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Rohini S, Sharma UR, Vinutha M, Shreelaxmi D, Vada S, Janandri S, Haribabu T, Taj N, Gayathri SV, Ghara A, Mudagal MP. Rheumatoid arthritis-associated complications during pregnancy and its effect on offspring: comprehensive review. Inflammopharmacology 2024; 32:1-17. [PMID: 38691248 DOI: 10.1007/s10787-024-01482-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 04/05/2024] [Indexed: 05/03/2024]
Abstract
This study comprehensively explores the complexities of rheumatoid arthritis during pregnancy and its impact on offspring. Through an extensive review of existing literature, we investigate maternal and fetal risks, including adverse pregnancy outcomes and developmental issues in offspring. Utilizing reputable databases such as PubMed, Google Scholar, and Science Direct, we meticulously examined studies exploring the connection between rheumatoid arthritis and pregnancy complications, with a focus on outcomes for offspring. We excluded studies lacking sufficient data or peer review. Synthesizing findings from selected studies, we identified common themes and patterns, presenting results in a clear, organized manner. Our examination reveals a heightened likelihood of preterm birth and preeclampsia among pregnant individuals with rheumatoid arthritis, often correlated with disease activity. Furthermore, we highlight the impact on fetal and neonatal outcomes, such as low birth weight, underscoring the importance of meticulous disease management throughout pregnancy. Balancing the necessity of disease-modifying agents with potential risks, and consideration of medication safety is paramount. A multidisciplinary approach involving rheumatologists and obstetricians is crucial for optimizing outcomes. In conclusion, this synthesis underscores the nuanced challenges of rheumatoid arthritis in pregnancy. A comprehensive understanding and personalized, multidisciplinary approach to an organization is essential for informed decision-making in clinical practice. Our review contributes to ongoing discourse, providing insights for enhanced patient care and guiding future research endeavors.
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Affiliation(s)
- S Rohini
- Department of Pharmacology, Acharya & BM Reddy College of Pharmacy, Acharya Dr. Sarvepalli Radhakrishna Road, Achit Nagar (Post), Soldevanahalli, Bengaluru, 560090, India
| | - Uday Raj Sharma
- Department of Pharmacology, Acharya & BM Reddy College of Pharmacy, Acharya Dr. Sarvepalli Radhakrishna Road, Achit Nagar (Post), Soldevanahalli, Bengaluru, 560090, India.
| | - M Vinutha
- Department of Pharmacology, Acharya & BM Reddy College of Pharmacy, Acharya Dr. Sarvepalli Radhakrishna Road, Achit Nagar (Post), Soldevanahalli, Bengaluru, 560090, India
| | - D Shreelaxmi
- Department of Pharmacology, Acharya & BM Reddy College of Pharmacy, Acharya Dr. Sarvepalli Radhakrishna Road, Achit Nagar (Post), Soldevanahalli, Bengaluru, 560090, India
| | - Surendra Vada
- Department of Pharmacology, Acharya & BM Reddy College of Pharmacy, Acharya Dr. Sarvepalli Radhakrishna Road, Achit Nagar (Post), Soldevanahalli, Bengaluru, 560090, India
| | - Suresh Janandri
- Department of Pharmacology, Acharya & BM Reddy College of Pharmacy, Acharya Dr. Sarvepalli Radhakrishna Road, Achit Nagar (Post), Soldevanahalli, Bengaluru, 560090, India
| | - T Haribabu
- Department of Pharmacology, Acharya & BM Reddy College of Pharmacy, Acharya Dr. Sarvepalli Radhakrishna Road, Achit Nagar (Post), Soldevanahalli, Bengaluru, 560090, India
| | - Nageena Taj
- Department of Pharmacology, Acharya & BM Reddy College of Pharmacy, Acharya Dr. Sarvepalli Radhakrishna Road, Achit Nagar (Post), Soldevanahalli, Bengaluru, 560090, India
| | - S V Gayathri
- Department of Pharmacology, Acharya & BM Reddy College of Pharmacy, Acharya Dr. Sarvepalli Radhakrishna Road, Achit Nagar (Post), Soldevanahalli, Bengaluru, 560090, India
| | - Abhishek Ghara
- Department of Pharmacology, Acharya & BM Reddy College of Pharmacy, Acharya Dr. Sarvepalli Radhakrishna Road, Achit Nagar (Post), Soldevanahalli, Bengaluru, 560090, India
| | - Manjunatha P Mudagal
- Department of Pharmacology, Acharya & BM Reddy College of Pharmacy, Acharya Dr. Sarvepalli Radhakrishna Road, Achit Nagar (Post), Soldevanahalli, Bengaluru, 560090, India
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Clardy SL, Smith TL. Therapeutic Approach to Autoimmune Neurologic Disorders. Continuum (Minneap Minn) 2024; 30:1226-1258. [PMID: 39088294 DOI: 10.1212/con.0000000000001463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2024]
Abstract
