outcomes, of which anti-integrins were associated with a higher incidence of adverse pregnancy outcomes than anti-TNF and anti-interleukins. Systematic Review Registration: http://www.crd.york.ac.uk/PROSPERO, identifier: CRD42020191275.
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Affiliation(s)
- Han Wang
- Department of Gynecology and Obstetrics, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Fang Chen
- Department of Gastroenterology, Hangzhou Red Cross Hospital, Hangzhou, China
| | - Yue Hu
- Department of Gastroenterology, First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
| | - Mengdie Shen
- Department of Internal Medicine, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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21
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Pham-Huy A, Top KA, Constantinescu C, Seow CH, El-Chaâr D. Utilisation et incidence des agents biologiques à base d’anticorps monoclonaux durant la grossesse. CMAJ 2021; 193:E1537-E1544. [PMID: 34607850 PMCID: PMC8568088 DOI: 10.1503/cmaj.202391-f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- Anne Pham-Huy
- Division d'infectiologie, immunologie et allergie (Pham-Huy), Hôpital pédiatrique de l'Est de l'Ontario; Faculté de médecine (Pham-Huy), Université d'Ottawa, Ottawa, Ont.; Centre de santé IWK, Division d'infectiologie, Centre canadien de vaccinologie (Top), Halifax, N.-É.; Faculté de médecine de l'Université de Calgary, Division d'infectiologie pédiatrique (Constantinescu); Division de gastro-entérologie et d'hépatologie (Seow), Départements de médecine et de sciences de la santé communautaire, Université de Calgary, Calgary, Alb.; Groupe de recherche OMNI de l'IRHO (El-Chaâr), Programme d'épidémiologie clinique; Service d'obstétrique, gynécologie et soins aux nouveau-nés (El-Chaâr), Hôpital d'Ottawa, Ottawa, Ont.
| | - Karina A Top
- Division d'infectiologie, immunologie et allergie (Pham-Huy), Hôpital pédiatrique de l'Est de l'Ontario; Faculté de médecine (Pham-Huy), Université d'Ottawa, Ottawa, Ont.; Centre de santé IWK, Division d'infectiologie, Centre canadien de vaccinologie (Top), Halifax, N.-É.; Faculté de médecine de l'Université de Calgary, Division d'infectiologie pédiatrique (Constantinescu); Division de gastro-entérologie et d'hépatologie (Seow), Départements de médecine et de sciences de la santé communautaire, Université de Calgary, Calgary, Alb.; Groupe de recherche OMNI de l'IRHO (El-Chaâr), Programme d'épidémiologie clinique; Service d'obstétrique, gynécologie et soins aux nouveau-nés (El-Chaâr), Hôpital d'Ottawa, Ottawa, Ont
| | - Cora Constantinescu
- Division d'infectiologie, immunologie et allergie (Pham-Huy), Hôpital pédiatrique de l'Est de l'Ontario; Faculté de médecine (Pham-Huy), Université d'Ottawa, Ottawa, Ont.; Centre de santé IWK, Division d'infectiologie, Centre canadien de vaccinologie (Top), Halifax, N.-É.; Faculté de médecine de l'Université de Calgary, Division d'infectiologie pédiatrique (Constantinescu); Division de gastro-entérologie et d'hépatologie (Seow), Départements de médecine et de sciences de la santé communautaire, Université de Calgary, Calgary, Alb.; Groupe de recherche OMNI de l'IRHO (El-Chaâr), Programme d'épidémiologie clinique; Service d'obstétrique, gynécologie et soins aux nouveau-nés (El-Chaâr), Hôpital d'Ottawa, Ottawa, Ont
| | - Cynthia H Seow
- Division d'infectiologie, immunologie et allergie (Pham-Huy), Hôpital pédiatrique de l'Est de l'Ontario; Faculté de médecine (Pham-Huy), Université d'Ottawa, Ottawa, Ont.; Centre de santé IWK, Division d'infectiologie, Centre canadien de vaccinologie (Top), Halifax, N.-É.; Faculté de médecine de l'Université de Calgary, Division d'infectiologie pédiatrique (Constantinescu); Division de gastro-entérologie et d'hépatologie (Seow), Départements de médecine et de sciences de la santé communautaire, Université de Calgary, Calgary, Alb.; Groupe de recherche OMNI de l'IRHO (El-Chaâr), Programme d'épidémiologie clinique; Service d'obstétrique, gynécologie et soins aux nouveau-nés (El-Chaâr), Hôpital d'Ottawa, Ottawa, Ont
| | - Darine El-Chaâr
- Division d'infectiologie, immunologie et allergie (Pham-Huy), Hôpital pédiatrique de l'Est de l'Ontario; Faculté de médecine (Pham-Huy), Université d'Ottawa, Ottawa, Ont.; Centre de santé IWK, Division d'infectiologie, Centre canadien de vaccinologie (Top), Halifax, N.-É.; Faculté de médecine de l'Université de Calgary, Division d'infectiologie pédiatrique (Constantinescu); Division de gastro-entérologie et d'hépatologie (Seow), Départements de médecine et de sciences de la santé communautaire, Université de Calgary, Calgary, Alb.; Groupe de recherche OMNI de l'IRHO (El-Chaâr), Programme d'épidémiologie clinique; Service d'obstétrique, gynécologie et soins aux nouveau-nés (El-Chaâr), Hôpital d'Ottawa, Ottawa, Ont
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De Felice KM, Kane S. Safety of anti-TNF agents in pregnancy. J Allergy Clin Immunol 2021; 148:661-667. [PMID: 34489011 DOI: 10.1016/j.jaci.2021.07.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 07/02/2021] [Accepted: 07/06/2021] [Indexed: 02/07/2023]
Abstract
Inflammatory bowel disease, rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, and psoriasis are associated with adverse pregnancy outcomes. Active maternal disease during pregnancy is associated with additional negative outcomes. Anti-TNF agents are effective treatments for inflammatory bowel disease, rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, and psoriasis. These agents cross the placenta starting in the second trimester, with levels detected for several months after birth. This has led to safety concerns, with continued therapy during pregnancy for both the mother and the infant. This review covers retrospective and prospective data published from various cohorts of pregnant women exposed to anti-TNF agents during pregnancy. It highlights the safety of anti-TNF drugs in pregnancy, breast-feeding, and during the first year of life of the infant.
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Affiliation(s)
- Kara M De Felice
- Department of Gastroenterology, Louisiana State University, Department of Gastroenterology, New Orleans, La.
| | - Sunanda Kane
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minn
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23
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Pham-Huy A, Top KA, Constantinescu C, Seow CH, El-Chaâr D. The use and impact of monoclonal antibody biologics during pregnancy. CMAJ 2021; 193:E1129-E1136. [PMID: 34312166 PMCID: PMC8321301 DOI: 10.1503/cmaj.202391] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Affiliation(s)
- Anne Pham-Huy
- Division of Infectious Diseases, Immunology and Allergy (Pham-Huy), Children's Hospital of Eastern Ontario; Faculty of Medicine (Pham-Huy), University of Ottawa, Ottawa, Ont.; IWK Health Centre, Division of Infectious Diseases, Canadian Center for Vaccinology (Top), Halifax, NS; University of Calgary Faculty of Medicine, Division of Pediatric Infectious Diseases (Constantinescu); Division of Gastroenterology and Hepatology (Seow), Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alta.; OHRI OMNI Research Group (El-Chaâr), Clinical Epidemiology Program; Department of Obstetrics, Gynecology and Newborn Care (El-Chaâr), Ottawa Hospital, Ottawa, Ont.
| | - Karina A Top
- Division of Infectious Diseases, Immunology and Allergy (Pham-Huy), Children's Hospital of Eastern Ontario; Faculty of Medicine (Pham-Huy), University of Ottawa, Ottawa, Ont.; IWK Health Centre, Division of Infectious Diseases, Canadian Center for Vaccinology (Top), Halifax, NS; University of Calgary Faculty of Medicine, Division of Pediatric Infectious Diseases (Constantinescu); Division of Gastroenterology and Hepatology (Seow), Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alta.; OHRI OMNI Research Group (El-Chaâr), Clinical Epidemiology Program; Department of Obstetrics, Gynecology and Newborn Care (El-Chaâr), Ottawa Hospital, Ottawa, Ont
| | - Cora Constantinescu
- Division of Infectious Diseases, Immunology and Allergy (Pham-Huy), Children's Hospital of Eastern Ontario; Faculty of Medicine (Pham-Huy), University of Ottawa, Ottawa, Ont.; IWK Health Centre, Division of Infectious Diseases, Canadian Center for Vaccinology (Top), Halifax, NS; University of Calgary Faculty of Medicine, Division of Pediatric Infectious Diseases (Constantinescu); Division of Gastroenterology and Hepatology (Seow), Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alta.; OHRI OMNI Research Group (El-Chaâr), Clinical Epidemiology Program; Department of Obstetrics, Gynecology and Newborn Care (El-Chaâr), Ottawa Hospital, Ottawa, Ont
| | - Cynthia H Seow
- Division of Infectious Diseases, Immunology and Allergy (Pham-Huy), Children's Hospital of Eastern Ontario; Faculty of Medicine (Pham-Huy), University of Ottawa, Ottawa, Ont.; IWK Health Centre, Division of Infectious Diseases, Canadian Center for Vaccinology (Top), Halifax, NS; University of Calgary Faculty of Medicine, Division of Pediatric Infectious Diseases (Constantinescu); Division of Gastroenterology and Hepatology (Seow), Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alta.; OHRI OMNI Research Group (El-Chaâr), Clinical Epidemiology Program; Department of Obstetrics, Gynecology and Newborn Care (El-Chaâr), Ottawa Hospital, Ottawa, Ont
| | - Darine El-Chaâr
- Division of Infectious Diseases, Immunology and Allergy (Pham-Huy), Children's Hospital of Eastern Ontario; Faculty of Medicine (Pham-Huy), University of Ottawa, Ottawa, Ont.; IWK Health Centre, Division of Infectious Diseases, Canadian Center for Vaccinology (Top), Halifax, NS; University of Calgary Faculty of Medicine, Division of Pediatric Infectious Diseases (Constantinescu); Division of Gastroenterology and Hepatology (Seow), Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alta.; OHRI OMNI Research Group (El-Chaâr), Clinical Epidemiology Program; Department of Obstetrics, Gynecology and Newborn Care (El-Chaâr), Ottawa Hospital, Ottawa, Ont
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Carnovale C, Parisi F, Battini V, Zavatta A, Cheli S, Cattaneo D, Gringeri M, Mosini G, Guarnieri G, Cammarata G, Cetin I. The use of biological agents in pregnant women affected by autoimmune disorders: Why we need more research of this neglected area. Pharmacol Res 2021; 171:105786. [PMID: 34314858 DOI: 10.1016/j.phrs.2021.105786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 07/12/2021] [Accepted: 07/22/2021] [Indexed: 11/20/2022]
Abstract
Women of childbearing age are largely affected by several autoimmune disorders (the estimates range between 1.5 and 10 per 10,000). The increasing number of effective biological agents has dramatically revolutionized the treatment of these clinical conditions, ameliorating the patient's quality of life. The use of these agents by women during pregnancy is growing to ensure the disease activity control and avoid adverse health outcomes. However, for many newer biological agents, the degree of information concerning their use in pregnancy is often incomplete to perform a conclusive risk assessment on fetal and maternal health given the exclusion of this specific population from pharmacological clinical trials. More recently, the COVID-19 pandemic has confirmed the unacceptable inequities of pharmacological research and medical treatment for pregnant and lactating women, exacerbating the need for filling the gaps of quantitative and qualitative pharmacology data in this sensitive population. ere we summarize (i) what is already known about safety and effectiveness of biological agents in this understudied population (with specific focus on pregnancy-related health outcomes), and what we are going to learn from the on-going studies among pregnant women treated with biological agents; (ii) the methodological and ethical considerations that characterize the pharmacological research in pregnancy, also discussing emerging evidence on the use of therapeutic drug monitoring (TDM) in this clinical setting.
