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Wu H, Shen YN, Wu Z, Mao F, Ren YG, Zhang L. Ustekinumab in the Treatment of Generalized Pustular Psoriasis in a Pregnant Patient. Clin Cosmet Investig Dermatol 2024; 17:1107-1110. [PMID: 38765193 PMCID: PMC11102752 DOI: 10.2147/ccid.s451738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Accepted: 04/08/2024] [Indexed: 05/21/2024]
Abstract
Although the use of biologics has led to great improvement in psoriasis patients, the treatment of psoriasis during pregnancy still faces many challenges. We herein report on a 29-year-old pregnant woman treated with ustekinumab for generalized pustular psoriasis. Upon becoming pregnant, the woman underwent continued treatment with ustekinumab in the first trimester. We also considered the need for neonatal vaccination. The patient discontinued ustekinumab therapy in the second trimester, and during the period of drug discontinuation we noted a slight rash recurrence. The patient was treated with ultraviolet B phototherapy and topical corticosteroids, and the rash was localized to the abdomen. However, in the 27th week of pregnancy, the patient was infected with COVID-19, which made the condition worse. The rash erupted rapidly and spread throughout her body, and she experienced a high fever with her blood count showing augmented numbers of white blood cells. The patients self-administered 0.3 g of acetaminophen three times per day, and after four days her core body temperature was 38.0°C; the rash, however, did not diminish. We diagnosed an outbreak of generalized pustular psoriasis and treated the patient with ustekinumab. The rash resolved quickly, and a healthy newborn was delivered by caesarean section at 39 weeks.
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Affiliation(s)
- Hao Wu
- Department of Dermatology, Ningbo No 6 Hospital, Ningbo, 315040, People’s Republic of China
| | - Yan Na Shen
- Department of Dermatology, Ningbo No 6 Hospital, Ningbo, 315040, People’s Republic of China
| | - Zhongxiao Wu
- Department of Dermatology, Ningbo No 6 Hospital, Ningbo, 315040, People’s Republic of China
| | - Feng Mao
- Department of Dermatology, Ningbo No 6 Hospital, Ningbo, 315040, People’s Republic of China
| | - You Gang Ren
- Department of Dermatology, Ningbo No 6 Hospital, Ningbo, 315040, People’s Republic of China
| | - Li Zhang
- Department of Dermatology, Ningbo No 6 Hospital, Ningbo, 315040, People’s Republic of China
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Sánchez-García V, Hernández-Quiles R, de-Miguel-Balsa E, Giménez-Richarte Á, Ramos-Rincón JM, Belinchón-Romero I. Exposure to biologic therapy before and during pregnancy in patients with psoriasis: Systematic review and meta-analysis. J Eur Acad Dermatol Venereol 2023; 37:1971-1990. [PMID: 37262303 DOI: 10.1111/jdv.19238] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 05/10/2023] [Indexed: 06/03/2023]
Abstract
Biologicals have transformed the management of severe disease phenotypes in psoriasis and are often prescribed in women of childbearing age. However, information on safety of biologicals in pregnancy are lacking. We conducted a systematic review and meta-analysis aimed to describe the characteristics and pregnancy outcomes in women with psoriasis exposed to biologics within 3 months before or during pregnancy, and to estimate the pooled prevalence of spontaneous, elective and total abortions, and congenital malformations in their newborns. Bibliographic searches were performed in the PubMed, Embase, Scopus and Web of Science databases up to 14 April 2022. No restrictions on sample size or publication date were applied. Review performance complied with PRISMA guidelines, and two reviewers assessed randomized controlled trials and nonrandomized studies reporting pregnancy outcomes in women exposed to biologics indicated for psoriasis during the pre-gestational and/or gestational period. Studies focusing on rheumatologic or gastroenterological immune-mediated inflammatory diseases were excluded. Regardless of data heterogeneity, a random-effects model was used to pool prevalence estimates. We included 51 observational studies, involving 739 pregnancies exposed to approved biologics for psoriasis. Administration was mostly (70.4%) limited to the first trimester, and the most common drug was ustekinumab (36.0%). The estimated prevalence of miscarriage was 15.3% (95% confidence interval [CI] 12.7-18.0) and elective abortions, 10.8% (95% CI 7.7-14.3). Congenital malformations occurred in about 3.0% (95% CI 1.6-4.8) of live births exposed to biologics during pregnancy. Altogether, exposure to biologics for psoriasis during pregnancy and/or conception does not seem to be associated with an increased risk of miscarriage/abortion or congenital malformations, showing similar rates to the general population. These results suggest that biologic drugs are safe and pose an acceptable risk to the foetuses/neonates.
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Affiliation(s)
- V Sánchez-García
- Dermatology Department, Dr. Balmis General University Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - R Hernández-Quiles
- Dermatology Department, Dr. Balmis General University Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - E de-Miguel-Balsa
- Department of Clinical Medicine, Miguel Hernández University, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | | | - J M Ramos-Rincón
- Department of Clinical Medicine, Miguel Hernández University, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - I Belinchón-Romero
- Dermatology Department, Dr. Balmis General University Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
- Department of Clinical Medicine, Miguel Hernández University, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
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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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Di Cesare A, Ricceri F, Rosi E, Fastame MT, Prignano F. Therapy of PsO in Special Subsets of Patients. Biomedicines 2022; 10:2879. [PMID: 36359399 PMCID: PMC9687729 DOI: 10.3390/biomedicines10112879] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 10/17/2022] [Accepted: 10/27/2022] [Indexed: 01/02/2024] Open
Abstract
Psoriasis is a chronic, inflammatory skin disease that may occur at any age, with a bimodal peak of incidence around the age of 16-20 years of age (early onset) and 57-60 years (late-onset). It is estimated that roughly 70% of patients develop the disease before the age of 40, which coincides with the reproductive years. Moreover, psoriasis is a chronic disease, meaning that, with increased life-duration expectancy, the number of patients affected with psoriasis aged over 65 years is going to increase and represent a big therapeutic challenge. Actually, no specific drug recommendation is available, based only on the age of the patients, while therapeutic prescription should take into account that elderly patients have more comorbidities than younger patients, with polypharmacy and an increased risk of drug interactions. Women with psoriasis are more likely to report a worse influence of the disease on their quality of life, and they are more susceptible to the development of depression. Furthermore, pregnancy and lactation represent a major contraindication to several systemic agents, and only a few studies exist providing the safety of certain drugs during these periods of life of a woman, such as certolizumab pegol. In this paper, we discuss systemic therapeutic strategies, including conventional and biological therapies, in a special subset of patients affected with moderate-to-severe psoriasis focusing on elderly patients and on female patients in fertile age, pregnancy, and lactation.
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Affiliation(s)
| | | | | | | | - Francesca Prignano
- Department of Health Sciences, Section of Dermatology, University of Florence, 50125 Florence, Italy
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Bucur Ș, Savu AP, Stănescu AMA, Șerban ED, Nicolescu AC, Constantin T, Bobircă A, Constantin MM. Oversight and Management of Women with Psoriasis in Childbearing Age. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:780. [PMID: 35744043 PMCID: PMC9227010 DOI: 10.3390/medicina58060780] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 05/31/2022] [Accepted: 06/04/2022] [Indexed: 11/16/2022]
Abstract
Psoriasis is a complex disease with many associated comorbidities, all of which have a negative impact on a patient's personal, social, and sexual life. There are some unique considerations in the effects of this disease among women. The average age of diagnosis in women with psoriasis is 28 years, and this onset corresponds to the fertile life of women. There is conflicting information about the effects of psoriasis on female fertility. Some studies suggest that this condition's associated comorbidities, personal behaviors, and reduced ovarian reserve, especially due to chronic inflammation, affect women's fertility. Another possible reason women with psoriasis are less likely to become pregnant is that their sexual intercourse frequency decreases after the condition's onset. The available information on the effects of pregnancy on women with psoriasis is limited. According to current evidence, most women will experience an improvement in their skin condition. Studies show that patients with moderate-to-severe psoriasis are more prone to experience pregnancy complications. The management of pregnant and lactating women with psoriasis is also difficult, as the safety profile of commonly used drugs in patients with psoriasis is not entirely known.