OBJECTIVE Autoimmune neurologic disorders encompass a broad category of diseases characterized by immune system attack of the central, peripheral, or autonomic nervous systems. This article provides information on both acute and maintenance immunotherapy used to treat autoimmune neurologic disorders as well as a review of symptomatic management and special considerations when caring for patients with these diseases. LATEST DEVELOPMENTS Over the past 20 years, more than 50 antibodies have been identified and associated with autoimmune neurologic disorders. Although advances in diagnostic testing have allowed for more rapid diagnosis, the therapeutic approach to these disorders has largely continued to rely on expert opinion, case series, and case reports. With US Food and Drug Administration (FDA) approval of biologic agents to treat neuromyelitis optica spectrum disorder (NMOSD) and myasthenia gravis as well as ongoing clinical trials for the treatment of autoimmune encephalitis, the landscape of immunotherapy options continues to expand. Consideration of the unique pathogenesis of individual autoimmune neurologic disorders as well as the mechanism of action of the diverse range of treatment options can help guide treatment decisions today while evidence from clinical trials informs new therapeutics in the future. ESSENTIAL POINTS Recognizing patients who have a clinical history and examination findings concerning for autoimmune neurologic disorders and conducting a thorough and directed imaging and laboratory evaluation aimed at ruling out mimics, identifying specific autoimmune syndromes, and screening for factors that may have an impact on immunotherapy choices early in the clinical course are essential to providing optimal care for these patients. Providers must consider immunotherapy, symptomatic treatment, and a multidisciplinary approach that addresses each patient's unique needs when treating patients with autoimmune neurologic disorders.
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Gul A, Khan M, Gill SK, Rizwanullah, Vasudevan K, Gurmessa K, Tahir S. New-Onset Rheumatoid Arthritis in Pregnancy: A Case Report. Cureus 2024; 16:e64899. [PMID: 39165440 PMCID: PMC11335133 DOI: 10.7759/cureus.64899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2024] [Indexed: 08/22/2024] Open
Abstract
Rheumatoid arthritis (RA) is extremely uncommon during pregnancy. The alterations in the immune system that occur to support the developing fetus make the onset of RA during this period unlikely. In this case report, we describe a 26-year-old pregnant woman who presented with bilateral symmetrical pain in her hands, wrists, and ankles at 24 weeks of gestation. After a thorough evaluation, she was diagnosed with active RA based on clinical symptoms and laboratory findings, including elevated inflammatory markers, positive RA factor, and anti-cyclic citrullinated peptide antibodies. Treatment was initiated with hydroxychloroquine (HCQ), prednisolone, and paracetamol, resulting in significant symptom improvement and no postpartum complications. The patient gave birth to a healthy baby via vaginal delivery, highlighting the management challenges and outcomes linked to RA during pregnancy.
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Affiliation(s)
- Aiysha Gul
- Obstetrics and Gynecology, Mardan Medical Complex, Mardan, PAK
| | - Muzamil Khan
- Internal Medicine, The George Washington University School of Medicine and Health Sciences, Washington DC, USA
| | | | - Rizwanullah
- Internal Medicine, Hayatabad Medical Complex, Peshawar, PAK
| | | | - Kiya Gurmessa
- Public Health, Johns Hopkins University, Baltimore, USA
| | - Sophia Tahir
- Internal Medicine, Windsor University School of Medicine, Cayon, KNA
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Sousa MI, Braga AC, Buchner GC, Braga JS. Rituximab as a treatment for refractory immune thrombocytopenia during pregnancy. Blood Coagul Fibrinolysis 2024; 35:286-292. [PMID: 38973519 DOI: 10.1097/mbc.0000000000001312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/09/2024]
Abstract
Immune thrombocytopenia (ITP) is most common in women during their reproductive years. When a low platelet count occurs for the first time during pregnancy, the differential diagnosis includes pregnancy-specific conditions. Although ITP is the most common cause of thrombocytopenia early in pregnancy, pregnancy-related thrombocytopenia develops mainly in late gestation. As maternal and neonatal outcomes are usually favourable, ITP per se is not a contraindication for pregnancy. We report the case with a literature review of patient with ITP, whose diagnosis was established in early pregnancy. This condition was refractory to first-line treatments, such as high-dose steroids and intravenous immunoglobulin and other splenectomy-sparing approaches, as rituximab, having the control been reached on the third trimester after splenectomy. Although not effective in this case, we still believe that rituximab should be considered before surgery during pregnancy.