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Affiliation(s)
- Carla Carnovale
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences L. Sacco, "Luigi Sacco" University Hospital, Università di Milano, Milan, Italy.
| | - Francesca Parisi
- Department of Woman, Mother and Neonate, "V. Buzzi" Children Hospital, ASST Fatebenefratelli Sacco, 20141 Milan, Italy
| | - Vera Battini
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences L. Sacco, "Luigi Sacco" University Hospital, Università di Milano, Milan, Italy
| | - Alice Zavatta
- Department of Woman, Mother and Neonate, "V. Buzzi" Children Hospital, ASST Fatebenefratelli Sacco, 20141 Milan, Italy
| | - Stefania Cheli
- Unit of Clinical Pharmacology, ASST Fatebenefratelli Sacco University Hospital, Via GB Grassi 74, 20157 Milan, Italy
| | - Dario Cattaneo
- Unit of Clinical Pharmacology, ASST Fatebenefratelli Sacco University Hospital, Via GB Grassi 74, 20157 Milan, Italy
| | - Michele Gringeri
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences L. Sacco, "Luigi Sacco" University Hospital, Università di Milano, Milan, Italy
| | - Giulia Mosini
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences L. Sacco, "Luigi Sacco" University Hospital, Università di Milano, Milan, Italy
| | - Greta Guarnieri
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences L. Sacco, "Luigi Sacco" University Hospital, Università di Milano, Milan, Italy
| | - Gianluca Cammarata
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences L. Sacco, "Luigi Sacco" University Hospital, Università di Milano, Milan, Italy
| | - Irene Cetin
- Department of Woman, Mother and Neonate, "V. Buzzi" Children Hospital, ASST Fatebenefratelli Sacco, 20141 Milan, Italy; Department of Biomedical and Clinical Sciences, "Luigi Sacco", University of Milan, 20157 Milan, Italy
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25
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Kanis SL, Modderman S, Escher JC, Erler N, Beukers R, de Boer N, Bodelier A, Depla ACT, Dijkstra G, van Dijk ABRM, Gilissen L, Hoentjen F, Jansen JM, Kuyvenhoven J, Mahmmod N, Mallant-Hent RC, van der Meulen-de Jong AE, Noruzi A, Oldenburg B, Oostenbrug LE, Ter Borg PC, Pierik M, Romberg- Camps M, Thijs W, West R, de Lima A, van der Woude CJ. Health outcomes of 1000 children born to mothers with inflammatory bowel disease in their first 5 years of life. Gut 2021; 70:1266-1274. [PMID: 33046558 PMCID: PMC8223671 DOI: 10.1136/gutjnl-2019-319129] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 09/02/2020] [Accepted: 09/05/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The aim of this study was to describe the long-term health outcomes of children born to mothers with inflammatory bowel disease (IBD) and to assess the impact of maternal IBD medication use on these outcomes. DESIGN We performed a multicentre retrospective study in The Netherlands. Women with IBD who gave birth between 1999 and 2018 were enrolled from 20 participating hospitals. Information regarding disease characteristics, medication use, lifestyle, pregnancy outcomes and long-term health outcomes of children was retrieved from mothers and medical charts. After consent of both parents, outcomes until 5 years were also collected from general practitioners. Our primary aim was to assess infection rate and our secondary aims were to assess adverse reactions to vaccinations, growth, autoimmune diseases and malignancies. RESULTS We included 1000 children born to 626 mothers (381 (61%) Crohn's disease, 225 (36%) ulcerative colitis and 20 (3%) IBD unclassified). In total, 196 (20%) had intrauterine exposure to anti-tumour necrosis factor-α (anti-TNF-α) (60 with concomitant thiopurine) and 240 (24%) were exposed to thiopurine monotherapy. The 564 children (56%) not exposed to anti-TNF-α and/or thiopurine served as control group. There was no association between adverse long-term health outcomes and in utero exposure to IBD treatment. We did find an increased rate of intrahepatic cholestasis of pregnancy (ICP) in case thiopurine was used during the pregnancy without affecting birth outcomes and long-term health outcomes of children. All outcomes correspond with the general age-adjusted population. CONCLUSION In our study, we found no association between in utero exposure to anti-TNF-α and/or thiopurine and the long-term outcomes antibiotic-treated infections, severe infections needing hospital admission, adverse reactions to vaccinations, growth failure, autoimmune diseases and malignancies.
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Affiliation(s)
- Shannon Linda Kanis
- Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Sanne Modderman
- Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Johanna C Escher
- Pediatric Gastroenterology, Erasmus MC Sophia Children Hospital, Rotterdam, The Netherlands
| | - Nicole Erler
- Biostatistics, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Ruud Beukers
- Gastroenterology and Hepatology, Albert Schweitzer Ziekenhuis, Dordrecht, The Netherlands
| | - Nanne de Boer
- Gastroenterology and Hepatology, Amsterdam UMC, Amsterdam, The Netherlands
| | - Alexander Bodelier
- Gastroenterology and Hepatology, Amphia Hospital site Molengracht, Breda, The Netherlands
| | | | - Gerard Dijkstra
- Gastroenterology and Hepatology, University of Groningen, Groningen, The Netherlands
| | | | - Lennard Gilissen
- Gastroenterology and Hepatology, Catharina Ziekenhuis, Eindhoven, The Netherlands
| | - Frank Hoentjen
- Gastroenterology and Hepatology, Radboudumc, Nijmegen, The Netherlands
| | - Jeroen M Jansen
- Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Johan Kuyvenhoven
- Gastroenterology and Hepatology, Spaarne Hospital, Haarlem, The Netherlands
| | - Nofel Mahmmod
- Gastroenterology and Hepatology, Sint Antonius Ziekenhuis, Nieuwegein, The Netherlands
| | | | | | - Anahita Noruzi
- Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Bas Oldenburg
- Gastroenterology and Hepatology, Utrecht Hospital, Utrecht, The Netherlands
| | - Liekele E Oostenbrug
- Gastroenterology and Hepatology, Zuyderland Medisch Centrum Heerlen, Heerlen, The Netherlands
| | | | - Marieke Pierik
- Gastroenterology and Hepatology, Maastricht Universitair Medisch Centrum+, Maastricht, The Netherlands
| | - Mariëlle Romberg- Camps
- Gastroenterology and Hepatology, Zuyderland Medical Centre Sittard-Geleen, Sittard-Geleen, The Netherlands
| | - Willem Thijs
- Gastroenterology and Hepatology, Martini Hospital, Groningen, The Netherlands
| | - Rachel West
- Gastroenterology and Hepatology, Franciscus Gasthuis, Rotterdam, New Caledonia
| | - Alison de Lima
- Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
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26
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Kucharzik T, Ellul P, Greuter T, Rahier JF, Verstockt B, Abreu C, Albuquerque A, Allocca M, Esteve M, Farraye FA, Gordon H, Karmiris K, Kopylov U, Kirchgesner J, MacMahon E, Magro F, Maaser C, de Ridder L, Taxonera C, Toruner M, Tremblay L, Scharl M, Viget N, Zabana Y, Vavricka S. ECCO Guidelines on the Prevention, Diagnosis, and Management of Infections in Inflammatory Bowel Disease. J Crohns Colitis 2021; 15:879-913. [PMID: 33730753 DOI: 10.1093/ecco-jcc/jjab052] [Citation(s) in RCA: 178] [Impact Index Per Article: 59.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- T Kucharzik
- Department of Gastroenterology, Klinikum Lüneburg, University of Hamburg, Lüneburg, Germany
| | - P Ellul
- Department of Medicine, Division of Gastroenterology, Mater Dei Hospital, Msida, Malta
| | - T Greuter
- University Hospital Zürich, Department of Gastroenterology and Hepatology, Zürich, Switzerland, and Division of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois CHUV, University Hospital Lausanne, Lausanne, Switzerland
| | - J F Rahier
- Department of Gastroenterology and Hepatology, CHU UCL Namur, Yvoir, Belgium
| | - B Verstockt
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium, and Department of Chronic Diseases, Metabolism and Ageing, TARGID-IBD, KU Leuven, Leuven, Belgium
| | - C Abreu
- Infectious Diseases Service, Centro Hospitalar Universitário São João, Porto, Portugal.,Instituto de Inovação e Investigação em Saúde [I3s], Faculty of Medicine, Department of Medicine, University of Porto, Portugal
| | - A Albuquerque
- Gastroenterology Department, St James University Hospital, Leeds, UK
| | - M Allocca
- Humanitas Clinical and Research Center - IRCCS -, Rozzano [Mi], Italy.,Humanitas University, Department of Biomedical Sciences, Milan, Italy
| | - M Esteve
- Hospital Universitari Mútua Terrassa, Digestive Diseases Department, Terrassa, Catalonia, and Centro de Investigación Biomédica en red de Enfermedades Hepáticas y Digestivas CIBERehd, Madrid, Spain
| | - F A Farraye
- Inflammatory Bowel Disease Center, Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - H Gordon
- Department of Gastroenterology, Barts Health NHS Trust, Royal London Hospital, London, UK
| | - K Karmiris
- Department of Gastroenterology, Venizeleio General Hospital, Heraklion, Greece
| | - U Kopylov
- Department of Gastroenterology, Sheba Medical Center, Ramat Gan, Israel, and Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - J Kirchgesner
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Saint-Antoine, Department of Gastroenterology, Paris, France
| | - E MacMahon
- Department of Infectious Diseases, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - F Magro
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal.,Institute of Pharmacology and Therapeutics, Faculty of Medicine, University of Porto, Portugal
| | - C Maaser
- Outpatient Department of Gastroenterology, Department of Geriatrics, Klinikum Lüneburg, University of Hamburg, Lüneburg, Germany
| | - L de Ridder
- Department of Paediatric Gastroenterology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - C Taxonera
- IBD Unit, Department of Gastroenterology, Hospital Clínico San Carlos and Instituto de Investigación del Hospital Clínico San Carlos [IdISSC], Madrid, Spain
| | - M Toruner
- Ankara University School of Medicine, Department of Gastroenterology, Ankara, Turkey
| | - L Tremblay
- Centre Hospitalier de l'Université de Montréal [CHUM] Pharmacy Department and Faculty of Pharmacy, Université de Montréal, Montréal, QC, Canada
| | - M Scharl