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Affiliation(s)
- Ștefana Bucur
- Department of Family Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (Ș.B.); (A.-C.N.); (T.C.); (A.B.); (M.-M.C.)
| | | | - Ana Maria Alexandra Stănescu
- Department of Family Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (Ș.B.); (A.-C.N.); (T.C.); (A.B.); (M.-M.C.)
| | - Elena-Daniela Șerban
- 2nd Department of Dermatology, Colentina Clinical Hospital, 020125 Bucharest, Romania;
| | - Alin-Codruț Nicolescu
- Department of Family Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (Ș.B.); (A.-C.N.); (T.C.); (A.B.); (M.-M.C.)
- Roma Medical Center for Diagnosis and Treatment, 011773 Bucharest, Romania
| | - Traian Constantin
- Department of Family Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (Ș.B.); (A.-C.N.); (T.C.); (A.B.); (M.-M.C.)
- Department of Urology, “Prof. Dr. Theodor Burghele” Hospital, 050659 Bucharest, Romania
| | - Anca Bobircă
- Department of Family Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (Ș.B.); (A.-C.N.); (T.C.); (A.B.); (M.-M.C.)
- Department of Internal Medicine and Rheumatology, “Dr. I. Cantacuzino” Hospital, 073206 Bucharest, Romania
| | - Maria-Magdalena Constantin
- Department of Family Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (Ș.B.); (A.-C.N.); (T.C.); (A.B.); (M.-M.C.)
- 2nd Department of Dermatology, Colentina Clinical Hospital, 020125 Bucharest, Romania;
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Actualización práctica de las recomendaciones del Grupo de Psoriasis de la Academia Española de Dermatología y Venereología (GPS) para el tratamiento de la psoriasis con terapia biológica. Parte 2 «Manejo de poblaciones especiales, pacientes con comorbilidad y gestión del riesgo». ACTAS DERMO-SIFILIOGRAFICAS 2022; 113:583-609. [DOI: 10.1016/j.ad.2022.01.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 01/26/2022] [Indexed: 12/19/2022] Open
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7
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Carrascosa JM, Puig L, Romero IB, Salgado-Boquete L, Del Alcázar E, Lencina JJA, Moreno D, de la Cueva P. [Translated article] Practical Update of the Guidelines Published by the Psoriasis Group of the Spanish Academy of Dermatology and Venereology (GPs) on the Treatment of Psoriasis With Biologic Agents: Part 2-Management of Special Populations, Patients With Comorbid Conditions, and Risk. ACTAS DERMO-SIFILIOGRAFICAS 2022; 113:T583-T609. [PMID: 35748004 DOI: 10.1016/j.ad.2022.01.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 01/26/2022] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Since its inception, the Psoriasis Group (GPs) of the Spanish Academy of Dermatology and Venereology (AEDV) has worked to continuously update recommendations for the treatment of psoriasis based on the best available evidence and incorporating proposals arising from and aimed at clinical practice. An updated GPs consensus document on the treatment of moderate to severe psoriasis was needed because of changes in the treatment paradigm and the approval in recent years of a large number of new biologic agents. METHODOLOGY The consensus document was developed using the nominal group technique complemented by a scoping review. First, a designated coordinator selected a group of GPs members for the panel based on their experience and knowledge of psoriasis. The coordinator defined the objectives and key points for the document and, with the help of a documentalist, conducted a scoping review of articles in Medline, Embase, and the Cochrane Library up to January 2021. The review included systematic reviews and meta-analyses as well as clinical trials not included in those studies and high-quality real-world studies. National and international clinical practice guidelines and consensus documents on the management of moderate to severe psoriasis were also reviewed. The coordinator then drew up a set of proposed recommendations, which were discussed and modified in a nominal group meeting. After several review processes, including external review by other GPs members, the final document was drafted. RESULTS The present guidelines include updated recommendations on assessing the severity of psoriasis and criteria for the indication of systemic treatment. They also include general principles for the treatment of patients with moderate to severe psoriasis and define treatment goals for these patients as well as criteria for the indication and selection of initial and subsequent therapies Practical issues, such as treatment failure and maintenance of response, are also addressed.
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Affiliation(s)
- J M Carrascosa
- Departamento de Dermatología, Hospital Universitari Germans Trias I Pujol, Badalona, Universitat Autònoma de Barcelona, IGTP, Barcelona, Spain.
| | - L Puig
- Departamento de Dermatología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - I B Romero
- Departamento de Dermatología, Hospital General Universitario de Alicante-ISABIAL - Universidad Miguel Hernández de Elche, Alicante, Spain
| | - L Salgado-Boquete
- Departamento de Dermatología, Complejo Hospitalario Universitario de Pontevedra, Pontevedra, Spain
| | - E Del Alcázar
- Departamento de Dermatología, Hospital Universitari Germans Trias I Pujol, Badalona, Universitat Autònoma de Barcelona, IGTP, Barcelona, Spain
| | - J J A Lencina
- Servicio de Dermatología, Hospital Universitario Vega Baja, Alicante, Spain
| | - D Moreno
- Departamento de Dermatología, Hospital Universitario Virgen Macarena, Universidad de Sevilla, Sevilla, Spain
| | - P de la Cueva
- Servicio de Dermatología, Hospital Universitario Infanta Leonor, Universidad Complutense de Madrid, Madrid, Spain
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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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9
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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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Honap S, Meade S, Ibraheim H, Irving PM, Jones MP, Samaan MA. Effectiveness and Safety of Ustekinumab in Inflammatory Bowel Disease: A Systematic Review and Meta-Analysis. Dig Dis Sci 2022; 67:1018-1035. [PMID: 33723700 DOI: 10.1007/s10620-021-06932-4] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 02/26/2021] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Ustekinumab, an interleukin-12 and interleukin-23 antagonist, is licensed for the treatment of Crohn's disease (CD) and ulcerative colitis (UC) after the phase III trial programs demonstrated efficacy over placebo. However, these findings may not be directly transferable to the real-world due to the stringent inclusion criteria of clinical trials. METHODS We conducted a systematic review and meta-analysis of the safety and effectiveness of ustekinumab in inflammatory bowel disease (IBD). A systematic literature search was conducted via Medline and Embase from inception to April 21, 2020. Observational studies assessing ustekinumab's safety and effectiveness by reporting response, remission and/or adverse events (AE) in either CD or UC were included. Two reviewers independently assessed risk of bias and extracted study data. Random-effects meta-analysis was performed to pool rates of clinical response, remission, and safety data. RESULTS Following deduplication, 2147 records were identified of which 41 studies (38 CD, 3 UC) comprising 4400 patients were included for quantitative analysis. Pooled clinical remission rates for CD were 34% (95% CI, 26%-42%) following induction and 31% (95% CI, 25%-38%) at one year. For UC, post-induction clinical remission rates were 39% (95% CI, 23%-56%). Serious AEs were reported in 5.6% of patients. Pregnancy outcomes were similar to the general population. One-third of patients with active baseline perianal disease responded or had fistula healing with ustekinumab. CONCLUSIONS In the most comprehensive systematic review and meta-analysis to date, and the first to include UC, ustekinumab was shown to be effective and safe in the real-world treatment of IBD.
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Affiliation(s)
- Sailish Honap
- IBD Centre, 1st Floor IBD Centre, Westminster Bridge Road, St Thomas Hospital, Guys and St Thomas NHS Foundation Trust, London, SE1 7EH, UK. .,School of Immunology and Microbial Sciences, Kings College London, London, UK.