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Affiliation(s)
- Maria I Sousa
- Serviço de Obstetrícia, Departamento da Mulher e da Medicina Reprodutiva, Centro Materno-Infantil do Norte, Unidade Local de Saúde de Santo António, Porto, Portugal
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Schwake C, Steinle J, Thiel S, Timmesfeld N, Haben S, Ayzenberg I, Gold R, Hellwig K. Neonatal B-Cell Levels and Infant Health in Newborns Potentially Exposed to Anti-CD20 Monoclonal Antibodies During Pregnancy or Lactation. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2024; 11:e200264. [PMID: 38870458 PMCID: PMC11178251 DOI: 10.1212/nxi.0000000000200264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 04/17/2024] [Indexed: 06/15/2024]
Abstract
OBJECTIVES To report CD19+ B-cell counts and possible adverse effects on infants of mothers exposed to anti-CD20 mAbs ≤6 months before/during pregnancy or lactation. METHODS We conducted a retrospective study using data from the German nationwide neuroimmunologic pregnancy registry. Inclusion criteria involved infants whose mothers received anti-CD20 mAbs ≤6 months before/during pregnancy or lactation, with ≥1 postnatal CD19+ B-cell count. Main outcomes were absolute and relative CD19+ B-cell counts. Comparison with reference values was performed conservatively in a subgroup with maternal exposure ≤3 months before/during pregnancy. Additional outcomes included pregnancy results, severe infections, and lymphocyte counts. RESULTS The cohort comprised 49 infants (F:M 25:24) exposed to anti-CD20 mAbs ≤6 months before/during pregnancy or lactation. CD19+ B-cell and lymphocyte counts in 40 infants with maternal exposure ≤3 months before/during pregnancy were comparable with normative values. Only 2 cases of complete CD19+ B-cell depletion occurred after second-trimester and third-trimester ocrelizumab exposure, with repopulation observed within 2 months. Exclusive lactation exposure had no significant effect on infants' absolute CD19+ B-cell counts. DISCUSSION Administering anti-CD20 mAbs before or at the pregnancy onset, or during lactation, seems safe without significant impact on infant B-cell development. However, second-trimester or third-trimester exposure can cause CD19+ B-cell depletion due to placental transfer, necessitating monitoring and postponing live vaccines.
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Affiliation(s)
- Carolin Schwake
- From the Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Germany
| | - Julia Steinle
- From the Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Germany
| | - Sandra Thiel
- From the Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Germany
| | - Nina Timmesfeld
- From the Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Germany
| | - Sabrina Haben
- From the Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Germany
| | - Ilya Ayzenberg
- From the Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Germany
| | - Ralf Gold
- From the Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Germany
| | - Kerstin Hellwig
- From the Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Germany
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6
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Perricone C, Castellucci A, Cafaro G, Calvacchi S, Bruno L, Dal Pozzolo R, Tromby F, Colangelo A, Gerli R, Bartoloni E. Rational approach to the prescription of anti-rheumatic drugs in rheumatoid arthritis: a product leaflet-based strategy in Italy. Front Immunol 2024; 15:1398314. [PMID: 38979406 PMCID: PMC11228816 DOI: 10.3389/fimmu.2024.1398314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Accepted: 05/06/2024] [Indexed: 07/10/2024] Open
Abstract
The treatment of patients with rheumatoid arthritis (RA) has dramatically changed in the past 30 years. Currently, numerous conventional, biologic, and targeted synthetic DMARDs have been licensed and used following recommendations provided by international and national scientific societies. However, the availability of biosimilars and the increasing necessity of savings impacted on the local/national prescription of these drugs. The information provided by data sheet of every single drug is a decisive factor on the choice of a certain treatment merged with the patient's profile. Thus, our purpose was to construct a rational algorithm for the treatment strategy in RA according to costs and the product leaflet of the biologic and targeted-synthetic DMARDs currently licensed in Italy. We used the most recent available recommendations and then we performed a review of the literature considering all the factors that are known to influence drug safety/effectiveness. All these factors were considered in the context of the data sheets of currently available originators and biosimilars.