- University Hospital Zürich, Department of Gastroenterology and Hepatology, Zürich, Switzerland
| | - N Viget
- Department of Infectious Diseases, Tourcoing Hospital, Tourcoing, France
| | - Y Zabana
- Hospital Universitari Mútua Terrassa, Digestive Diseases Department, Terrassa, Catalonia, and Centro de Investigación Biomédica en red de Enfermedades Hepáticas y Digestivas CIBERehd, Madrid, Spain
| | - S Vavricka
- University Hospital Zürich, Department of Gastroenterology and Hepatology, Zürich, Switzerland
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27
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Barenbrug L, Groen MT, Hoentjen F, van Drongelen J, Reek JMPAVD, Joosten I, de Jong EMGJ, van der Molen RG. Pregnancy and neonatal outcomes in women with immune mediated inflammatory diseases exposed to anti-tumor necrosis factor-α during pregnancy: A systemic review and meta-analysis. J Autoimmun 2021; 122:102676. [PMID: 34126302 DOI: 10.1016/j.jaut.2021.102676] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 05/27/2021] [Accepted: 05/29/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Anti-TNFα is increasingly used as treatment for immune mediated inflammatory diseases (IMID), such as inflammatory bowel disease (IBD), rheumatoid arthritis (RA) and psoriasis (PS). However, the impact of anti-TNFα during pregnancy on mother and newborn is under debate. This requires a sound knowledge of the effects of this treatment on pregnancy and neonatal outcomes. OBJECTIVES To assess pregnancy and neonatal outcomes after anti-TNFα therapy during pregnancy in women with IMID, specifically IBD, RA and PS. METHODS We performed a systematic review and meta-analysis of 39 studies assessing pregnancy and neonatal outcomes of women with IMID exposed to anti-TNFα agents during pregnancy. We used a random-effects model to determine pooled outcome measures. RESULTS An increased risk of preterm births (OR 1.45, 95% CI = 1.16 to 1.82, p = 0.001) and infections in newborns (OR 1.12, 95% CI = 1.00 to 1.27, p = 0.05)) was seen for women in the combined group of IMID exposed to anti-TNFα compared to diseased controls. Specifically for IBD patients exposed to anti-TNFα, the risk was increased for preterm birth (OR 1.66, 95% CI = 1.14 to 2.42, p = 0.009), and low birth weight (OR 1.49, 95% CI = 1.01 to 2.20, p = 0.047) compared to diseased controls. Combined data from studies of women with RA and PS, showed no increased risk for adverse pregnancy outcome after exposure to anti-TNFα. Most children of mothers with IMID received vaccination according to national vaccination schemes and only minor adverse events were reported. CONCLUSION Exposure to anti-TNFα agents during pregnancy is associated with increased risk of preterm birth and infections in newborns of women with IMID compared to diseased controls. The risk of preterm birth and low birth weight was increased in women with IBD specifically. The increased risk of infections in newborns underlines the importance of vaccination, which seems to be safe in children exposed to anti-TNFα. Delay of vaccination is therefore unnecessary in these children. These data may aid in balancing the continuing anti-TNFα therapy versus the risk of adverse pregnancy outcomes.
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Affiliation(s)
- Liana Barenbrug
- Laboratory of Medical Immunology, Department of Laboratory Medicine, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Maarten Te Groen
- Inflammatory Bowel Disease Centre, Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Frank Hoentjen
- Inflammatory Bowel Disease Centre, Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Joris van Drongelen
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Irma Joosten
- Laboratory of Medical Immunology, Department of Laboratory Medicine, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Elke M G J de Jong
- Department of Dermatology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Renate G van der Molen
- Laboratory of Medical Immunology, Department of Laboratory Medicine, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands.
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van der Giessen J, Fuhler GM, van der Woude CJ. A first pregnancy seems associated with a positive effect on the course of inflammatory bowel disease: data from a prospective pregnancy cohort. Scand J Gastroenterol 2021; 56:693-698. [PMID: 33877953 DOI: 10.1080/00365521.2021.1910996] [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] [Indexed: 02/04/2023]
Abstract
Objectives: The effect of pregnaSSncy on the course of inflammatory bowel disease (IBD) remains controversial. We aimed to describe the disease course before and after a first pregnancy in IBD patients.Methods: We analyzed data from a prospectively followed-up pregnancy cohort (minimal follow-up of 7 years), with clinical, biochemical and endoscopic characteristics obtained pre-pregnancy, during pregnancy and post-pregnancy. Possible factors associated with relapse (disease activity during pregnancy, maternal age, smoking, alcohol use, pre-pregnancy BMI, mode of delivery, thiopurine use during pregnancy, biological use during pregnancy, combination of thiopurine and biological use during pregnancy, breastfeeding, IBD diagnosis, endoscopic scores) were scored.Results: One hundred twenty six patients (95 Crohn's Disease [CD; 75%] and 31 Ulcerative Colitis/IBD unclassified [UC/IBD-U; 25%]) were enrolled, with one hundred pregnancies occurring in 100 primigravida patients. All pregnancies resulted in live birth. Twenty patients (20%) had a relapse during pregnancy. The median number of relapses/patient/year was 0.25 (IQR 0.5) and 0 (IQR 0.43) respectively before and after pregnancy (p = .00). For CD patients the median relapses/person/year was 0.25 (IQR 0.5) before and 0 (IQR 0.25) after delivery (p = .00), for UC/IBD-U patients there was no significant difference. In the post-partum period more UC patients relapsed compared to CD patients (68% vs 30.7%, p = .01). Seven-year IBD-course was unchanged in the 26 women who did not become pregnant.Conclusion: In this prospective observational cohort study, we found a lower rate of relapses in the 4 years after delivery compared to the 3 years prior to a first pregnancy. Post-partum, more UC patients experienced a relapse compared to CD patients.
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Affiliation(s)
- J van der Giessen
- Department of Gastroenterology and Hepatology, Erasmus Medical Center Rotterdam, Rotterdam, the Netherlands
| | - G M Fuhler
- Department of Gastroenterology and Hepatology, Erasmus Medical Center Rotterdam, Rotterdam, the Netherlands
| | - C J van der Woude
- Department of Gastroenterology and Hepatology, Erasmus Medical Center Rotterdam, Rotterdam, the Netherlands
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Guerrero Vinsard D, Kane SV. Biologics and pregnancy: a clinician's guide to the management of IBD in pregnant women. Expert Rev Gastroenterol Hepatol 2021; 15:633-641. [PMID: 33440996 DOI: 10.1080/17474124.2021.1876562] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: Women with inflammatory bowel disease (IBD) endorse a tremendous amount of concern about medication exposure during pregnancy and their effects on the fetus. Medical providers caring for this patient population should be well informed and feel comfortable counseling their patients for the best pregnancy outcome possible.Areas covered: It is of particular importance to understand the implications of use of biologics in preconception, pregnancy, and postpartum timeframes. Herein, we aim to inform the clinician about the impact of uncontrolled inflammation during pregnancy, the mechanisms of biologic transport through the placenta, the effects of biologics in maternal and neonatal outcomes, and additional postpartum considerations such as breastfeeding and vaccination safety.Expert opinion: The groundwork already set by previous research in terms of safety of biologic therapy during pregnancy has been reassuring. With the advent of more mechanisms of action but similar protein structure, i.e. they are IgG1 antibodies; the authors anticipate the recommendation of continuation of therapy throughout pregnancy will be sustained.
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Affiliation(s)
| | - Sunanda V Kane
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, MN, USA
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Kim MA, Kim YH, Chun J, Lee HS, Park SJ, Cheon JH, Kim TI, Kim WH, Park JJ. The Influence of Disease Activity on Pregnancy Outcomes in Women With Inflammatory Bowel Disease: A Systematic Review and Meta-Analysis. J Crohns Colitis 2021; 15:719-732. [PMID: 33175122 DOI: 10.1093/ecco-jcc/jjaa225] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Robust evidence regarding the impact of disease activity on pregnancy outcomes in women with inflammatory bowel disease [IBD] is crucial for both clinicians and patients in preparing a birth plan. We sought to perform a systematic review and meta-analysis to assess the pooled influences of disease activity on pregnancy outcomes in women with IBD. METHODS We searched MEDLINE, EMBASE and the COCHRANE library to identify articles comparing pregnancy outcomes between active and inactive IBD at the time of conception or during pregnancy. A meta-analysis was performed using a random-effects model to pool estimates and report odds ratios [ORs]. RESULTS A total of 28 studies were identified as eligible for the meta-analysis. In women with active IBD, the pooled ORs for low birth weight [LBW], preterm birth, small for gestational age [SGA], spontaneous abortion and stillbirths were respectively 3.81 (95% confidence interval [CI] 1.81-8.02), 2.42 [95% CI 1.74-3.35], 1.48 [95% CI 1.19-1.85], 1.87 [95% CI 1.17-3.0] and 2.27 [95% CI 1.03-5.04] compared to women with inactive IBD. In the subgroup analysis based on disease type, women with active ulcerative colitis had an increased risk of LBW, preterm birth and spontaneous abortion. Women with active Crohn's disease had a higher risk of preterm birth, SGA and spontaneous abortion. CONCLUSIONS Active IBD during the periconception period and pregnancy is associated with an increased risk of adverse pregnancy outcomes. Our data suggest that pregnancy should be planned when the disease is quiescent, and continuous disease control is important even during pregnancy.