| | - Susanna Meade
- IBD Centre, 1st Floor IBD Centre, Westminster Bridge Road, St Thomas Hospital, Guys and St Thomas NHS Foundation Trust, London, SE1 7EH, UK
| | - Hajir Ibraheim
- Department of Metabolism, Digestion and Reproduction, Norfolk Place, St Marys Campus, Imperial College London, London, W2 1PG, UK
| | - Peter M Irving
- IBD Centre, 1st Floor IBD Centre, Westminster Bridge Road, St Thomas Hospital, Guys and St Thomas NHS Foundation Trust, London, SE1 7EH, UK.,School of Immunology and Microbial Sciences, Kings College London, London, UK
| | - Michael P Jones
- Center for Emotional Health, Department of Psychology, Macquarie University, New South Wales, NSW, 2109, Australia
| | - Mark A Samaan
- IBD Centre, 1st Floor IBD Centre, Westminster Bridge Road, St Thomas Hospital, Guys and St Thomas NHS Foundation Trust, London, SE1 7EH, UK
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Nguyen H, Ahmed K, Luo W, Flint J, Giles I. A Systematic Review of the safety of non-TNF inhibitor biologic and targeted synthetic drugs in rheumatic disease in pregnancy. Semin Arthritis Rheum 2021; 51:1205-1217. [PMID: 34689007 DOI: 10.1016/j.semarthrit.2021.09.004] [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: 07/06/2021] [Revised: 08/07/2021] [Accepted: 09/13/2021] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Despite increasing evidence to support safe use of tumour necrosis factor inhibitors (TNFi) and other biologic disease modifying anti-rheumatic drugs (bDMARDs) during pre-conception/pregnancy, there remains a paucity of evidence regarding the safety and compatibility of other non-TNFi and novel targeted synthetic (ts)DMARDs during pre-conception/pregnancy. Therefore, we conducted a systematic review to determine the compatibility of these drugs in pre-conception, during pregnancy and post-partum period. METHOD Databases including; EMBASE, Pubmed (MEDLINE), and Cochrane were searched up to 23rd October 2020 to find relevant peer-reviewed papers, using keywords including; rheumatic disease, pregnancy, conception/pre-conception, lactation/breastfeeding, childhood and vaccination/infection, and commonly prescribed non-TNFi drugs and tsDMARDs. RESULTS Our search yielded 1483 papers that were screened independently by two authors, and 109 full-text papers were eligible for final analysis. These studies reported 1291 maternal pregnancies exposed to non-TNFi bDMARDs and tsDMARDs with known outcomes, including 721 live births, 219 spontaneous miscarriages and 27 congenital abnormalities. Paternal exposures in 174 pregnancies had reassuring outcomes. A total of 48 breast-fed infants were exposed to non-TNFi bDMARDs and no adverse events reported upon long-term follow-up. Fifteen infants exposed to bDMARDs received normal vaccination regimes, including live vaccines, and had normal developmental outcomes, without any complications or infections. CONCLUSION Overall, the findings are reassuring and do not suggest a cause for any major concerns or an increased risk of adverse pregnancy outcomes for maternal or paternal exposures to non-TNFi bDMARDs or tsDMARDs. There were no major concerns for breastfeeding exposures to non-TNFi bDMARDs.
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Affiliation(s)
- Hanh Nguyen
- Centre for Rheumatology Research, Rayne Institute, University College London (UCL), London, UK
| | | | - Weike Luo
- University College London (UCL), London, UK
| | | | - Ian Giles
- Centre for Rheumatology Research, Rayne Institute, University College London (UCL), London, UK; Department of Rheumatology, University College London Hospital, London, UK.
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Thatiparthi A, Martin A, Liu J, Egeberg A, Wu JJ. Biologic Treatment Algorithms for Moderate-to-Severe Psoriasis with Comorbid Conditions and Special Populations: A Review. Am J Clin Dermatol 2021; 22:425-442. [PMID: 33861409 PMCID: PMC8051287 DOI: 10.1007/s40257-021-00603-w] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/27/2021] [Indexed: 02/06/2023]
Abstract
The emergence of data from clinical trials of biologics, the approval of new biologics, and our improved understanding of psoriasis pathogenesis have increased the therapeutic possibilities for the treatment of moderate-to-severe psoriasis. Biologics currently approved for the treatment of psoriasis include tumor necrosis factor inhibitors, interleukin (IL)-17 inhibitors, ustekinumab (an IL-12/23 inhibitor), and IL-23 inhibitors. Data from clinical trials and studies of the safety and efficacy of biologics provide essential information for the personalization of patient care. We discuss the benefits and disadvantages of biologics as a first-line treatment choice, update treatment recommendations according to current evidence, and propose psoriasis treatment algorithms. Our discussion includes the following comorbid conditions: psoriatic arthritis, multiple sclerosis, congestive heart failure, inflammatory bowel disease, hepatitis B, nonmelanoma skin cancer, lymphoma, and latent tuberculosis. We make evidence-based treatment recommendations for special populations, including pediatric patients, patients with coronavirus 2019 (COVID-19), and pregnant and breastfeeding patients with psoriasis. Ultimately, individualized recommendations that consider patient preferences, disease severity, comorbid conditions, and additional risk factors should be offered to patients and updated as new trial data emerges.
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Laube R, Paramsothy S, Leong RW. Review of pregnancy in Crohn's disease and ulcerative colitis. Therap Adv Gastroenterol 2021; 14:17562848211016242. [PMID: 34046084 PMCID: PMC8135214 DOI: 10.1177/17562848211016242] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 04/19/2021] [Indexed: 02/04/2023] Open
Abstract
Inflammatory bowel disease (IBD) frequently affects women of childbearing age and can have implications in pregnancy. Most women with IBD have comparable fertility with women in the general population. Fertility is reduced in women with active disease or previous ileal-pouch-anal anastomosis (IPAA) surgery and is temporarily reduced in men taking sulfasalazine. Women with IBD have an increased risk of preterm delivery, low birth weight, small-for-gestational-age infants and Cesarean section (CS) delivery, however, no increased risk of congenital abnormalities. These adverse outcomes are particularly prevalent for women with active IBD compared with those with quiescent disease. Conception should occur during disease remission to optimize maternal and fetal outcomes and reduce the risk of disease exacerbations during pregnancy. Pre-conception counseling is therefore pertinent to provide patient education, medication review for risk of teratogenicity and objective disease assessment. Most medications are safe during pregnancy and breastfeeding, with the exception of methotrexate, ciclosporin, allopurinol and tofacitinib. Delivery modality should be guided by obstetric factors in most cases; however, CS is recommended for women with active perianal disease and can be considered for women with inactive perianal disease or IPAA. In conclusion, most women with IBD have uncomplicated pregnancies. Active IBD is the predominant predictor of poor outcomes and disease exacerbations; therefore, maintenance of disease remission during and before pregnancy is crucial.
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Affiliation(s)
- Robyn Laube
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
- Department of Gastroenterology, Macquarie University Hospital, Sydney, NSW, Australia
| | - Sudarshan Paramsothy
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
- Department of Gastroenterology, Macquarie University Hospital, Sydney, NSW, Australia
- Department of Gastroenterology and Hepatology, Concord Repatriation General Hospital, Sydney, Australia
| | - Rupert W. Leong
- Department of Gastroenterology and Hepatology, Concord Repatriation General Hospital, Hospital Road, Concord, NSW 2137, Australia
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
- Department of Gastroenterology, Macquarie University Hospital, Sydney, NSW, Australia
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Gisbert JP, Chaparro M. Safety of New Biologics (Vedolizumab and Ustekinumab) and Small Molecules (Tofacitinib) During Pregnancy: A Review. Drugs 2021; 80:1085-1100. [PMID: 32562207 DOI: 10.1007/s40265-020-01346-4] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Two new biological drugs (vedolizumab and ustekinumab) and one small molecule (tofacitinib) have been recently approved for the treatment of inflammatory bowel disease. Therefore, we must be familiar with the safety of these "new" drugs during pregnancy and breastfeeding. In the present article, we critically review available data on the safety of new biologics (vedolizumab and ustekinumab) and small molecules (tofacitinib) during pregnancy and breastfeeding, with special focus on women with inflammatory bowel disease. Bibliographical searches (MEDLINE) up to April 2020 were performed. The timing and mechanisms of placental transfer of vedolizumab and ustekinumab are expected to be similar to anti-TNF agents. Animal studies show no evidence of adverse effects on pre- or post-natal development after administration of vedolizumab and ustekinumab. Just a few studies including patients treated with vedolizumab or ustekinumab during pregnancy have been published, reporting uneventful pregnancies in most cases. The clinical programme of both drugs and post-marketing studies showed no new safety concerns. Due to the expected safety of vedolizumab and ustekinumab during pregnancy, it may be recommended to plan the final pregnancy dose approximately 8 or 12 weeks, respectively, before the estimated date of delivery. Live vaccines should be avoided for up to a year in children exposed in utero to vedolizumab or ustekinumab unless drug elimination has been documented. Miniscule amounts of vedolizumab and ustekinumab are transferred to breast milk, so breastfeeding is probably safe. There is no evidence of adverse effect of vedolizumab or ustekinumab paternal exposure. Regarding tofacitinib, it is reasonable to assume that this molecule crosses the placenta from the beginning of pregnancy. In animal studies, tofacitinib was feticidal and teratogenic in rats and rabbits, although at exposures many times greater than the standard human dose. Reported outcomes of pregnancy cases identified from tofacitinib randomised controlled trials, post-approval and non-interventional studies, and spontaneous adverse-event reporting appear similar to those observed in the general population. Nevertheless, at present, the use of tofacitinib during pregnancy should be avoided. Although no human studies have reported outcomes of breastfeeding with small molecules such as tofacitinib, this drug is present in lactating rat milk so, at present, breastfeeding should be avoided. Pregnancy among patients with paternal exposure to tofacitinib appears to be safe. In summary, we can conclude that new biologic agents (vedolizumab and ustekinumab) and small molecules (tofacitinib) should be used during pregnancy only if the benefits to the mother outweigh the risks to the mother and unborn child.