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Affiliation(s)
- Carlo Perricone
- Rheumatology, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Andrea Castellucci
- Rheumatology, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Giacomo Cafaro
- Rheumatology, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Santina Calvacchi
- Rheumatology, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Lorenza Bruno
- Rheumatology, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Roberto Dal Pozzolo
- Rheumatology, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Francesco Tromby
- Rheumatology, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Anna Colangelo
- Rheumatology, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Roberto Gerli
- Rheumatology, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Elena Bartoloni
- Rheumatology, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
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D'Gama JD, Bermas BL. Safety of biologic agents for the management of rheumatic diseases during pregnancy. Curr Opin Rheumatol 2024; 36:184-190. [PMID: 38456470 DOI: 10.1097/bor.0000000000001014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
PURPOSE OF REVIEW To discuss the current understanding regarding the use of biologic therapeutics in pregnancy. RECENT FINDINGS Our understanding of the mechanisms underlying the potential fetal and infant exposure to biologics as well as a growing body of empirical evidence from real world use of biologics in pregnancy have demonstrated that biologics are generally compatible preconception and during pregnancy. Long-term effects of exposure to biologic agents in utero are not known, but will be uncovered in time. Biosimilars, which are becoming more popular, may not always share the same safety profiles as their originators. SUMMARY Biologics have revolutionized the management of rheumatologic disease and ushered in a new era of clinical remission among patients. These agents, developed and introduced into clinical use at the beginning of the new millennium, are very potent, yet their efficacy in treating disease often in reproductive aged women, raises questions regarding their safety during pregnancy. These therapeutics can cause immunosuppression and can inhibit immunologic circuits that are not only involved in disease pathophysiology but hypothetically could impact the development of the fetal immune system. Reassuringly, biologics, typically antibodies or antibody-based proteins, are introduced to the fetus via the typical route of transplacental antibody transfer, and thus only begin to be transferred in appreciable amounts in the second trimester (after organogenesis). From theoretic and empirical standpoints, biologic use during pregnancy appears well tolerated for fetal development and to not substantially affect infant immune development.
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Affiliation(s)
- Jonathan D D'Gama
- Division of Rheumatic Diseases, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Chadwick V, Kim M, Mills G, Tang C, Anazodo A, Dear R, Rodgers R, Lavee O, Milliken S, McCaughan G, Hamad N. A minority of women of childbearing potential are tested for pregnancy before chemoimmunotherapy: an Australian cancer centre experience. Intern Med J 2024; 54:750-754. [PMID: 37929784 DOI: 10.1111/imj.16287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 11/02/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Chemotherapy is potentially harmful to a developing foetus, and there are limited data on the foetal impact of chemoimmunotherapy (CIT). Therefore, determining pregnancy status prior to initiation of CIT should be standard of care. AIMS To determine how many women of childbearing age are tested for pregnancy prior to immunochemotherapy administration. METHODS A retrospective chart review at a large Australian metropolitan cancer referral centre, including 304 women aged 18-51 years with a diagnosis of cancer receiving outpatient-based CIT between 1 May 2015 and 12 June 2020. We assessed the uptake of pregnancy screening and contraception counselling prior to and during first-line CIT. RESULTS Only 17.3% of CIT cycles (n = 416) screened patients for pregnancy no more than 90 days prior to administration, and the median time between pregnancy screening and treatment was approximately 3 weeks. One patient with early breast cancer had a spontaneous miscarriage estimated at 3-4 weeks' gestation, and neither the patient nor the treating oncologist was aware of this event. This was also the only patient who had a pregnancy test beyond the first cycle of CIT during their treatment. CONCLUSIONS Our results highlight a concerningly low rate of pregnancy screening in women of childbearing age receiving CIT. The implication of missing a positive pregnancy test in this group of women could result in foetal complications, accidental miscarriage, potential bleeding risks and avoidable psychosocial stress. This highlights the urgent need for guidelines to mandate pregnancy testing in women of childbearing age receiving CIT and evidence-based implementation tools.
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Affiliation(s)
- Verity Chadwick
- Women's and Babies Service, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Michaela Kim
- School of Clinical Medicine, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Georgia Mills
- Department of Haematology, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Catherine Tang
- Department of Haematology and Flow Cytometry, Laverty Pathology, Sydney, New South Wales, Australia
| | - Antoinette Anazodo
- School of Clinical Medicine, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- Kids Cancer Centre, Sydney Children's Hospital, Sydney, New South Wales, Australia
- Nelune Cancer Centre, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Rachel Dear
- School of Clinical Medicine, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- Department of Oncology, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Rachael Rodgers
- School of Clinical Medicine, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- Department of Reproductive Medicine, Royal Hospital for Women, Sydney, New South Wales, Australia
- School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Orly Lavee
- School of Clinical Medicine, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- Department of Haematology, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Sam Milliken
- School of Clinical Medicine, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- Department of Haematology, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Georgia McCaughan
- Department of Haematology, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Nada Hamad
- Department of Haematology, St Vincent's Hospital, Sydney, New South Wales, Australia
- St Vincent's Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- School of Medicine, University of Notre Dame, Sydney, New South Wales, Australia
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Kafagi AH, Li AS, Jayne D, Brix SR. Anti-GBM disease in pregnancy. BMJ Case Rep 2024; 17:e257767. [PMID: 38688578 PMCID: PMC11085961 DOI: 10.1136/bcr-2023-257767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024] Open
Abstract
We present the case of a pregnant woman in her 20s who presented in her second trimester with severe pulmonary haemorrhage and dialysis-dependent acute kidney failure due to antiglomerular basement membrane (GBM) disease. Responding to therapy, she recovered kidney function and delivered a baby. During her pregnancy, she developed cytomegalovirus viraemia, gestational diabetes and pre-eclampsia. Here, we report the first combined use of cyclophosphamide, rituximab and intensified plasma exchange in anti-GBM disease in pregnancy, allowing minimal exposure to cytotoxic medication, resulting in live birth and dialysis independence.