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Affiliation(s)
- Min-A Kim
- Department of Obstetrics and Gynecology, Gangnam Severance Hospital, Institute of Women's Life Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - Young-Han Kim
- Department of Obstetrics and Gynecology, Severance Hospital, Institute of Women's Life Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - Jaeyoung Chun
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hye Sun Lee
- Biostatics Collaboration Unit, Yonsei University College of Medicine, Seoul, Korea
| | - Soo Jung Park
- Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Hee Cheon
- Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Tae Il Kim
- Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Won Ho Kim
- Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Jun Park
- Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Grišić AM, Dorn-Rasmussen M, Ungar B, Brynskov J, Ilvemark JFKF, Bolstad N, Warren DJ, Ainsworth MA, Huisinga W, Ben-Horin S, Kloft C, Steenholdt C. Infliximab clearance decreases in the second and third trimesters of pregnancy in inflammatory bowel disease. United European Gastroenterol J 2021; 9:91-101. [PMID: 33079627 PMCID: PMC8259366 DOI: 10.1177/2050640620964619] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 09/16/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Infliximab therapy during pregnancy in inflammatory bowel disease is challenged by a dilemma between maintaining adequate maternal disease control while minimizing fetal infliximab exposure. We investigated the effects of pregnancy on infliximab pharmacokinetics. METHODS The study population comprised 23 retrospectively identified pregnancies. Patients with inflammatory bowel disease were generally in clinical remission at pregnancy conception (74%) and received steady infliximab maintenance therapy (5 mg/kg q8w n = 17; q6w n = 4; q10w n = 1; 10 mg/kg q8w n = 1). Trough blood samples had been obtained in the same patients prior to pregnancy (n = 119), the first trimester (n = 16), second trimester (n = 18), third trimester (n = 7), and postpregnancy (n = 12). Data were analyzed using nonlinear mixed-effects population pharmacokinetic modeling. RESULTS Dose-normalized infliximab concentrations were significantly higher during the second trimester (median 15 mg/ml/kg, interquartile range 10-21) compared to prepregnancy (7, 2-12; p = 0.003), the first trimester (9, 1-12; p = 0.04), or postpregnancy (6, interquartile range 3-11; p > 0.05) in patients with inflammatory bowel disease. Similar trends were observed in the third trimester (13, 7-36; p > 0.05). A one-compartment model with linear elimination described the pharmacokinetics of infliximab (volume of distribution n = 18.2 L; clearance 0.61 L/day). Maternal infliximab exposure was influenced by the second and third trimester of pregnancy and anti-infliximab antibodies, and not by pregnancy-imposed physiological changes in, for example, body weight or albumin. Infliximab clearance decreased significantly during the second and third trimesters by up to 15% as compared to pre- and postpregnancy and the first trimester. The increased maternal infliximab exposure was weakly associated with lowered clinical disease activity. Pharmacokinetic model simulations of virtual patients indicated the increased maternal infliximab trough concentrations imposed by pregnancy will not completely counteract the decrease in infliximab concentration if therapy is paused in the third trimester. CONCLUSION Infliximab clearance decreases significantly in the second and third trimesters, leading to increasing maternal infliximab concentrations in any given regimen. Maternal infliximab levels may thus be maintained as constant in a de-intensified regimen by therapeutic drug monitoring guidance in inflammatory bowel disease.
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Affiliation(s)
- Ana-Marija Grišić
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany.,Graduate Research Training Program, PharMetrX, Berlin, Germany
| | - Maria Dorn-Rasmussen
- Department of Gastroenterology, Copenhagen University Hospital Herlev, Herlev, Denmark
| | - Bella Ungar
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer, Sackler School of Medicine, Tel-Aviv University, Ramat Gan, Israel
| | - Jørn Brynskov
- Department of Gastroenterology, Copenhagen University Hospital Herlev, Herlev, Denmark
| | - Johan F K F Ilvemark
- Department of Gastroenterology, Copenhagen University Hospital Herlev, Herlev, Denmark
| | - Nils Bolstad
- Department of Medical Biochemistry, Oslo University Hospital, Oslo, Norway
| | - David J Warren
- Department of Medical Biochemistry, Oslo University Hospital, Oslo, Norway
| | - Mark A Ainsworth
- Department of Gastroenterology, Copenhagen University Hospital Herlev, Herlev, Denmark
| | | | - Shomron Ben-Horin
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer, Sackler School of Medicine, Tel-Aviv University, Ramat Gan, Israel
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany
| | - Casper Steenholdt
- Department of Gastroenterology, Copenhagen University Hospital Herlev, Herlev, Denmark
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32
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Laube R, Paramsothy S, Leong RW. Use of medications during pregnancy and breastfeeding for Crohn's disease and ulcerative colitis. Expert Opin Drug Saf 2021; 20:275-292. [PMID: 33412078 DOI: 10.1080/14740338.2021.1873948] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Introduction: The peak age of diagnosis of inflammatory bowel disease (IBD) occurs during childbearing years, therefore management of IBD during pregnancy is a frequent occurrence. Maintenance of disease remission is crucial to optimize pregnancy outcomes, and potential maternal or fetal toxicity from medications must be balanced against the risks of untreated IBD.Areas covered: This review summarizes the literature on safety and use of medications for IBD during pregnancy and lactation.Expert opinion: 5-aminosalicylates, corticosteroids and thiopurines are safe for use during pregnancy, while methotrexate and tofacitinib should only be used with extreme caution. Anti-TNF agents (except certolizumab), vedolizumab, ustekinumab and tofacitinib readily traverse the placenta via active transport, therefore theoretically may affect fetal development. Certolizumab only undergoes passive transfer across the placenta, thus has markedly lower cord blood levels making it likely the safest biologic agent for infants. There is reasonable evidence to support the safety of anti-TNF monotherapy and combination therapy during pregnancy and lactation. Vedolizumab and ustekinumab are also thought to be safe in pregnancy and lactation, while tofacitinib is generally avoided due to teratogenic effects in animal studies.
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Affiliation(s)
- Robyn Laube
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia.,Department of Gastroenterology, Macquarie University Hospital, Sydney, Australia
| | - Sudarshan Paramsothy
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia.,Department of Gastroenterology, Macquarie University Hospital, Sydney, Australia.,Department of Gastroenterology and Hepatology, Concord Repatriation General Hospital, Sydney, Australia
| | - Rupert W Leong
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia.,Department of Gastroenterology, Macquarie University Hospital, Sydney, Australia.,Department of Gastroenterology and Hepatology, Concord Repatriation General Hospital, Sydney, Australia
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Gubatan J, Nielsen OH, Levitte S, Juhl CB, Maxwell C, Streett SE, Habtezion A. Biologics During Pregnancy in Women With Inflammatory Bowel Disease and Risk of Infantile Infections: A Systematic Review and Meta-Analysis. Am J Gastroenterol 2021; 116:243-253. [PMID: 33110017 PMCID: PMC8628857 DOI: 10.14309/ajg.0000000000000910] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 08/20/2020] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Biologics, such as tumor necrosis factor inhibitors, anti-integrins and anticytokines, are therapies for inflammatory bowel disease (IBD) that may increase the risk of infection. Most biologics undergo placental transfer during pregnancy and persist at detectable concentrations in exposed infants. Whether this is associated with an increased risk of infantile infections is controversial. We performed a systematic review and meta-analysis evaluating the risk of infantile infections after in utero exposure to biologics used to treat IBD. METHODS We searched PubMed, Embase, Scopus, Web of Science, and CENTRAL from inception to June 2020 to evaluate the association of biologic therapy during pregnancy in women with IBD and risk of infantile infections. Odds ratios of outcomes were pooled and analyzed using a random effects model. RESULTS Nine studies met the inclusion criteria comprising 8,013 women with IBD (5,212 Crohn's disease, 2,801 ulcerative colitis) who gave birth to 8,490 infants. Biologic use during pregnancy was not associated with an increased risk of all infantile infections (odds ratio [OR] 0.91, 95% confidence interval [CI] 0.73-1.14, I2 = 30%). In a subgroup analysis for the type of infection, biologic use was associated with increased infantile upper respiratory infections (OR 1.57, 95% CI 1.02-2.40, I2 = 4%). Biologic use during pregnancy was not associated with infantile antibiotic use (OR 0.91, 95% CI 0.73-1.14, I2 = 30%) or infection-related hospitalizations (OR 1.33, 95% CI 0.95-1.86, I2 = 26%). DISCUSSION Biologics use during pregnancy in women with IBD is not associated with the overall risk of infantile infections or serious infections requiring antibiotics or hospitalizations but is associated with an increased risk of upper respiratory infections.
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Affiliation(s)
- John Gubatan
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Ole Haagen Nielsen
- Department of Gastroenterology,Medical Section, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Steven Levitte
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Carsten Bogh Juhl
- Department of Sports Science and Biomechanics, University of Southern Denmark, Odense, Denmark
- Department of Physiotherapy and Occupational Therapy, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Cynthia Maxwell
- Department of Obstetrics & Gynaecology, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Sarah E. Streett
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Aida Habtezion
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
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34
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Zheng L, Wen XL. Gut microbiota and inflammatory bowel disease: The current status and perspectives. World J Clin Cases 2021; 9:321-333. [PMID: 33521100 PMCID: PMC7812881 DOI: 10.12998/wjcc.v9.i2.321] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 11/20/2020] [Accepted: 12/06/2020] [Indexed: 02/06/2023] Open
Abstract
Inflammatory bowel disease (IBD) is a chronic immune-mediated disease that affects the gastrointestinal tract. It is argued that environment, microbiome, and immune-mediated factors interact in a genetically susceptible host to trigger IBD. Recently, there has been increased interest in the development, progression, and treatment of IBD because of our understanding of the microbiome. Researchers have proved that some factors can alter the microbiome and the pathogenesis of IBD. As a result, there has been increasing interest in the application of probiotics, prebiotics, antibiotics, fecal microbiota transplantation, and gene manipulation in treating IBD because of the possible curative effect of microbiome-modulating interventions. In this review, we summarize the findings from human and animal studies and discuss the effect of the gut microbiome in treating patients with IBD.