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Affiliation(s)
- Javier P Gisbert
- Gastroenterology Unit, Hospital Universitario de la Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Diego de León, 62, 28006, Madrid, Spain.
| | - María Chaparro
- Gastroenterology Unit, Hospital Universitario de la Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Diego de León, 62, 28006, Madrid, Spain
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15
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Belinchón I, Velasco M, Ara-Martín M, Armesto Alonso S, Baniandrés Rodríguez O, Ferrándiz Pulido L, García-Bustinduy M, Martínez-López JA, Martínez Sánchez N, Pérez Ferriols A, Pérez Pascual E, Rivera Díaz R, Ruiz-Villaverde R, Taberner Ferrer R, Vicente Villa A, Carrascosa JM. Management of Psoriasis During Preconception, Pregnancy, Postpartum, and Breastfeeding: A Consensus Statement. ACTAS DERMO-SIFILIOGRAFICAS 2021; 112:225-241. [PMID: 33065101 DOI: 10.1016/j.ad.2020.10.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 10/02/2020] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVE To develop evidence- and experience-based recommendations for the management of psoriasis during preconception, pregnancy, postpartum, and breastfeeding. METHODS The nominal group technique and the Delphi method were used. Fifteen experts (12 dermatologists, 2 of whom were appointed coordinators; 1 rheumatologist; and 2 gynecologists) were selected to form an expert panel. Following a systematic review of the literature on fertility, pregnancy, postpartum, and breastfeeding in women with psoriasis, the coordinators drew up a series of preliminary recommendations for discussion by the panel at a nominal group meeting. The experts defined the scope, sections, and intended users of the statement and prepared a final list of recommendations. Consensus was obtained using a Delphi process in which an additional 51 dermatologists rated their level of agreement with each recommendation on a scale of 1 (total disagreement) to 10 (total agreement). Consensus was defined by a score of 7 or higher assigned by at least 70% of participants. Level of evidence and strength of recommendation were reported using the Oxford Center for Evidence-Based Medicine categories. The final statement was approved by the expert panel. RESULTS The resulting consensus statement includes 23 recommendations on preconception (fertility and contraception), pregnancy (planning, pharmacological management, and follow-up), and breastfeeding (management and follow-up). Consensus was achieved for all recommendations generated except one. CONCLUSIONS These recommendations for the better management of psoriasis in women of childbearing age could improve outcomes and prognosis.
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Affiliation(s)
- I Belinchón
- Servicio de Dermatología, Hospital General Universitario de Alicante-ISABIAL-UMH, Alicante, España.
| | - M Velasco
- Servicio de Dermatología, Hospital Universitario Arnau de Vilanova, Valencia, España
| | - M Ara-Martín
- Servicio de Dermatología, Hospital Clínico Lozano Blesa, Zaragoza, España
| | - S Armesto Alonso
- Servicio de Dermatología, Hospital Universitario Marqués de Valdecilla, Santander, España
| | | | - L Ferrándiz Pulido
- Servicio de Dermatología, Hospital Universitario Virgen Macarena, Sevilla, España
| | - M García-Bustinduy
- Servicio de Dermatología, Hospital Universitario de Canarias, Santa Cruz de Tenerife, España
| | - J A Martínez-López
- Servicio de Reumatología, Hospital Universitario Fundación Jiménez Díaz, Madrid, España
| | - N Martínez Sánchez
- Servicio de Ginecología-Obstetricia, Hospital Universitario La Paz, Madrid, España
| | - A Pérez Ferriols
- Servicio de Dermatología, Hospital General de Valencia, Valencia, España
| | - E Pérez Pascual
- Servicio de Ginecología-Obstetricia, Hospital General Universitario de Alicante-ISABIAL, Alicante, España
| | - R Rivera Díaz
- Servicio de Dermatología, Hospital Universitario 12 de Octubre, Madrid, España
| | - R Ruiz-Villaverde
- Servicio de Dermatología, Hospital Universitario San Cecilio, Granada, España
| | - R Taberner Ferrer
- Servicio de Dermatología, Hospital Son Llàtzer, Palma de Mallorca, España
| | - A Vicente Villa
- Servicio de Dermatología, Hospital Sant Joan de Déu, Esplugues de Llobregat, Barcelona, España
| | - J M Carrascosa
- Servicio de Dermatología, Hospital Universitario Germans Trias i Pujol, Badalona, Barcelona, España
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16
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Belinchón I, Velasco M, Ara-Martín M, Armesto Alonso S, Baniandrés Rodríguez O, Ferrándiz Pulido L, García-Bustinduy M, Martínez-López J, Martínez Sánchez N, Pérez Ferriols A, Pérez Pascual E, Rivera Díaz R, Ruiz-Villaverde R, Taberner Ferrer R, Vicente Villa A, Carrascosa J. Management of Psoriasis During Preconception, Pregnancy, Postpartum, and Breastfeeding: A Consensus Statement. ACTAS DERMO-SIFILIOGRAFICAS 2021. [DOI: 10.1016/j.adengl.2020.10.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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17
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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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18
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Chhabra G, Chanana C, Verma P, Saxena A. Impetigo herpetiformis responsive to secukinumab. Dermatol Ther 2019; 32:e13040. [PMID: 31361940 DOI: 10.1111/dth.13040] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 07/20/2019] [Accepted: 07/24/2019] [Indexed: 11/28/2022]
Abstract
Treatment of pustular psoriasis in pregnancy is often difficult to manage and is hampered by limited treatment options. We describe herein a patient who was treated with secukinumab after an unsatisfying response to oral steroids and cyclosporin.
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Affiliation(s)
- Geetika Chhabra
- Department of Dermatology & STD, Vardhaman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | - Charvi Chanana
- Department of Dermatology & STD, Vardhaman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | - Prashant Verma
- Department of Dermatology & STD, Vardhaman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | - Ashok Saxena
- Department of Dermatology & STD, Vardhaman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
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19
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Soh MC, Moretto M. The use of biologics for autoimmune rheumatic diseases in fertility and pregnancy. Obstet Med 2019; 13:5-13. [PMID: 32284726 DOI: 10.1177/1753495x19841799] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 03/10/2019] [Indexed: 12/18/2022] Open
Abstract
In an age where autoimmune rheumatic diseases are successfully managed with biologics, their discontinuation in pregnancy is inadvisable without careful forethought; maternal disease activity is associated with adverse pregnancy outcomes, which has long-term implications for both mother and offspring. We aim to provide clinicians with the necessary tools to facilitate decision-making - when a biologic should be used, when it can be discontinued in pregnancy if appropriate. The pathophysiology of these biologic molecules and their effect on fertility, pregnancy and parturition are discussed. A summary of the 2016 international guidelines (European League Against Rheumatism and British Society in Rheumatology) on biologics in pregnancy has been tabulated; more recent publications are discussed in depth. Data on transplacental-transfer ratios and breastmilk excretion rates are also included. Biologic effects on organogenesis, their implications for the exposed infant in terms of infection risks and vaccination requirements are included, and future directions for research proposed.
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Affiliation(s)
- May Ching Soh
- Department of Rheumatology, Tauranga Hospital, Bay of Plenty District Health Board, Tauranga, New Zealand.,Department of Obstetrics and Gynaecology, Elizabeth Rothwell Building, Waikato Hospital, Waikato District Health Board, Hamilton, New Zealand.,Women's Health Academic Centre, King's College London, London, UK
| | - Marcelo Moretto
- Department of Gynaecology, Hospital São Lucas da Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brazil.,Clínica Generar-Human Reproduction, Porto Alegre, Brazil
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20
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Puchner A, Gröchenig HP, Sautner J, Helmy-Bader Y, Juch H, Reinisch S, Högenauer C, Koch R, Hermann J, Studnicka-Benke A, Weger W, Puchner R, Dejaco C. Immunosuppressives and biologics during pregnancy and lactation : A consensus report issued by the Austrian Societies of Gastroenterology and Hepatology and Rheumatology and Rehabilitation. Wien Klin Wochenschr 2019; 131:29-44. [PMID: 30643992 PMCID: PMC6342891 DOI: 10.1007/s00508-019-1448-y] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 12/06/2018] [Indexed: 12/14/2022]
Abstract
An increasing and early-onset use of immunosuppressives and biologics has become more frequently seen among patients with inflammatory bowel diseases (IBD) and rheumatic disorders. Many women in their childbearing years currently receive such medications, and some of them in an interdisciplinary setting. Many questions arise in women already pregnant or wishing to conceive with respect to continuing or discontinuing treatment, the risks borne by the newborns and their mothers and long-term safety. Together with the Austrian Society of Rheumatology and Rehabilitation, the IBD working group of the Austrian Society of Gastroenterology and Hepatology has elaborated consensus statements on the use of immunosuppressives and biologics in pregnancy and lactation. This is the first Austrian interdisciplinary consensus on this topic. It is intended to serve as a basis and support for providing advice to our patients and their treating physicians.