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Affiliation(s)
| | - Anna S Li
- Renal, Urology and Transplantation Unit, Manchester University NHS Foundation Trust, Manchester, UK
- Division of Cell Matrix Biology and Regenerative Medicine, School of Biological Sciences, The University of Manchester, Manchester, UK
| | | | - Silke R Brix
- Renal, Urology and Transplantation Unit, Manchester University NHS Foundation Trust, Manchester, UK
- Division of Cell Matrix Biology and Regenerative Medicine, School of Biological Sciences, The University of Manchester, Manchester, UK
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10
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Tarter L, Bermas BL. Expert Perspective on a Clinical Challenge: Lupus and Pregnancy. Arthritis Rheumatol 2024; 76:321-331. [PMID: 37975160 DOI: 10.1002/art.42756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/10/2023] [Accepted: 11/13/2023] [Indexed: 11/19/2023]
Abstract
Systemic lupus erythematosus (SLE), a multiorgan systemic inflammatory disorder, predominantly affects women during their reproductive years. In this review, we summarize the state of knowledge about preconception planning and management of SLE during pregnancy. Achieving remission or low disease activity for several months on medications compatible with pregnancy prior to conception is essential to decreasing the risk of disease flare and improving pregnancy outcomes, including pre-eclampsia, preterm birth, and intrauterine growth restriction. With close management and well-controlled disease before and during pregnancy, <10% of patients flare. All patients with SLE should remain on hydroxychloroquine unless contraindicated. Expectant mothers with a history of antiphospholipid syndrome should be treated with anticoagulant therapy during pregnancy. Women with anti-Ro/SSA or anti-La/SSB antibodies require additional monitoring because their offspring are at increased risk for congenital heart block. Patients with SLE should be offered low-dose aspirin starting at the end of the first trimester to reduce the risk of pre-eclampsia. Flares of SLE during pregnancy require escalation of therapy. The immunosuppressives azathioprine, tacrolimus, and cyclosporine are compatible with pregnancy, and biologic agents can also be considered. Glucocorticoid use in pregnancy should be limited to the lowest effective dose. Mycophenolate mofetil/mycophenolic acid, methotrexate, leflunomide, and cyclophosphamide are known to be teratogenic and are contraindicated in pregnancy. Distinguishing a flare of lupus nephritis during pregnancy from pre-eclampsia can be particularly challenging. Overall, outcomes in pregnancy for women with lupus are improving, but gaps in knowledge about optimal management strategies persist.
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Affiliation(s)
- Laura Tarter
- Brigham and Women's Hospital, Boston, Massachusetts
| | - Bonnie L Bermas
- University of Texas Southwestern Medical Center, Dallas, Texas
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11
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Campbell N, Deer E, Solise D, Cornelius DC, Turner T, Amaral LM, Herrock O, Jordan A, Shukla S, Ibrahim T, LaMarca B. AT1-AA Is Produced in Offspring in Response to Placental Ischemia and Is Lowered by B-Cell Depletion Without Compromising Overall Offspring Health. J Am Heart Assoc 2024; 13:e031417. [PMID: 38353227 PMCID: PMC11010106 DOI: 10.1161/jaha.123.031417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 12/01/2023] [Indexed: 02/21/2024]
Abstract
BACKGROUND Preeclampsia, new-onset hypertension during pregnancy alongside other organ dysfunction, is the leading cause of mortality for the mother and low birth weight for the baby. Low birth weight contributes to high risk of cardiovascular disorders later in life. Women with preeclampsia have activated B cells producing agonistic autoantibodies to AT1-AA (angiotensin II type I receptor). We hypothesize that rituximab, a B cell-depleting chemotherapeutic, will deplete maternal B cells in reduced uterine perfusion pressure (RUPP) rats without worsening the effect of placental ischemia on pup growth and survival. METHODS AND RESULTS To test this hypothesis, the RUPP procedure was performed, and rituximab was continuously infused via miniosmotic pump. Maternal blood and tissues were collected. A separate group of dams were allowed to deliver, pup weights were recorded, and at 4 months of age, tissues were collected from offspring. Immune cells were measured via flow cytometry, and AT1-AA was quantified using a contraction bioassay. Blood pressure increased in RUPP rats and was normalized with rituximab treatment. RUPP offspring also had increased circulating B cells, cytolytic natural killer cells, and increased circulating AT1-AA, which were normalized with maternal rituximab treatment. This is the first study to analyze the AT1-AA in RUPP offspring, which was normalized with rituximab. CONCLUSIONS Our findings indicate that perinatal rituximab lowers maternal mean arterial pressure in RUPP rats and improves birth weight, circulating AT1-AA, and circulating natural killer cells, indicating that rituximab improves adverse fetal outcomes in response to placental ischemia.