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Affiliation(s)
- Lie Zheng
- Department of Gastroenterology, Shaanxi Provincial Hospital of Traditional Chinese Medicine, Xi’an 730000, Shaanxi Province, China
| | - Xin-Li Wen
- Department of Gastroenterology, Shaanxi Provincial Hospital of Traditional Chinese Medicine, Xi’an 730000, Shaanxi Province, China
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35
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Ali MF, He H, Friedel D. Inflammatory bowel disease and pregnancy: fertility, complications and treatment. Ann Gastroenterol 2020; 33:579-590. [PMID: 33162735 PMCID: PMC7599341 DOI: 10.20524/aog.2020.0536] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 07/27/2020] [Indexed: 12/30/2022] Open
Abstract
Inflammatory bowel disease (IBD) is commonly diagnosed and treated in the young population. Therefore, it is common that women anticipating or undergoing pregnancy will have to cope with the additional burden of their IBD. Pregnancy in an IBD patient also presents challenges for the practitioner, in that the usual diagnostic and therapeutic armamentarium of potential tests and therapies is disrupted. This review covers the implications of IBD for fertility, pregnancy and offspring, and discusses the management of IBD in pregnancy.
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Affiliation(s)
- Mohammad Fahad Ali
- Department of Gastroenterology and Hepatology, Guthrie Cortland Medical Center (Mohammad Fahad Ali)
| | - Harry He
- Department of Medicine, NYU Winthrop University Hospital (Harry He)
| | - David Friedel
- Department of Gastroenterology, NYU Winthrop University Hospital (David Friedel), USA
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36
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Ghalandari N, Dolhain RJEM, Hazes JMW, van Puijenbroek EP, Kapur M, Crijns HJMJ. Intrauterine Exposure to Biologics in Inflammatory Autoimmune Diseases: A Systematic Review. Drugs 2020; 80:1699-1722. [PMID: 32852745 PMCID: PMC7568712 DOI: 10.1007/s40265-020-01376-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Inflammatory autoimmune diseases are chronic diseases that often affect women of childbearing age. Therefore, detailed knowledge of the safety profile of medications used for management of inflammatory autoimmune diseases during pregnancy is important. However, in many cases the potential harmful effects of medications (especially biologics) during pregnancy (and lactation) on mother and child have not been fully identified. OBJECTIVE Our aim was to update the data on the occurrence of miscarriages and (major) congenital malformations when using biologics during pregnancy based on newly published articles. Additionally, we selected several different secondary outcomes that may be of interest for clinicians, especially information on adverse events in the use of a specific biologic during pregnancy. MATERIAL AND METHODS A search was conducted from 1 January 2015 until 4 July 2019 in Embase.com, Medline Ovid, Web of Science, Cochrane CENTRAL, and Google Scholar with specific search terms for each database. Selection of publications was based on title/abstract and followed by full text (double blinded, two researchers). An overview was made based on outcomes of interest. References of the included publications were reviewed to include and minimize the missing publications. RESULTS A total of 143 publications were included. The total number of cases ranged from nine for canakinumab to 4276 for infliximab. The rates of miscarriages and major congenital malformations did not show relevant differences from those rates in the general population. CONCLUSION Despite limitations to our study, no major safety issues were reported and no trend could be identified in the reported malformations.
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Affiliation(s)
- N Ghalandari
- Department of Rheumatology, Erasmus University Medical Center, Rotterdam, The Netherlands.
- Medicines Evaluation Board (MEB), Graadt van Roggenweg 500, 3531 AH, Utrecht, The Netherlands.
- Academic Center of Inflammunity, Erasmus University Medical Center, Rotterdam, The Netherlands.
| | - R J E M Dolhain
- Department of Rheumatology, Erasmus University Medical Center, Rotterdam, The Netherlands
- Academic Center of Inflammunity, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - J M W Hazes
- Department of Rheumatology, Erasmus University Medical Center, Rotterdam, The Netherlands
- Medicines Evaluation Board (MEB), Graadt van Roggenweg 500, 3531 AH, Utrecht, The Netherlands
- Academic Center of Inflammunity, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - E P van Puijenbroek
- Netherlands Pharmacovigilance Centre Lareb, 's Hertogenbosch, The Netherlands
| | - M Kapur
- Utrecht University of Medical Sciences, Utrecht, The Netherlands
| | - H J M J Crijns
- Medicines Evaluation Board (MEB), Graadt van Roggenweg 500, 3531 AH, Utrecht, The Netherlands
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De Lima-Karagiannis A, Juillerat P, Sebastian S, Pedersen N, Bar-Gil Shitrit A, van der Woude CJ. Management of Pregnant Inflammatory Bowel Disease Patients During the COVID-19 Pandemic. J Crohns Colitis 2020; 14:S807-S814. [PMID: 33085970 PMCID: PMC7665400 DOI: 10.1093/ecco-jcc/jjaa125] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
UNLABELLED The rapid emergence of the novel coronavirus [SARS-CoV2] and the coronavirus disease 2019 [COVID-19] has caused significant global morbidity and mortality. This is particularly concerning for vulnerable groups such as pregnant women with inflammatory bowel disease [IBD]. Care for pregnant IBD patients in itself is a complex issue because of the delicate balance between controlling maternal IBD as well as promoting the health of the unborn child. This often requires continued immunosuppressive maintenance medication or the introduction of new IBD medication during pregnancy. The current global COVID-19 pandemic creates an additional challenge in the management of pregnant IBD patients. In this paper we aimed to answer relevant questions that can be encountered in daily clinical practice when caring for pregnant women with IBD during the current COVID-19 pandemic. PODCAST This article has an associated podcast which can be accessed at https://academic.oup.com/ecco-jcc/pages/podcast.
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Affiliation(s)
- A De Lima-Karagiannis
- Erasmus University Medical Center, Department of Gastroenterology and Hepatology, the Netherlands
| | - P Juillerat
- Gastroenterology, Clinic for Visceral Surgery and Medicine, Bern University Hospital, Bern, Switzerland
| | - S Sebastian
- IBD Unit, Hull University Teaching Hospital NHS Trust, Hull, UK
| | - N Pedersen
- Slagelse Hospital, University of Copenhagen, Department of Gastroenterology, Denmark
| | - A Bar-Gil Shitrit
- IBD MOM unit, Digestive Diseases Institute, Shaare Zedek Medical Center affiliated with the Hebrew University School of Medicine, Jerusalem, Israel
| | - C J van der Woude
- Erasmus University Medical Center, Department of Gastroenterology and Hepatology, the Netherlands,Corresponding author: C. Janneke van der Woude, Erasmus University Medical Center, Department of Gastroenterology and Hepatology, The Netherlands. Tel: 003110703320;
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38
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Duricova D, Mitrova K. Editorial: safety of prenatal exposure to anti-TNF therapy on postnatal infectious complications. Aliment Pharmacol Ther 2020; 52:1216-1217. [PMID: 33016561 DOI: 10.1111/apt.16029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
LINKED CONTENTThis article is linked to Bröms et al paper. To view this article, visit https://doi.org/10.1111/apt.15971
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Affiliation(s)
- Dana Duricova
- IBD Clinical and Research Centre, ISCARE, a.s., Prague, Czech Republic
- Institute of Pharmacology, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Katarina Mitrova
- IBD Clinical and Research Centre, ISCARE, a.s., Prague, Czech Republic
- Department of Paediatrics, 2nd Faculty of Medicine, Charles University in Prague and University Hospital Motol, Prague, Czech Republic
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Nørgård BM, Nielsen J, Friedman S. In utero exposure to thiopurines/anti-TNF agents and long-term health outcomes during childhood and adolescence in Denmark. Aliment Pharmacol Ther 2020; 52:829-842. [PMID: 32677731 DOI: 10.1111/apt.15956] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 05/15/2020] [Accepted: 06/20/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Data on long-term health outcomes of children exposed in utero to thiopurines and anti-TNF medications are lacking. AIMS To examine the association between in utero exposure to thiopurines and anti-TNF medications and child health outcomes of site-specific groups of infections, using a composite endpoint including psychiatric diagnoses/autism spectrum disorder (ASD)/attention deficit hyperactivity disorder (ADHD), and malignancies during childhood/adolescence. METHODS A nationwide cohort study based on Danish health registries included 1 311 009 live born children during 1995 through 2015. Outcomes were based on hospital diagnoses (in-patients/out-patients/emergency department contacts). RESULTS In total, 1048 children were exposed in utero to thiopurines and 1 309 961 were unexposed. The adjusted hazard ratios (HRs) for site-specific groups of infections in the first 3 years of life were close to unity. The adjusted HR of psychiatric diagnoses/ASD/ADHD was 1.11 (95% CI 0.81-1.52). The HR of malignancies was not calculated (only two events among the exposed). In total, 493 children were exposed in utero to anti-TNF medications and 728 055 were unexposed. Within the first year of life, the adjusted HR of respiratory, urological/gynaecological infections and other infections were 1.34 (95% CI 1.03-1.74), 2.36 (95% CI 1.15-4.81) and 1.61 (95% CI 1.21-2.13), respectively. We found no increased risk of other adverse outcomes. CONCLUSIONS After in utero exposure to thiopurines, we found no increased risk of infections, psychiatric diagnoses/ASD/ADHD, or malignancies during childhood/adolescence. After in utero exposure to anti-TNF medications, the risk of respiratory, urological/gynaecological infections and other infections was increased during the first year of life.