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Affiliation(s)
- Antonia Puchner
- Division of Rheumatology, Third Medical Department, Medical University of Vienna/Vienna General Hospital, Vienna, Austria
| | - Hans Peter Gröchenig
- Medical Department, Hospital of the Brothers of Mercy, St. Veit an der Glan, Austria
| | - Judith Sautner
- Second Medical Department, Korneuburg-Stockerau Hospital/Lower Austrian Center for Rheumatology, Stockerau, Austria
| | - Yvonne Helmy-Bader
- Department of Obstetrics and Gynecology, Medical University of Vienna, Vienna, Austria
| | - Herbert Juch
- Department of Cell Biology, Histology and Embryology, Medical University of Graz, Graz, Austria
| | - Sieglinde Reinisch
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Christoph Högenauer
- Division of Gastroenterology and Hepatology, Medical Department, Medical University of Graz, Graz, Austria
| | - Robert Koch
- Division of Gastroenterology, First Medical Department, Medical University of Innsbruck, Innsbruck, Austria
| | - Josef Hermann
- Division of Rheumatology and Immunology, Medical Department, Medical University of Graz, Graz, Austria
| | | | - Wolfgang Weger
- Department of Dermatology and Venereology, Medical University of Graz, Graz, Austria
| | - Rudolf Puchner
- Division of Rheumatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Clemens Dejaco
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria.
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21
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Plachouri KM, Georgiou S. Special aspects of biologics treatment in psoriasis: management in pregnancy, lactation, surgery, renal impairment, hepatitis and tuberculosis. J DERMATOL TREAT 2018; 30:668-673. [PMID: 30428753 DOI: 10.1080/09546634.2018.1544413] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Background of the article: Biologics are modern immunomodulatory drugs, whose use in the treatment of psoriasis has led to remarkable results in psoriatic patients. The administration of these agents in special population groups, such as patients with chronic infections and renal impairment, as well as perioperative, pregnant or lactating patients, has not been thoroughly addressed, mostly because these patients are excluded from clinical studies. Materials and methods: This report is an updated systematic overview of the use of biologics in the above-mentioned types of patients and was conducted according to the PRISMA Guidelines for systematic reviews. Articles derived from the databases PubMed, EMBASE and SCOPUS, published between 1999 and 2018, were analyzed for the study. Results: Research efforts as well as clinical reporting are necessary in order to provide more insight on the management of these therapeutic dilemmas. Conclusion: The aim of this review, other than providing a summarized update on the clinical knowledge on this special topic, is also to raise awareness for the need to conduct larger systematic studies in order to adequately evaluate the use of biologics in these special patient categories and therefore draw definite conclusions on their safety profile.
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Affiliation(s)
- Kerasia-Maria Plachouri
- a Dermatology Department, University of Patras, University General Hospital of Patras , Patras , Greece
| | - Sophia Georgiou
- a Dermatology Department, University of Patras, University General Hospital of Patras , Patras , Greece
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22
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López-Estebaranz J, de la Cueva-Dobao P, de la Torre Fraga C, Galán Gutiérrez M, González Guerra E, Mollet Sánchez J, Belinchón Romero I. Manejo de la psoriasis moderada-grave en condiciones de práctica habitual en el ámbito hospitalario español. ACTAS DERMO-SIFILIOGRAFICAS 2018; 109:631-642. [DOI: 10.1016/j.ad.2018.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 02/12/2018] [Accepted: 02/26/2018] [Indexed: 10/14/2022] Open
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López-Estebaranz J, de la Cueva-Dobao P, de la Torre Fraga C, Galán Gutiérrez M, González Guerra E, Mollet Sánchez J, Belinchón Romero I. Management of Moderate to Severe Psoriasis in Routine Clinical Practice in Spanish Hospitals. ACTAS DERMO-SIFILIOGRAFICAS 2018. [DOI: 10.1016/j.adengl.2018.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Targeted drugs in spondyloarthritis during pregnancy and lactation. Pharmacol Res 2018; 136:21-28. [PMID: 30125669 DOI: 10.1016/j.phrs.2018.08.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 07/29/2018] [Accepted: 08/13/2018] [Indexed: 12/16/2022]
Abstract
Spondyloarthritis (SpA) are a heterogeneous group of chronic inflammatory joint diseases that includes several clinical subgroups. SpA can affect women in the reproductive stage so pregnancy can influence the course of the disease and SpA can affect the maternal-fetal outcome. The treatment of SpA has changed dramatically in recent years and the use of targeted drugs is part of therapeutic armamentarium. The use of targeted drugs during pregnancy is controversial because the information available on safety during this period is still limited. Several cytokines have an important role in the normal development of pregnancy or other cytokines may play a role in certain maternal-fetal complications. Potentially targeted drugs can affect the function of these cytokines during pregnancy. The aim of this study is to review the interrelationship between SpA during pregnancy and lactation, the role of some cytokines during normal pregnancy and the development of maternal-fetal complications as well as to review recent information on targeted drugs during pregnancy and breastfeeding in these patients in order to maximize their use in these critical periods of life.
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Galluzzo M, D'Adamio S, Bianchi L, Talamonti M. Psoriasis in pregnancy: case series and literature review of data concerning exposure during pregnancy to ustekinumab. J DERMATOL TREAT 2018; 30:40-44. [PMID: 29676599 DOI: 10.1080/09546634.2018.1468066] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Psoriasis tends to improve for approximately half of patients during pregnancy, but an equal number of patients report no change or worsening during this period, when lots of medications, like biologics, are not indicated. The aim of our study was to review data of patient that had been pregnant during ustekinumab treatment, analyzing data of our data set between September 2010 and February 2018. We found data of three patients that had been pregnant during ustekinumab treatment. All three patients successfully completed the pregnancy without complications. One of the three patients was pregnant even twice during treatment with ustekinumab, with also a successful birth of two perfectly healthy twins. Biologic agents approved for the treatment of moderate-to-severe psoriasis are currently classified as pregnancy category B, even if, particularly for ustekinumab, there are several case reports regarding exposure during pregnancy in humans related to a healthy pregnancy, both for women and children. Although further studies are required to find real indication of biological treatment in pregnant patients, according to our and to the reviewed experience, ustekinumab does not interfere with gestation.
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Affiliation(s)
- Marco Galluzzo
- a Division of Dermatology, Department of "Medicina dei Sistemi" , University of Rome "Tor Vergata" , Rome , Italy
| | - Simone D'Adamio
- a Division of Dermatology, Department of "Medicina dei Sistemi" , University of Rome "Tor Vergata" , Rome , Italy
| | - Luca Bianchi
- a Division of Dermatology, Department of "Medicina dei Sistemi" , University of Rome "Tor Vergata" , Rome , Italy
| | - Marina Talamonti
- a Division of Dermatology, Department of "Medicina dei Sistemi" , University of Rome "Tor Vergata" , Rome , Italy
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Choosing First-Line Biologic Treatment for Moderate-to-Severe Psoriasis: What Does the Evidence Say? Am J Clin Dermatol 2018; 19:1-13. [PMID: 29080066 DOI: 10.1007/s40257-017-0328-3] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
An advanced understanding of the pathogenesis of psoriasis has led to the development of multiple therapeutic options for moderate-to-severe psoriasis. Tumor necrosis factor inhibitors, ustekinumab, interleukin-17 inhibitors, and guselkumab (an interleukin-23 inhibitor recently approved for psoriasis) are commercially available biologic agents for psoriasis. Evidence from clinical trials provides pertinent information regarding the safety and efficacy of biologic agents for psoriasis, which should be integrated into clinical decision making. However, disease presentations, disease severity, and comorbid conditions can complicate the choice of initial treatment, which underscores the importance of providing personalized therapy for patients with psoriasis. Furthermore, each biologic agent offers unique benefits and limitations for the treatment of patients with psoriasis. Here, evidence-based recommendations are presented and discussed regarding first-line biologic therapy options for patients with psoriasis and distinct comorbid conditions or patient-related factors. We discuss the comorbid conditions of psoriatic arthritis, multiple sclerosis, congestive heart failure, inflammatory bowel disease, hepatitis B, and latent tuberculosis. Moreover, we describe treatment recommendations for distinct patient populations with psoriasis, including pediatric patients with psoriasis and patients with psoriasis of childbearing potential and nursing.