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Affiliation(s)
- Nathan Campbell
- Department of Pharmacology & ToxicologyUniversity of Mississippi Medical CenterJacksonMS
| | - Evangeline Deer
- Department of Pharmacology & ToxicologyUniversity of Mississippi Medical CenterJacksonMS
| | - Dylan Solise
- Department of Obstetrics and GynecologyUniversity of Mississippi Medical CenterJacksonMS
| | - Denise C. Cornelius
- Department of Pharmacology & ToxicologyUniversity of Mississippi Medical CenterJacksonMS
- Department of Emergency MedicineUniversity of Mississippi Medical CenterJacksonMS
| | - Ty Turner
- Department of Pharmacology & ToxicologyUniversity of Mississippi Medical CenterJacksonMS
| | - Lorena M. Amaral
- Department of Pharmacology & ToxicologyUniversity of Mississippi Medical CenterJacksonMS
| | - Owen Herrock
- Department of Pharmacology & ToxicologyUniversity of Mississippi Medical CenterJacksonMS
| | - Ariel Jordan
- Department of Pharmacology & ToxicologyUniversity of Mississippi Medical CenterJacksonMS
| | - Shivani Shukla
- Department of Pharmacology & ToxicologyUniversity of Mississippi Medical CenterJacksonMS
| | - Tarek Ibrahim
- Department of Pharmacology & ToxicologyUniversity of Mississippi Medical CenterJacksonMS
| | - Babbette LaMarca
- Department of Pharmacology & ToxicologyUniversity of Mississippi Medical CenterJacksonMS
- Department of Obstetrics and GynecologyUniversity of Mississippi Medical CenterJacksonMS
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12
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Hahn C, Budhram A, Alikhani K, AlOhaly N, Beecher G, Blevins G, Brooks J, Carruthers R, Comtois J, Cowan J, de Robles P, Hébert J, Kapadia RK, Lapointe S, Mackie A, Mason W, McLane B, Muccilli A, Poliakov I, Smyth P, Williams KG, Uy C, McCombe JA. Canadian Consensus Guidelines for the Diagnosis and Treatment of Autoimmune Encephalitis in Adults. Can J Neurol Sci 2024:1-21. [PMID: 38312020 DOI: 10.1017/cjn.2024.16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2024]
Abstract
Autoimmune encephalitis is increasingly recognized as a neurologic cause of acute mental status changes with similar prevalence to infectious encephalitis. Despite rising awareness, approaches to diagnosis remain inconsistent and evidence for optimal treatment is limited. The following Canadian guidelines represent a consensus and evidence (where available) based approach to both the diagnosis and treatment of adult patients with autoimmune encephalitis. The guidelines were developed using a modified RAND process and included input from specialists in autoimmune neurology, neuropsychiatry and infectious diseases. These guidelines are targeted at front line clinicians and were created to provide a pragmatic and practical approach to managing such patients in the acute setting.