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Affiliation(s)
- Bente Mertz Nørgård
- Center for Clinical Epidemiology, Odense University Hospital, and Research Unit of Clinical Epidemiology, University of Southern Denmark, Odense, Denmark.,Center for Crohn's and Colitis, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jan Nielsen
- Center for Clinical Epidemiology, Odense University Hospital, and Research Unit of Clinical Epidemiology, University of Southern Denmark, Odense, Denmark
| | - Sonia Friedman
- Center for Clinical Epidemiology, Odense University Hospital, and Research Unit of Clinical Epidemiology, University of Southern Denmark, Odense, Denmark.,Center for Crohn's and Colitis, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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40
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Wolloff S, Moore E, Glanville T, Limdi J, Kok KB, Fraser A, Kent A, Mulgabal K, Nelson-Piercy C, Selinger C. Provision of care for pregnant women with IBD in the UK: the current landscape. Frontline Gastroenterol 2020; 12:487-492. [PMID: 34712466 PMCID: PMC8515275 DOI: 10.1136/flgastro-2020-101546] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 06/04/2020] [Accepted: 06/14/2020] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Suboptimal control of inflammatory bowel disease (IBD) can result in increased rates of adverse pregnancy-related outcomes. We aimed to describe the current landscape of provision of antenatal care for women with IBD in the UK. METHODS This cross-sectional survey collected data on service setup; principles of care pre-conception, during pregnancy and post partum; and on perceived roles and responsibilities of relevant clinicians. RESULTS Data were provided for 97 IBD units. Prepregnancy counselling was offered mostly on request only (54%) and in an ad hoc manner. In 86% of units, IBD antenatal care was provided by the patient's usual gastroenterologist, rather than a gastroenterologist with expertise in pregnancy (14%). Combined clinics with obstetricians and gastroenterologists were offered in 14% of units (24% academic vs 7% district hospitals; p=0.043). Communication with obstetrics was 'as and when required' in 51% and 30% of IBD units reviewed pregnant women with IBD 'only when required'. The majority of respondents thought gastroenterologists should be involved in decisions regarding routine vaccinations (70%), breast feeding (80%), folic acid dosage (61%) and venous thromboembolism (VTE) prophylaxis (53%). Sixty-five per cent of respondents thought that gastroenterologists should be involved in decisions around mode of delivery and 30% recommended caesarean sections for previous but healed perianal disease. CONCLUSIONS This nationwide survey found considerable variation in IBD antenatal services. We identified deficiencies in service setup, care provided by IBD units and clinician knowledge. A basic framework to inform service setup, and better education on the available clinical guidance, is required to ensure consistent high-quality multidisciplinary care.
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Affiliation(s)
- Sarah Wolloff
- Leeds Gastroenterology Institute, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Emma Moore
- Leeds Gastroenterology Institute, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Tracey Glanville
- Department of Obstetrics, Leeds Teaching Hospitals NHS Trust, Leeds, Leeds, UK
| | - Jimmy Limdi
- Section of IBD—Division of Gastroenterology, The Pennine Acute Hospitals NHS Trust, Manchester, UK,Gastroenteterology, Manchester Academic Health Science Centre, Manchester, UK
| | - Klaartje B Kok
- Department of Gastroenterology, Barts and The London NHS Trust, London, UK
| | - Aileen Fraser
- Department of Gastroenterology, United Hospitals Bristol, Bristol, UK
| | - Alexandra Kent
- Department of Gastroenterology, King's College Hospital NHS Foundation Trust, London, UK
| | - Khasia Mulgabal
- Department of Obstetrics, Royal Bolton Foundation NHS Trust, Bolton, UK
| | | | - Christian Selinger
- Leeds Gastroenterology Institute, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Rottenstreich A, Mishael T, Granovsky SG, Koslowsky B, Schweistein H, Abitbol G, Goldin E, Shitrit ABG. Clinical utility of fecal calprotectin in monitoring disease activity and predicting relapse in pregnant patients with inflammatory bowel diseases. Eur J Intern Med 2020; 77:105-110. [PMID: 32197833 DOI: 10.1016/j.ejim.2020.03.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 03/12/2020] [Indexed: 12/28/2022]
Abstract
OBJECTIVES Inflammatory bowel diseases (IBDs) are commonly diagnosed in reproductive-aged women and can substantially affect pregnancy outcomes. Non-invasive monitoring of IBD during the prenatal course is particularly challenging as traditional laboratory biomarkers are often affected by pregnancy-related physiologic changes. We aimed to evaluate the role of fecal calprotectin (FC) in monitoring disease activity and predicting relapse among IBD women throughout gestation. METHODS Women with IBD attending a multidisciplinary clinic for the preconception, antenatal and postnatal treatment were prospectively recruited during 2014-2018. FC levels were determined with an enzyme-linked immunoassay. RESULTS A total of 265 FC (preconception, n = 41; 1st trimester, n = 48; 2nd trimester, n = 84; 3rd trimester, n = 76; postpartum, n = 16) measurements were obtained in 157 pregnancies. Higher FC concentrations were found in all time points in those with active disease than those in remission as assessed by either physician global assessment or disease clinical scores. FC levels were significantly correlated with physician global assessment and disease activity indices in all 5 periods of investigation. Excluding those with disease flare at the time of conception, disease relapse was encountered during the prenatal course in 40 (31.5%) of the remaining 127 pregnancies. FC levels were significantly higher in those who experienced a disease flare later in the course of gestation as compared to those who maintained clinical remission (median 341 vs. 224 μg/g, P = 0.04). CONCLUSION FC appears to be a reliable marker of ongoing disease activity throughout the prenatal course as well as a predictor of imminent disease flare among IBD pregnant patients.
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Affiliation(s)
- Amihai Rottenstreich
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
| | - Tali Mishael
- IBD MOM Unit, Digestive Diseases Institute, Shaare Zedek Medical Center, Affiliated with the Medical School, Hebrew University, Jerusalem, Israel
| | - Sorina Grisaru Granovsky
- IBD MOM Unit, Digestive Diseases Institute, Shaare Zedek Medical Center, Affiliated with the Medical School, Hebrew University, Jerusalem, Israel
| | - Benjamin Koslowsky
- IBD MOM Unit, Digestive Diseases Institute, Shaare Zedek Medical Center, Affiliated with the Medical School, Hebrew University, Jerusalem, Israel
| | - Hagai Schweistein
- IBD MOM Unit, Digestive Diseases Institute, Shaare Zedek Medical Center, Affiliated with the Medical School, Hebrew University, Jerusalem, Israel
| | - Guila Abitbol
- IBD MOM Unit, Digestive Diseases Institute, Shaare Zedek Medical Center, Affiliated with the Medical School, Hebrew University, Jerusalem, Israel
| | - Eran Goldin
- IBD MOM Unit, Digestive Diseases Institute, Shaare Zedek Medical Center, Affiliated with the Medical School, Hebrew University, Jerusalem, Israel
| | - Ariella Bar-Gil Shitrit
- IBD MOM Unit, Digestive Diseases Institute, Shaare Zedek Medical Center, Affiliated with the Medical School, Hebrew University, Jerusalem, Israel
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Abstract
The disease course of autoimmune diseases such as rheumatoid arthritis is altered during pregnancy, and a similar modulatory role of pregnancy on inflammatory bowel disease (IBD) has been proposed. Hormonal, immunological, and microbial changes occurring during normal pregnancy may interact with the pathophysiology of IBD. IBD consists of Crohn's disease and ulcerative colitis, and because of genetic, immunological, and microbial differences between these disease entities, they may react differently during pregnancy and should be described separately. This review will address the pregnancy-induced physiological changes and their potential effect on the disease course of ulcerative colitis and Crohn's disease, with emphasis on the modulation of epithelial barrier function and immune profiles by pregnancy hormones, microbial changes, and microchimerism.
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43
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Singh S, Picardo S, Seow CH. Management of Inflammatory Bowel Diseases in Special Populations: Obese, Old, or Obstetric. Clin Gastroenterol Hepatol 2020; 18:1367-1380. [PMID: 31712084 PMCID: PMC7183892 DOI: 10.1016/j.cgh.2019.11.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 10/25/2019] [Accepted: 11/04/2019] [Indexed: 02/07/2023]
Abstract
The epidemiology of inflammatory bowel disease (IBD) is progressively evolving impacting the type of patients with IBD we will see in clinical practice. In this review, we discuss specific challenges and solutions in the management of (1) obese, (2) older and (3) obstetric (pregnant) patients with IBD. With the global obesity epidemic, almost 1 in 3 patients with IBD are obese. Obesity is associated with greater difficulty in achieving remission, higher risk of disease relapse and higher burden and costs of hospitalization in patients with IBD. Obese patients also have inferior response to biologic therapy related to altered pharmacokinetics and obesity-mediated chronic inflammation. Surgical management of obese patients with IBD is also challenging. Similar to obesity, the prevalence of IBD in older patients is rising and it is anticipated that almost one-third of patients with IBD will be older than 60 years within the next decade. Older patients present unique diagnostic and therapeutic dilemmas, and management of these individuals warrants careful consideration of the risks of disease-related versus treatment-related complications, non-IBD-related extra-intestinal complications (eg, cardiovascular disease, malignancy), in the context of individual values, preferences, functional status and comorbidities. With evolving therapeutics, medical management of IBD surrounding pregnancy continues to be challenging. Overall, the management of pregnant patients requires a pro-active, multidisciplinary approach, with an emphasis on optimal disease control not just during, but prior to pregnancy. This often involves continuation of highly effective therapies, of which the vast majority are safe during pregnancy and breastfeeding, resulting in a reduction of risk of adverse maternal fetal outcomes.
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Affiliation(s)
- Siddharth Singh
- Division of Gastroenterology, University of California San Diego, La Jolla, California; Division of Biomedical Informatics, University of California San Diego, La Jolla, California.
| | - Sherman Picardo
- Inflammatory Bowel Disease Centre, Department of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
| | - Cynthia H. Seow
- Inflammatory Bowel Disease Centre, Department of Gastroenterology, University of Calgary, Calgary, Alberta, Canada,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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44
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Geldhof A, Slater J, Clark M, Chandran U, Coppola D. Exposure to Infliximab During Pregnancy: Post-Marketing Experience. Drug Saf 2020; 43:147-161. [PMID: 31677004 PMCID: PMC7007430 DOI: 10.1007/s40264-019-00881-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background Women of childbearing potential are often treated with monoclonal antibodies to control chronic and debilitating inflammatory diseases. Remicade® (innovator infliximab [IFX]) may cross the placenta after the first trimester of pregnancy. Hence, evidence is needed to optimize treatment while carefully weighing benefits and risks to the mother and child. Here, we report on birth and infant outcomes (up to 2 years) following gestational exposure to IFX based on a summary of cumulative pregnancy reports in women exposed to IFX during pregnancy from the Janssen global safety database. Methods Prospective and medically confirmed safety data on IFX-exposed pregnancies from Janssen’s global safety surveillance database since authorization in 1998 are summarized. Descriptive statistics were used to summarize pregnancy and infant outcomes overall, by disease and timing of exposure. Results As of 23 August 2018, 1850 maternally IFX-exposed pregnancies with known outcomes were identified from the safety database. Of the 1850 pregnancies (mean age 29.7 years), 1526 (82.5%) resulted in live births. When reported, most women had Crohn’s disease (67.7%) or ulcerative colitis (18.4%), and 82.8% of live births were exposed to IFX in the first trimester. Spontaneous abortion/intrauterine death/ectopic pregnancy/molar pregnancy (12.1%), preterm births (9.2%), low birth weight infants (3.6%), congenital anomalies (2.0%), and infant infections (1.2%) were documented. The type of congenital anomalies and frequency of serious infant infections observed were consistent with the general population. Frequencies of congenital anomalies and other adverse outcomes were similar in women exposed to IFX in the first trimester and those exposed in the third trimester. More preterm births (13–18.8%) and infant complications (8.7–12.5%) were reported with concomitant immunosuppressant use. Conclusions The observed prevalence of adverse pregnancy and infant outcomes including congenital anomalies following exposure to IFX did not exceed estimates reported for the general population and no unexpected patterns were observed.