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Abstract
Many factors influence the sexual health of people with Crohn's disease, but active disease and depression play key roles. The fertility rate in nonoperated patients with inflammatory bowel disease with quiescent disease is similar to that in the general population. Crohn's disease can increase the risk for adverse pregnancy outcomes, but being in remission on a stable, steroid-free medication regimen for at least 3 months before conception and adhering to the treatment throughout pregnancy can improve outcomes. Infants with intrauterine exposure to anti-tumor necrosis factor medications should avoid live vaccines for the first 9 months or until drug concentrations are undetectable.
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Affiliation(s)
- Jill K J Gaidos
- GI/Hepatology Service, McGuire VA Medical Center, Virginia Commonwealth University, 111-N, 1201 Broad Rock Boulevard, Richmond, VA 23249, USA
| | - Sunanda V Kane
- Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
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28
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Venturin C, Nancey S, Danion P, Uzzan M, Chauvenet M, Bergoin C, Roblin X, Flourié B, Boschetti G. Fetal death in utero and miscarriage in a patient with Crohn's disease under therapy with ustekinumab: case-report and review of the literature. BMC Gastroenterol 2017. [PMID: 28629323 PMCID: PMC5477379 DOI: 10.1186/s12876-017-0633-6] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background Ustekinumab is a fully human monoclonal antibody against the p40 subunit of interleukin (IL) 12 and 23 which is involved in the pathogenesis of several inflammatory diseases. Ustekinumab is approved for psoriasis and psoriatic arthritis treatment and has been successfully evaluated in phase II and III trials for patients with Crohn’s disease (CD). Case presentation We report here the case of a patient who became pregnant during treatment with ustekinumab for a refractory CD and which ended in miscarriage. Conclusion Ustekinumab is a relatively new pharmacotherapy and in addition to this clinical case, we reviewed the published literature concerning the use of this treatment during pregnancy and its consequences on pregnancy and fetus outcome.
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Affiliation(s)
- C Venturin
- Department of Gastroenterology, Lyon-Sud hospital, Hospices Civils de Lyon, Université Lyon1, Lyon, France
| | - S Nancey
- Department of Gastroenterology, Lyon-Sud hospital, Hospices Civils de Lyon, Université Lyon1, Lyon, France.,INSERM U1111, Centre International de Recherche en Infectiologie, Lyon, France
| | - P Danion
- Department of Gastroenterology, Lyon-Sud hospital, Hospices Civils de Lyon, Université Lyon1, Lyon, France
| | - M Uzzan
- Department of Gastroenterology and Nutritional Support, Beaujon Hospital, Assistance Publique des Hôpitaux de Paris, Université Paris VII, Clichy, France
| | - M Chauvenet
- Department of Gastroenterology, Lyon-Sud hospital, Hospices Civils de Lyon, Université Lyon1, Lyon, France
| | - C Bergoin
- Department of Gastroenterology, Lyon-Sud hospital, Hospices Civils de Lyon, Université Lyon1, Lyon, France
| | - X Roblin
- Department of Gastroenterology, Saint-Etienne hospital, Saint-Etienne, France
| | - B Flourié
- Department of Gastroenterology, Lyon-Sud hospital, Hospices Civils de Lyon, Université Lyon1, Lyon, France.,INSERM U1111, Centre International de Recherche en Infectiologie, Lyon, France
| | - G Boschetti
- Department of Gastroenterology, Lyon-Sud hospital, Hospices Civils de Lyon, Université Lyon1, Lyon, France. .,INSERM U1111, Centre International de Recherche en Infectiologie, Lyon, France. .,Service d'Hépato-Gastroentérologie, Centre Hospitalier Lyon-Sud, 165 Chemin du Grand Revoyet, 69495, Pierre Benite, France.
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Verstockt B, Deleenheer B, Van Assche G, Vermeire S, Ferrante M. A safety assessment of biological therapies targeting the IL-23/IL-17 axis in inflammatory bowel diseases. Expert Opin Drug Saf 2017; 16:809-821. [DOI: 10.1080/14740338.2017.1338273] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Bram Verstockt
- Translational Research in Gastrointestinal Disorders (TARGID), Department of Clinical and Experimental Medicine, KU Leuven, Leuven, Belgium
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Barbara Deleenheer
- Department of Pharmaceutical and Pharmacological Sciences, Clinical Pharmacology and Pharmacotherapy, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Gert Van Assche
- Translational Research in Gastrointestinal Disorders (TARGID), Department of Clinical and Experimental Medicine, KU Leuven, Leuven, Belgium
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Séverine Vermeire
- Translational Research in Gastrointestinal Disorders (TARGID), Department of Clinical and Experimental Medicine, KU Leuven, Leuven, Belgium
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Marc Ferrante
- Translational Research in Gastrointestinal Disorders (TARGID), Department of Clinical and Experimental Medicine, KU Leuven, Leuven, Belgium
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
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30
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Rademaker M, Agnew K, Andrews M, Armour K, Baker C, Foley P, Frew J, Gebauer K, Gupta M, Kennedy D, Marshman G, Sullivan J. Psoriasis in those planning a family, pregnant or breast-feeding. The Australasian Psoriasis Collaboration. Australas J Dermatol 2017; 59:86-100. [PMID: 28543445 DOI: 10.1111/ajd.12641] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2016] [Accepted: 01/28/2017] [Indexed: 12/20/2022]
Abstract
The Australasian Psoriasis Collaboration has reviewed the evidence for managing moderate to severe psoriasis in those who are pregnant or are breast-feeding, or planning a family. The severity of the psoriasis, associated comorbidities and specific anti-psoriasis treatment, along with other exposures, can have a deleterious effect on pregnancy outcomes. Psoriasis itself increases the risk of preterm and low birthweight babies, along with spontaneous and induced abortions, but no specific birth defects have been otherwise demonstrated. The baseline risk for a live born baby to have a major birth defect is 3%, and significant neuro-developmental problem is 5%. In Australia, pregnant women with psoriasis are more likely to be overweight or obese, depressed, or smoke in their first trimester, and are also less likely to take prenatal vitamins or supplements. Preconception counselling to improve maternal, pregnancy and baby health is therefore strongly encouraged. The topical and systemic therapies commonly used in psoriasis are each discussed separately, with regards to pregnancy exposure, breast-feeding and effects on male fertility and mutagenicity. The systemic therapies included are acitretin, adalimumab, apremilast, certolizumab, ciclosporin, etanercept, infliximab, ixekizumab, methotrexate, NBUVB, prednisone, PUVA, secukinumab and ustekinumab. The topical therapies include dithranol (anthralin), calcipotriol, coal tar, corticosteroids (weak, potent and super-potent), moisturisers, salicylic acid, tacrolimus, and tazarotene. As a general recommendation, effective drugs that have been widely used for years are preferable to newer alternatives with less foetal safety data. It is equally important to evaluate the risks of not treating, as severe untreated disease may negatively impact both mother and the foetus.