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Affiliation(s)
- Christopher Hahn
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Adrian Budhram
- Clinical Neurological Sciences, London Health Sciences Centre, London, ON, Canada
- Department of Pathology and Laboratory Medicine, Western University, London Health Sciences Centre, London, ON, Canada
| | - Katayoun Alikhani
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Nasser AlOhaly
- Division of Neurology, University of Toronto, Toronto, ON, Canada
| | - Grayson Beecher
- Division of Neurology, University of Alberta, Edmonton, AB, Canada
| | - Gregg Blevins
- Division of Neurology, University of Alberta, Edmonton, AB, Canada
| | - John Brooks
- Division of Neurology, University of Toronto, Toronto, ON, Canada
| | - Robert Carruthers
- Division of Neurology, University of British Columbia, Vancouver, BC, Canada
| | - Jacynthe Comtois
- Neurosciences, Universite de Montreal Faculte de Medecine, Montreal, QC, Canada
| | - Juthaporn Cowan
- Division of Infectious Diseases, Department of Medicine Ottawa Hospital, Ottawa, ON, Canada
| | - Paula de Robles
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
- Department of Oncology, University of Calgary, Calgary, AB, Canada
| | - Julien Hébert
- Division of Neurology, University of Toronto, Toronto, ON, Canada
| | - Ronak K Kapadia
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Sarah Lapointe
- Neurosciences, Universite de Montreal Faculte de Medecine, Montreal, QC, Canada
| | - Aaron Mackie
- Department of Psychiatry, University of Calgary, Calgary, AB, Canada
| | - Warren Mason
- Division of Neurology, University of Toronto, Toronto, ON, Canada
| | - Brienne McLane
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
- Department of Psychiatry, University of Calgary, Calgary, AB, Canada
| | | | - Ilia Poliakov
- Division of Neurology, University of Saskatchewan College of Medicine, Saskatoon, SK, Canada
| | - Penelope Smyth
- Division of Neurology, University of Alberta, Edmonton, AB, Canada
| | | | - Christopher Uy
- Division of Neurology, University of British Columbia, Vancouver, BC, Canada
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13
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Thiel S, Hellwig K. Anti-CD20 therapy in pregnancy: Balancing risks and benefits. Mult Scler 2024; 30:274-275. [PMID: 38149611 DOI: 10.1177/13524585231222125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2023]
Affiliation(s)
- Sandra Thiel
- Department of Neurology, St. Josef Hospital, Katholisches Klinikum Bochum, Ruhr University Bochum, Bochum, Germany
| | - Kerstin Hellwig
- Department of Neurology, St. Josef Hospital, Katholisches Klinikum Bochum, Ruhr University Bochum, Bochum, Germany
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14
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Siriratnam P, Huda S, Butzkueven H, van der Walt A, Jokubaitis V, Monif M. Risks and outcomes of pregnancy in neuromyelitis optica spectrum disorder: A comprehensive review. Autoimmun Rev 2024; 23:103499. [PMID: 38061621 DOI: 10.1016/j.autrev.2023.103499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 11/30/2023] [Indexed: 04/30/2024]
Abstract
Neuromyelitis optica spectrum disorder (NMOSD) is a rare central nervous system autoimmune disease. Aquaporin-4 antibody (AQP4-IgG) is present in over 75% of cases and criteria also exist for the diagnosis of seronegative NMOSD. AQP4-IgG NMOSD has a strong female predominance (9:1 ratio), with a median onset age of 40 years. Pregnancy in those with NMOSD is therefore an important topic. Fecundity in NMOSD is likely impaired, and for females who conceive, obstetric complications including miscarriages and pre-eclampsia are significantly higher in NMOSD compared to the general population and in related conditions such as multiple sclerosis (MS). In contrast to MS, NMOSD disease activity does not subside during pregnancy. Also, relapse risk substantially rises above pre-pregnancy rates in the early postpartum period. In view of the evolving landscape of NMOSD, we provide a contemporary update of the impacts of pregnancy in NMOSD.
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Affiliation(s)
- Pakeeran Siriratnam
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia; Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
| | - Saif Huda
- Department of Neurology, Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Helmut Butzkueven
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia; Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
| | - Anneke van der Walt
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia; Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
| | - Vilija Jokubaitis
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia; Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
| | - Mastura Monif
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia; Department of Neurology, Alfred Health, Melbourne, Victoria, Australia; Department of Neurology, The Royal Melbourne Hospital, Parkville, VIC, Australia.
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15
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Kanitthamniyom C, Siladech P, Polpichai N, McCullough M, Saowapa S. Combined life-threatening internal organ bleeding and postpartum hemorrhage associated with acquired hemophilia A. Clin Case Rep 2024; 12:e8399. [PMID: 38173887 PMCID: PMC10761610 DOI: 10.1002/ccr3.8399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 12/06/2023] [Accepted: 12/14/2023] [Indexed: 01/05/2024] Open
Abstract
Key Clinical Message Acquired hemophilia A (AHA) can present as life-threatening bleeding during the postpartum period. Prompt treatment allows patients with AHA to achieve complete remission and have normal subsequent pregnancies. Abstract Acquired hemophilia A (AHA) is a rare bleeding disorder caused by the production of autoantibodies against factor VIII (FVIII). AHA can present with severe bleeding, especially in postpartum patient. We report a 38-year-old woman who presented in an emergency department with severe postpartum hemorrhage 2 weeks after cesarean section. Her investigation showed an isolated prolongation of partial thromboplastin time (PTT), low factor VIII assay and a factor VIII inhibitor test, resulting in abnormal Bethesda units which consistent with AHA. This case report highlights the importance of early diagnosis and treatment of AHA. With timely and appropriate management, most patients can achieve a good outcome.