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Affiliation(s)
- Anja Geldhof
- Janssen Biologics B.V., Medical Affairs, Einsteinweg 101, 2333, Leiden, CB, The Netherlands.
| | | | - Michael Clark
- Janssen Research and Development, Spring House, PA, USA
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45
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Fuhler GM. The immune system and microbiome in pregnancy. Best Pract Res Clin Gastroenterol 2020; 44-45:101671. [PMID: 32359685 DOI: 10.1016/j.bpg.2020.101671] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 02/19/2020] [Accepted: 03/05/2020] [Indexed: 01/31/2023]
Abstract
Hormonal changes during pregnancy instigate numerous physiological changes aimed at the growth and delivery of a healthy baby. A careful balance between immunological tolerance against fetal antigens and immunity against infectious agents needs to be maintained. A three-way interaction between pregnancy hormones, the immune system and our microbiota is now emerging. Recent evidence suggests that microbial alterations seen during pregnancy may help maintain homeostasis and aid the required physiological changes occurring in pregnancy. However, these same immunological and microbial alterations may also make women more vulnerable during pregnancy and the post-partum period, especially regarding immunological and infectious diseases. Thus, a further understanding of the host-microbial interactions taking place during pregnancy may improve identification of populations at risk for adverse pregnancy outcomes.
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Affiliation(s)
- G M Fuhler
- Erasmus MC University Medical Center Rotterdam, Department of Gastroenterology and Hepatology, Erasmus Medical Center, Gravendijkwal 230, 3015CE, Rotterdam, the Netherlands.
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46
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Bröms G, Kieler H, Ekbom A, Gissler M, Hellgren K, Lahesmaa-Korpinen AM, Pedersen L, Schmitt-Egenolf M, Sørensen HT, Granath F. Anti-TNF treatment during pregnancy and birth outcomes: A population-based study from Denmark, Finland, and Sweden. Pharmacoepidemiol Drug Saf 2020; 29:316-327. [PMID: 32020767 DOI: 10.1002/pds.4930] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 09/24/2019] [Accepted: 10/29/2019] [Indexed: 12/17/2022]
Abstract
PURPOSE To study the risk of preterm birth, caesarean section, and small for gestational age after anti-tumor necrosis factor agent treatment (anti-TNF) in pregnancy. METHODS Population-based study including women with inflammatory bowel disease, rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, and psoriasis, and their infants born 2006 to 2013 from the national health registers in Denmark, Finland, and Sweden. Women treated with anti-TNF were compared with women with nonbiologic systemic treatment. Adalimumab, etanercept, and infliximab were compared pairwise. Continuation of treatment in early pregnancy was compared with discontinuation. Odds ratios with 95% confidence intervals were calculated in logistic regression models adjusted for country and maternal characteristics. RESULTS Among 1 633 909 births, 1027 infants were to women treated with anti-TNF and 9399 to women with nonbiologic systemic treatment. Compared with non-biologic systemic treatment, women with anti-TNF treatment had a higher risk of preterm birth, odds ratio 1.61 (1.29-2.02) and caesarean section, 1.57 (1.35-1.82). The odds ratio for small for gestational age was 1.36 (0.96-1.92). In pairwise comparisons, infliximab was associated with a higher risk of severely small for gestational age for inflammatory joint and skin diseases but not for inflammatory bowel disease. Discontinuation of anti-TNF had opposite effects on preterm birth for inflammatory bowel disease and inflammatory joint and skin diseases. CONCLUSIONS Anti-TNF agents were associated with increased risks of preterm birth, caesarean section, and small for gestational age. However, the diverse findings across disease groups may indicate an association related to the underlying disease activity, rather than to agent-specific effects.
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Affiliation(s)
- Gabriella Bröms
- Centre for Pharmacoepidemiology, Department of Medicine Solna, Karolinska Institutet and Department of Internal Medicine, Danderyd Hospital, Stockholm, Sweden
| | - Helle Kieler
- Centre for Pharmacoepidemiology, Department of Medicine Solna and Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Anders Ekbom
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska institutet, Stockholm, Sweden
| | - Mika Gissler
- Information Services Department, THL National Institute for Health and Welfare, Helsinki, Finland and Division of Family Medicine, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - Karin Hellgren
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska institutet, Stockholm, Sweden
| | | | - Lars Pedersen
- Department of Clinical Epidemiology, Aarhus University, Denmark
| | - Marcus Schmitt-Egenolf
- Dermatology, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | | | - Fredrik Granath
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska institutet, Stockholm, Sweden
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47
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Julsgaard M, Hvas CL, Gearry RB, Gibson PR, Fallingborg J, Sparrow MP, Bibby BM, Connell WR, Brown SJ, Kamm MA, Lawrance IC, Vestergaard T, Svenningsen L, Baekdal M, Kammerlander H, Walsh A, Boysen T, Bampton P, Radford-Smith G, Kjeldsen J, Andrews JM, Subramaniam K, Moore GT, Jensen NM, Connor SJ, Wildt S, Wilson B, Ellard K, Christensen LA, Bell SJ. Anti-TNF Therapy in Pregnant Women With Inflammatory Bowel Disease: Effects of Therapeutic Strategies on Disease Behavior and Birth Outcomes. Inflamm Bowel Dis 2020; 26:93-102. [PMID: 31141607 DOI: 10.1093/ibd/izz110] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Active inflammatory bowel disease (IBD) adversely affects pregnancy outcomes. Little is known about the risk of relapse after stopping anti-tumor necrosis factor (anti-TNF) treatment during pregnancy. We assessed the risk of relapse before delivery in women who discontinued anti-TNF treatment before gestational week (GW) 30, predictors of reduced infant birth weight, a marker associated with long-term adverse outcomes, and rates and satisfaction with counseling. METHODS Pregnant women with IBD receiving anti-TNF treatment were prospectively invited to participate in an electronic questionnaire carried out in 22 hospitals in Denmark, Australia, and New Zealand from 2011 to 2015. Risk estimates were calculated, and birth weight was investigated using t tests and linear regression. RESULTS Of 175 women invited, 153 (87%) responded. In women in remission, the relapse rate did not differ significantly between those who discontinued anti-TNF before GW 30 (1/46, 2%) compared with those who continued treatment (8/74, 11%; relative risk, 0.20; 95% confidence interval [CI], 0.02 to 1.56; P = 0.08). Relapse (P = 0.001) and continuation of anti-TNF therapy after GW 30 (P = 0.007) were independently associated with reduced mean birth weight by 367 g (95% CI, 145 to 589 g; relapse) and 274 g (95% CI, 77 to 471 g; anti-TNF exposure after GW 30). Of 134 (88%) women who received counseling, 116 (87%) were satisfied with the information provided. CONCLUSIONS To minimize fetal exposure in women in remission, discontinuation of anti-TNF before GW 30 seems safe. Relapse and continuation of anti-TNF therapy after GW 30 were each independently associated with lower birth weight, although without an increased risk for birth weight <2500 g. Most women received and were satisfied with counseling.
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Affiliation(s)
- Mette Julsgaard
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark.,Department of Medicine, Horsens Hospital, Horsens, Denmark.,Department of Gastroenterology, St Vincent's Hospital, and University of Melbourne, Melbourne, Australia
| | - Christian L Hvas
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Richard B Gearry
- Department of Medicine, Christchurch Hospital, University of Otago, Christchurch, New Zealand
| | - Peter R Gibson
- Department of Gastroenterology, Alfred Hospital, and Monash University, Melbourne, VIC, Australia
| | - Jan Fallingborg
- Department of Gastroenterology, Aalborg University Hospital, Aalborg, Denmark
| | - Miles P Sparrow
- Department of Gastroenterology, Alfred Hospital, and Monash University, Melbourne, VIC, Australia
| | - Bo M Bibby
- Department of Biostatistics, University of Aarhus, Aarhus, Denmark
| | - William R Connell
- Department of Gastroenterology, St Vincent's Hospital, and University of Melbourne, Melbourne, Australia
| | - Steven J Brown
- Department of Gastroenterology, St Vincent's Hospital, and University of Melbourne, Melbourne, Australia
| | - Michael A Kamm
- Department of Gastroenterology, St Vincent's Hospital, and University of Melbourne, Melbourne, Australia
| | - Ian C Lawrance
- School of Medicine and Pharmacology, University of Western Australia, Harry Perkins Institute for Medical Research, Murdoch, WA, Australia.,Centre for inflammatory Bowel Diseases, Saint John of God Hospital, Subiaco, WA, Australia
| | - Thea Vestergaard
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Lise Svenningsen
- Department of Medicine, Horsens Hospital, Horsens, Denmark.,Department of Medicine, Herning Hospital, Herning, Denmark
| | - Mille Baekdal
- Gastrounit, Medical Division, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark
| | - Heidi Kammerlander
- Department of Gastroenterology, Hospital of Southwest Jutland, Esbjerg, Denmark.,Department of Gastroenterology, Odense University Hospital, Odense, Denmark
| | - Alissa Walsh
- Department of Gastroenterology, St. Vincent's Hospital, Sydney, NSW, Australia
| | - Trine Boysen
- Gastrounit, Medical Division, Herlev Hospital, University of Copenhagen, Herlev, Denmark
| | - Peter Bampton
- Department of Gastroenterology, Flinders Medical Centre, Bedford Park, SA, Australia
| | - Graham Radford-Smith
- Inflammatory Bowel Diseases Unit, Royal Brisbane & Women's Hospital, University of Queensland School of Medicine, Brisbane, QLD, Australia
| | - Jens Kjeldsen
- Department of Gastroenterology, Odense University Hospital, Odense, Denmark
| | - Jane M Andrews
- Department of Gastroenterology & Hepatology, Royal Adelaide Hospital, University of Adelaide, Adelaide, SA, Australia
| | - Kavitha Subramaniam
- Gastroenterology and Hepatology Unit, The Canberra Hospital, Australian National University, Canberra, ACT, Australia
| | - Gregory T Moore
- Department of Gastroenterology, Monash Health, and School of Clinical Sciences Monash University, Melbourne, VIC, Australia
| | - Nanna M Jensen
- Abdominalcenter K, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Susan J Connor
- Department of Gastroenterology, Liverpool Hospital, Sydney, University of NSW, and Ingham Institute of Applied Medical Research, Sydney, Australia
| | - Signe Wildt
- Medical Department, Zealand University Hospital, Køge, Denmark
| | - Benedicte Wilson
- Department of Internal Medicine, Nykøbing Falster Hospital, Nykøbing, Denmark
| | - Kathrine Ellard
- Mater Hospital, Department of Gastroenterology, Sydney, Australia
| | - Lisbet A Christensen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark.,Institute of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Sally J Bell
- Department of Gastroenterology, St Vincent's Hospital, and University of Melbourne, Melbourne, Australia.,Department of Gastroenterology, Monash Health, and School of Clinical Sciences Monash University, Melbourne, VIC, Australia
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48
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Wieringa JW, van der Woude CJ. Effect of biologicals and JAK inhibitors during pregnancy on health-related outcomes in children of women with inflammatory bowel disease. Best Pract Res Clin Gastroenterol 2019; 44-45:101665. [PMID: 32359679 DOI: 10.1016/j.bpg.2019.101665] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 10/14/2019] [Accepted: 12/26/2019] [Indexed: 02/06/2023]
Abstract
Current guidelines advise to maintain immunomodulators and biologicals in pregnant patients because relapse of inflammatory bowel is associated with unfavourable pregnancy outcome. With the exception of Methotrexate, IBD therapy seems not to be related to an increase of congenital malformations or infections requiring hospitalisation of the babies, although the effect the on the developing immune system of the exposed infants remains unknown. In this review we will focus on the effect of IBD drugs on health-related outcomes in children taking into account possible long-term effects of biologicals and immunomodulators, which are transferred across the placenta.