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Affiliation(s)
- Marius Rademaker
- Department of Dermatology, Waikato Clinical Campus, Auckland Medical School, Auckland, New Zealand
| | - Karen Agnew
- Department of Dermatology, Greenlane Clinical Centre, Auckland, New Zealand.,Starship Children's Hospital, Auckland, New Zealand
| | - Megan Andrews
- The Skin and Cancer Foundation of Victoria, Melbourne, Victoria, Australia
| | - Katherine Armour
- The Skin and Cancer Foundation of Victoria, Melbourne, Victoria, Australia
| | - Chris Baker
- Department of Medicine (Dermatology), University of Melbourne, St Vincent's Hospital, Melbourne, Victoria, Australia.,University of Melbourne, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Peter Foley
- Department of Medicine (Dermatology), University of Melbourne, St Vincent's Hospital, Melbourne, Victoria, Australia.,University of Melbourne, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - John Frew
- Department of Dermatology, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Kurt Gebauer
- Department of Dermatology, University of Western Australia, Freemantle, Western Australia, Australia
| | - Monisha Gupta
- Department of Dermatology, Liverpool Hospital, Skin Hospital, Sydney, New South Wales, Australia.,University of New South Wales, Sydney, New South Wales, Australia
| | - Debra Kennedy
- Royal Hospital for Women, Sydney, New South Wales, Australia
| | - Gillian Marshman
- Flinders Medical Centre and Repatriation General Hospital, Adelaide, South Australia, Australia
| | - John Sullivan
- Holdsworth House Medical Practice, Sydney, New South Wales, Australia
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31
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Perng P, Zampella JG, Okoye GA. Management of hidradenitis suppurativa in pregnancy. J Am Acad Dermatol 2017; 76:979-989. [DOI: 10.1016/j.jaad.2016.10.032] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 10/21/2016] [Accepted: 10/24/2016] [Indexed: 12/16/2022]
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32
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Echeverría-García B, Nuño-González A, Dauden E, Vanaclocha F, Torrado R, Belinchón I, Pérez-Zafrilla B. Serie de casos de pacientes psoriásicas expuestas a terapia biológica durante el embarazo. Registro BIOBADADERM y revisión de la literatura. ACTAS DERMO-SIFILIOGRAFICAS 2017; 108:168-170. [DOI: 10.1016/j.ad.2016.09.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 08/12/2016] [Accepted: 09/04/2016] [Indexed: 01/28/2023] Open
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33
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Echeverría-García B, Nuño-González A, Dauden E, Vanaclocha F, Torrado R, Belinchón I, Pérez-Zafrilla B. A Case Series of Patients With Psoriasis Exposed to Biologic Therapy During Pregnancy: The BIOBADADERM Register and a Review of the Literature. ACTAS DERMO-SIFILIOGRAFICAS 2017. [DOI: 10.1016/j.adengl.2016.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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34
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Gisondi P, Altomare G, Ayala F, Bardazzi F, Bianchi L, Chiricozzi A, Costanzo A, Conti A, Dapavo P, De Simone C, Foti C, Naldi L, Offidani A, Parodi A, Piaserico S, Prignano F, Rongioletti F, Stingeni L, Talamonti M, Girolomoni G. Italian guidelines on the systemic treatments of moderate-to-severe plaque psoriasis. J Eur Acad Dermatol Venereol 2017; 31:774-790. [PMID: 28244153 DOI: 10.1111/jdv.14114] [Citation(s) in RCA: 117] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 12/21/2016] [Indexed: 02/06/2023]
Abstract
Psoriasis is a common disease, which has a considerable impact on the healthcare system. Therefore, appropriate use of therapeutic resources is very important. Management of psoriasis in daily clinical practice is highly variable because many issues are still debated and not definitely addressed by the evidence-based medicine. Moreover, the different availability and reimbursability of drugs in each country justifies national guidelines. Expert consensus can provide helpful guidelines for optimizing patient care. A total of 20 dermatologists from different areas of Italy and with large experience in the treatment of psoriasis agreed to participate in the guidelines expert panel who aimed to reach consensus on the factors influencing psoriasis severity, the indications for systemic treatments, the parameters to be considered in the choice of treatment, and the factors to be considered in the choice of biological treatment. The recommendations for the use, screening and monitoring of systemic therapies were based on the 2015 S3 European Dermatology Forum/European Academy of Dermatology and Venereology psoriasis guidelines. Recommendations on the treatment of psoriasis in special patient populations were also agreed. The final document was discussed in a meeting moderated by a facilitator with participation of the entire group and adopting a nominal group technique to reach consensus. A statement was regarded as consented when agreement was achieved by at least 75% of the voting experts according to the Delphi procedure.
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Affiliation(s)
- P Gisondi
- Department of Medicine, Section of Dermatology and Venereology, University of Verona, Verona, Italy
| | - G Altomare
- Department of Dermatology and Venereology, I.R.C.C.S. Istituto Ortopedico Galeazzi, University of Milan, Milano, Italy
| | - F Ayala
- Department of Dermatology, University of Naples Federico II, Napoli, Italy
| | - F Bardazzi
- Division of Dermatology, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - L Bianchi
- Department of Dermatology, University of Rome Tor Vergata, Rome, Italy
| | - A Chiricozzi
- Department of Dermatology, University of Pisa, Pisa, Italy
| | - A Costanzo
- Department of Dermatology, Humanitas Research Hospital, Rozzano, Italy
| | - A Conti
- Department of Dermatology, University of Modena and Reggio Emilia, Modena, Italy
| | - P Dapavo
- Department of Biomedical Science and Human Oncology, Second Dermatologic Clinic, University of Turin, Turin, Italy
| | - C De Simone
- Department of Dermatology, Catholic University of the Sacred Heart, Rome, Italy
| | - C Foti
- Department of Biomedical Science and Human Oncology, Section of Dermatology, University of Bari, Bari, Italy
| | - L Naldi
- Department of Dermatology, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy
| | - A Offidani
- Department of Clinical and Molecular Sciences, Dermatology Unit, Polytechnic Marche University, Ancona, Italy
| | - A Parodi
- Department of Dermatology, University of Genoa, Genova, Italy
| | - S Piaserico
- Department of Dermatology, University of Padua, Padova, Italy
| | - F Prignano
- Department of Dermatology, University of Florence, Firenze, Italy
| | - F Rongioletti
- Department of Medical Sciences and Public Health, Section of Dermatology, University of Cagliari, Cagliari, Italy
| | - L Stingeni
- Department of Medicine, Section of Clinical, Allergological and Venereological Dermatology, University of Perugia, Perugia, Italy
| | - M Talamonti
- Department of Dermatology, University of Rome Tor Vergata, Rome, Italy
| | - G Girolomoni
- Department of Medicine, Section of Dermatology and Venereology, University of Verona, Verona, Italy
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Abstract
OPINION STATEMENT Inflammatory bowel disease is frequently diagnosed before or during key childbearing years. One of the most important factors for a healthy pregnancy is having quiescent disease prior to conception and maintaining disease remission for the duration of the pregnancy. In order to achieve that, most women will need to continue their inflammatory bowel disease (IBD) treatment during pregnancy. One of the main concerns these women have is whether these medications will have adverse effects on their growing fetus. Aminosalicylates, antibiotics, and steroids are all relatively low risk for use during pregnancy and breastfeeding. Recent studies also support the safety of continuing immunomodulators and anti-tumor necrosis factor agents during pregnancy and with breastfeeding. There seems to be an increased risk for infection, however, with use of combination therapy including both a biologic agent and an immunomodulator. Less evidence is available on the use of anti-integrins in pregnancy; however, the current data suggest they may be safe as well. Conversations about a patient's desire for pregnancy should occur between the patient and provider on a regular basis prior to conception and particularly with any change in disease activity or change in the treatment regimen. This chapter will review the current evidence on the safety of IBD medications during pregnancy and lactation so that providers can more easily discuss the importance of medication adherence for disease remission with their patients who are contemplating conception.
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Cortes X, Borrás-Blasco J, Antequera B, Fernandez-Martinez S, Casterá E, Martin S, Molés JR. Ustekinumab therapy for Crohn's disease during pregnancy: a case report and review of the literature. J Clin Pharm Ther 2016; 42:234-236. [PMID: 28004853 DOI: 10.1111/jcpt.12492] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Accepted: 10/31/2016] [Indexed: 12/13/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVES The safety of continued ustekinumab (UST) therapy during pregnancy remains unclear in patients with Crohn's disease (CD). There are no meta-analysis reports of exposure to UST during pregnancy. The objective was to describe a case of a pregnant patient with CD who was successfully treated with UST maintenance therapy throughout the pregnancy and delivered a baby boy without any congenital malformations, neurological abnormalities or birth defects. CASE SUMMARY A 37-year-old patient with CD treated with UST became pregnant. She had been receiving UST for 8 months at the time. After discussion with the patient and the obstetric team, the UST therapy was continued. The result of treatment was an uneventful pregnancy with delivery, at term, of a healthy boy and the maintenance of clinical, biological and endoscopic remission of CD during and after pregnancy. WHAT IS NEW AND CONCLUSION To our knowledge, this is the first reported use of continued UST therapy for CD throughout a pregnancy. The result of treatment was an uncomplicated pregnancy with the mother giving birth to a healthy boy at term and the maintenance of clinical biological and endoscopic remission of CD during and after pregnancy.