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Affiliation(s)
- J W Wieringa
- Department of Pediatrics, Haaglanden Medical Center and Department of Pediatrics, Subdivision of Infectious Diseases and Immunology, Erasmus MC University Medical Center-Sophia Children's Hospital, Rotterdam, Lijnbaan 32, CK The Hague, 2501, the Netherlands.
| | - C J van der Woude
- Department of Gastroenterology, Erasmus MC University Medical Center, 's Gravendijkwal 230, 3015, CE, Rotterdam, the Netherlands.
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49
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Luu M, Benzenine E, Barkun A, Doret M, Michiels C, Degand T, Quantin C, Bardou M. Safety of first year vaccination in children born to mothers with inflammatory bowel disease and exposed in utero to anti-TNFα agents: a French nationwide population-based cohort. Aliment Pharmacol Ther 2019; 50:1181-1188. [PMID: 31617226 DOI: 10.1111/apt.15504] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 04/30/2019] [Accepted: 08/27/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Children born to mothers with IBD may be exposed to anti-TNFα agents antenatally. Current European guidelines recommend postponing live vaccines until after 6 months of life in this population. Data on the safety of live vaccines administration in the first year of life of these children are sparse with one reported fatality following bacillus Calmette-Guerin (BCG) administration. AIMS To describe the use and safety of vaccines administered in children born to mothers with IBD and exposed antenatally to anti-TNFα agents METHODS: Data from children born to mothers with IBD between 2013 and 2014 were collected retrospectively from the French Health Insurance Database. Vaccines recommended before or at 1 year of age were considered. RESULTS Among 4741 children, 670 (14.1%) were exposed to anti-TNFα agents antenatally, with concomitant thiopurines in 16.0% (n = 107) and steroids in 19.3% (n = 214). Among these 670 children, 315 (47%) were exposed up to delivery. Exposed children were less likely than non-exposed to receive BCG (88/670, 13.1% vs 780/4071, 19.2% respectively, P < .05) and received it later in life (months, mean ± SD, 4.3 ± 3.9 and 2.4 ± 2.9 respectively, P < .001). In exposed children, 64/88 (73%) received BCG vaccination before 6 months of age, but with no BCG-related severe adverse event observed during the first year. Uptake of other vaccines recommended before 6 months was above 85% in both groups. CONCLUSION In children exposed antenatally to anti-TNFα agents, vaccinations are often not postponed in keeping with the recommendations, but no BCG-related severe adverse events were reported in children vaccinated before 6 months of life.
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Affiliation(s)
- Maxime Luu
- Clinical Investigation Center (INSERM 1432), Dijon - Bourgogne University Hospital, Dijon, France.,UFR Sciences Santé, Université Bourgogne Franche-Comté, Dijon, France
| | - Eric Benzenine
- Biostatistics and Bioinformatics Department, Dijon Bourgogne University Hospital, Dijon, France
| | - Alan Barkun
- The McGill University Health Centre, Montreal General Hospital, McGill University, Montreal, Canada
| | - Muriel Doret
- Hôpital Femme-Mère-Enfant Service de Gynécologie Obstétrique, Bron, France
| | - Christophe Michiels
- Division of Gastroenterology, Dijon Bourgogne University Hospital, Dijon, France
| | - Thibault Degand
- Division of Gastroenterology, Dijon Bourgogne University Hospital, Dijon, France
| | - Catherine Quantin
- Biostatistics and Bioinformatics Department, Dijon Bourgogne University Hospital, Dijon, France.,Biostatistics, Biomathematics, Pharmacoepidemiology and Infectious Diseases (B2PHI), UVSQ, Institut Pasteur, Université Paris-Saclay, INSERM, Paris, France
| | - Marc Bardou
- Clinical Investigation Center (INSERM 1432), Dijon - Bourgogne University Hospital, Dijon, France.,UFR Sciences Santé, Université Bourgogne Franche-Comté, Dijon, France
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50
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Lamb CA, Kennedy NA, Raine T, Hendy PA, Smith PJ, Limdi JK, Hayee B, Lomer MCE, Parkes GC, Selinger C, Barrett KJ, Davies RJ, Bennett C, Gittens S, Dunlop MG, Faiz O, Fraser A, Garrick V, Johnston PD, Parkes M, Sanderson J, Terry H, Gaya DR, Iqbal TH, Taylor SA, Smith M, Brookes M, Hansen R, Hawthorne AB. British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults. Gut 2019; 68:s1-s106. [PMID: 31562236 PMCID: PMC6872448 DOI: 10.1136/gutjnl-2019-318484] [Citation(s) in RCA: 1251] [Impact Index Per Article: 250.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 06/10/2019] [Accepted: 06/10/2019] [Indexed: 02/06/2023]
Abstract
Ulcerative colitis and Crohn's disease are the principal forms of inflammatory bowel disease. Both represent chronic inflammation of the gastrointestinal tract, which displays heterogeneity in inflammatory and symptomatic burden between patients and within individuals over time. Optimal management relies on understanding and tailoring evidence-based interventions by clinicians in partnership with patients. This guideline for management of inflammatory bowel disease in adults over 16 years of age was developed by Stakeholders representing UK physicians (British Society of Gastroenterology), surgeons (Association of Coloproctology of Great Britain and Ireland), specialist nurses (Royal College of Nursing), paediatricians (British Society of Paediatric Gastroenterology, Hepatology and Nutrition), dietitians (British Dietetic Association), radiologists (British Society of Gastrointestinal and Abdominal Radiology), general practitioners (Primary Care Society for Gastroenterology) and patients (Crohn's and Colitis UK). A systematic review of 88 247 publications and a Delphi consensus process involving 81 multidisciplinary clinicians and patients was undertaken to develop 168 evidence- and expert opinion-based recommendations for pharmacological, non-pharmacological and surgical interventions, as well as optimal service delivery in the management of both ulcerative colitis and Crohn's disease. Comprehensive up-to-date guidance is provided regarding indications for, initiation and monitoring of immunosuppressive therapies, nutrition interventions, pre-, peri- and postoperative management, as well as structure and function of the multidisciplinary team and integration between primary and secondary care. Twenty research priorities to inform future clinical management are presented, alongside objective measurement of priority importance, determined by 2379 electronic survey responses from individuals living with ulcerative colitis and Crohn's disease, including patients, their families and friends.
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Affiliation(s)
- Christopher Andrew Lamb
- Newcastle University, Newcastle upon Tyne, UK
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Nicholas A Kennedy
- Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
- University of Exeter, Exeter, UK
| | - Tim Raine
- Cambridge University Hospitals NHS FoundationTrust, Cambridge, UK
| | - Philip Anthony Hendy
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
- Imperial College London, London, UK
| | - Philip J Smith
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Jimmy K Limdi
- The Pennine Acute Hospitals NHS Trust, Manchester, UK
- University of Manchester, Manchester, UK
| | - Bu'Hussain Hayee
- King's College Hospital NHS Foundation Trust, London, UK
- King's College London, London, UK
| | - Miranda C E Lomer
- King's College London, London, UK
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Gareth C Parkes
- Barts Health NHS Trust, London, UK
- Barts and the London School of Medicine and Dentistry, London, UK
| | - Christian Selinger
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
- University of Leeds, Leeds, UK
| | | | - R Justin Davies
- Cambridge University Hospitals NHS FoundationTrust, Cambridge, UK
- University of Cambridge, Cambridge, UK
| | - Cathy Bennett
- Systematic Research Ltd, Quorn, UK
- Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
| | | | - Malcolm G Dunlop
- University of Edinburgh, Edinburgh, UK
- Western General Hospital, Edinburgh, UK
| | - Omar Faiz
- Imperial College London, London, UK
- St Mark's Hospital, Harrow, UK
| | - Aileen Fraser
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | | | | | - Miles Parkes
- Cambridge University Hospitals NHS FoundationTrust, Cambridge, UK
| | - Jeremy Sanderson
- King's College London, London, UK
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Daniel R Gaya
- Glasgow Royal Infirmary, Glasgow, UK
- University of Glasgow, Glasgow, UK
| | - Tariq H Iqbal
- Queen Elizabeth Hospital Birmingham NHSFoundation Trust, Birmingham, UK
- University of Birmingham, Birmingham, UK
| | - Stuart A Taylor
- University College London, London, UK
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Melissa Smith
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
- Brighton and Sussex Medical School, Brighton, UK
| | - Matthew Brookes
- Royal Wolverhampton NHS Trust, Wolverhampton, UK
- University of Wolverhampton, Wolverhampton, UK
| | - Richard Hansen
- Royal Hospital for Children Glasgow, Glasgow, UK
- University of Glasgow, Glasgow, UK
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