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Affiliation(s)
- X Cortes
- Gastroenterology Section, Internal Medicine, Hospital de Sagunto, Sagunt, Spain
| | | | - B Antequera
- Internal Medicine, Hospital de Sagunto, Sagunt, Spain
| | | | - E Casterá
- Pharmacy Service, Hospital de Sagunto, Sagunt, Spain
| | - S Martin
- Pediatric Service, Hospital de Sagunto, Sagunt, Spain
| | - J R Molés
- Gastroenterology Section, Internal Medicine, Hospital de Sagunto, Sagunt, Spain
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37
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Verstockt B, Van Assche G, Vermeire S, Ferrante M. Biological therapy targeting the IL-23/IL-17 axis in inflammatory bowel disease. Expert Opin Biol Ther 2016; 17:31-47. [PMID: 27817215 DOI: 10.1080/14712598.2017.1258399] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION As many inflammatory bowel disease (IBD) patients do not benefit from long-term anti-tumour necrosis factor treatment, new anti-inflammatories are urgently needed. After the discovery of the interleukin (IL) 23/17 axis being pivotal in IBD pathogenesis, many different compounds were developed, targeting different components within this pathway. Areas covered: A literature search to March 2016 was performed to identify the most relevant reports on the role of the IL-23/IL-17 axis in IBD and on the different molecules targeting this pathway. First, the authors briefly summarize the immunology of the IL-23/IL-17 pathway to elucidate the mode of action of all different agents. Second, they describe all different molecules targeting this pathway. Besides discussing efficacy and safety data, they also explore immunogenicity, exposure during pregnancy and pharmacokinetics. Expert opinion: A new era in IBD treatment has recently been initiated: besides immunomodulators and TNF-antagonists, anti-adhesion molecules and monoclonal antibodies targeting the IL-23/IL-17 pathway have been developed. Biomarkers for personalized medicine are urgently needed. This therapeutic (r)evolution will further improve disease-related and patient-reported outcome, though a lot of questions should still be addressed in future years.
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Affiliation(s)
- Bram Verstockt
- a Translational Research in Gastrointestinal Disorders (TARGID), Department of Clinical and Experimental Medicine , KU Leuven , Leuven , Belgium.,b Department of Medicine and Cambridge Institute for Medical Research , University of Cambridge, School of Clinical Medicine, Cambridge Biomedical Campus , Cambridge , UK
| | - Gert Van Assche
- a Translational Research in Gastrointestinal Disorders (TARGID), Department of Clinical and Experimental Medicine , KU Leuven , Leuven , Belgium.,c Department of Gastroenterology and Hepatology , University Hospitals Leuven, KU Leuven , Leuven , Belgium
| | - Séverine Vermeire
- a Translational Research in Gastrointestinal Disorders (TARGID), Department of Clinical and Experimental Medicine , KU Leuven , Leuven , Belgium.,c Department of Gastroenterology and Hepatology , University Hospitals Leuven, KU Leuven , Leuven , Belgium
| | - Marc Ferrante
- a Translational Research in Gastrointestinal Disorders (TARGID), Department of Clinical and Experimental Medicine , KU Leuven , Leuven , Belgium.,c Department of Gastroenterology and Hepatology , University Hospitals Leuven, KU Leuven , Leuven , Belgium
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38
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Pinder M, Lummis K, Selinger CP. Managing inflammatory bowel disease in pregnancy: current perspectives. Clin Exp Gastroenterol 2016; 9:325-335. [PMID: 27789969 PMCID: PMC5072556 DOI: 10.2147/ceg.s96676] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Inflammatory bowel disease (IBD) affects many women of childbearing age. The course of IBD is closely related to pregnancy outcomes with poorly controlled IBD increasing the risk of prematurity, low weight for gestation, and fetal loss. As such, women with IBD face complex decision making weighing the risks of active disease versus those of medical treatments. This review summarizes the current evidence regarding the safety and efficacy of IBD treatments during pregnancy and lactation aiming to provide up-to-date guidance for clinicians. Over 50% of women have poor IBD- and pregnancy-related knowledge, which is associated with views contrary to medical evidence and voluntary childlessness. This review highlights the effects of poor patient knowledge and critically evaluates interventions for improving patient knowledge and outcomes.
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Affiliation(s)
- Matthew Pinder
- Leeds Gastroenterology Institute, Leeds Teaching Hospitals NHS Trust
| | - Katie Lummis
- Leeds Gastroenterology Institute, Leeds Teaching Hospitals NHS Trust
| | - Christian P Selinger
- Leeds Gastroenterology Institute, Leeds Teaching Hospitals NHS Trust; University of Leeds, Leeds, UK
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39
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Nguyen GC, Seow CH, Maxwell C, Huang V, Leung Y, Jones J, Leontiadis GI, Tse F, Mahadevan U, van der Woude CJ. The Toronto Consensus Statements for the Management of Inflammatory Bowel Disease in Pregnancy. Gastroenterology 2016; 150:734-757.e1. [PMID: 26688268 DOI: 10.1053/j.gastro.2015.12.003] [Citation(s) in RCA: 317] [Impact Index Per Article: 39.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS The management of inflammatory bowel disease (IBD) poses a particular challenge during pregnancy because the health of both the mother and the fetus must be considered. METHODS A systematic literature search identified studies on the management of IBD during pregnancy. The quality of evidence and strength of recommendations were rated using the Grading of Recommendation Assessment, Development and Evaluation (GRADE) approach. RESULTS Consensus was reached on 29 of the 30 recommendations considered. Preconception counseling and access to specialist care are paramount in optimizing disease management. In general, women on 5-ASA, thiopurine, or anti-tumor necrosis factor (TNF) monotherapy for maintenance should continue therapy throughout pregnancy. Discontinuation of anti-TNF therapy or switching from combination therapy to monotherapy may be considered in very select low-risk patients. Women who have a mild to moderate disease flare while on optimized 5-ASA or thiopurine therapy should be managed with systemic corticosteroid or anti-TNF therapy, and those with a corticosteroid-resistant flare should start anti-TNF therapy. Endoscopy or urgent surgery should not be delayed during pregnancy if indicated. Decisions regarding cesarean delivery should be based on obstetric considerations and not the diagnosis of IBD alone, with the exception of women with active perianal Crohn's disease. With the exception of methotrexate, the use of medications for IBD should not influence the decision to breast-feed and vice versa. Live vaccinations are not recommended within the first 6 months of life in the offspring of women who were on anti-TNF therapy during pregnancy. CONCLUSIONS Optimal management of IBD before and during pregnancy is essential to achieving favorable maternal and neonatal outcomes.
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Affiliation(s)
- Geoffrey C Nguyen
- Mount Sinai Hospital Centre for Inflammatory Bowel Disease, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
| | - Cynthia H Seow
- Departments of Medicine & Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Cynthia Maxwell
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada
| | - Vivian Huang
- Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Yvette Leung
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
| | - Jennifer Jones
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | | | - Frances Tse
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Uma Mahadevan
- Department of Medicine, University of California, San Francisco, San Francisco, California
| | - C Janneke van der Woude
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
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40
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Galli-Novak E, Mook SC, Büning J, Schmidt E, Zillikens D, Thaci D, Ludwig RJ. Successful pregnancy outcome under prolonged ustekinumab treatment in a patient with Crohn's disease and paradoxical psoriasis. J Eur Acad Dermatol Venereol 2015; 30:e191-e192. [PMID: 26559393 DOI: 10.1111/jdv.13499] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- E Galli-Novak
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - S-C Mook
- Department of Dermatology, University of Lübeck, Lübeck, Germany.,Comprehensive Center for Inflammation Medicine, University of Lübeck, Lübeck, Germany
| | - J Büning
- Gastroenterology, Medical Department I, University Hospital of Schleswig-Holstein, Lübeck, Germany
| | - E Schmidt
- Department of Dermatology, University of Lübeck, Lübeck, Germany.,Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
| | - D Zillikens
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - D Thaci
- Comprehensive Center for Inflammation Medicine, University of Lübeck, Lübeck, Germany
| | - R J Ludwig
- Department of Dermatology, University of Lübeck, Lübeck, Germany.,Comprehensive Center for Inflammation Medicine, University of Lübeck, Lübeck, Germany.,Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
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