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Affiliation(s)
| | | | - Natchaya Polpichai
- Department of Internal Medicine Louis A Weiss Memorial HospitalMahidol UniversityBangkokThailand
| | - Maireigh McCullough
- Internal Medicine DepartmentTexas Tech University Health Sciences CenterLubbockTexasUSA
| | - Sakditad Saowapa
- Internal Medicine DepartmentTexas Tech University Health Sciences CenterLubbockTexasUSA
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16
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Lin J, Wang TF, Huang MJ, Huang HB, Chen PF, Zhou Y, Dai WC, Zhou L, Feng XS, Wang HL. Recombinant human thrombopoietin therapy for primary immune thrombocytopenia in pregnancy: a retrospective comparative cohort study. BMC Pregnancy Childbirth 2023; 23:820. [PMID: 38012579 PMCID: PMC10680270 DOI: 10.1186/s12884-023-06134-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 11/17/2023] [Indexed: 11/29/2023] Open
Abstract
BACKGROUND Treatment options for pregnant women with immune thrombocytopenia (ITP) who do not respond to first-line treatment are limited. Few studies have reported the use of recombinant human thrombopoietin (rhTPO) for this subset of patients. AIMS To investigate the efficacy and safety of rhTPO in ITP during pregnancy and determine obstetric outcomes and predictors of treatment response. METHODS From July 2013 to October 2022, the data of 81 pregnant women with ITP and a platelet count < 30 × 109/L who did not respond to steroids and/or intravenous immunoglobulin were retrospectively analysed. Of these patients, 33 received rhTPO treatment (rhTPO group) while 48 did not (control group). Baseline characteristics, haematological disease outcomes before delivery, obstetric outcomes, and adverse events were compared between groups. In the rhTPO group, a generalised estimating equation (GEE) was used to investigate the factors influencing the response to rhTPO treatment. RESULTS The baseline characteristics were comparable between both groups (P > 0.05, both). Compared with controls, rhTPO patients had higher platelet counts (median [interquartile range]: 42 [21.5-67.5] vs. 25 [19-29] × 109/L, P = 0.002), lower bleeding rate (6.1% vs. 25%, P = 0.027), and lower platelet transfusion rate before delivery (57.6% vs. 97.9%, P < 0.001). Gestational weeks of delivery (37.6 [37-38.4] vs 37.1 [37-37.2] weeks, P = 0.001) were longer in the rhTPO group than in the control group. The rates of caesarean section, postpartum haemorrhage, foetal or neonatal complications, and complication types in both groups were similar (all P > 0.05). No liver or renal function impairment or thrombosis cases were observed in the rhTPO group. GEE analysis revealed that the baseline mean platelet volume (MPV) (odds ratio [OR]: 0.522, P = 0.002) and platelet-to-lymphocyte ratio (PLR) (OR: 1.214, P = 0.025) were predictors of response to rhTPO treatment. CONCLUSION rhTPO may be an effective and safe treatment option for pregnancies with ITP that do not respond to first-line treatment; it may have slightly prolonged the gestational age of delivery. Patients with a low baseline MPV and high baseline PLR may be more responsive to rhTPO treatment. The present study serves as a foundation for future research.
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Affiliation(s)
- Jing Lin
- Department of Ob and Gyn, Fujian Medical University Union Hospital, Fuzhou, China
| | - Tong-Fei Wang
- Department of Ob and Gyn, Fujian Medical University Union Hospital, Fuzhou, China
| | - Mei-Juan Huang
- Fujian Institute of Haematology, Fujian Provincial Key Laboratory of Haematology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Hao-Bo Huang
- Department of Blood Transfusion, Fujian Medical University Union Hospital, Fuzhou, China
| | - Pei-Fang Chen
- Department of Ob and Gyn, Fujian Medical University Union Hospital, Fuzhou, China
| | - Yu Zhou
- Department of Ob and Gyn, Fujian Medical University Union Hospital, Fuzhou, China
| | - Wei-Chao Dai
- Department of Ob and Gyn, Fujian Medical University Union Hospital, Fuzhou, China
| | - Ling Zhou
- Department of Ob and Gyn, Fujian Medical University Union Hospital, Fuzhou, China
| | - Xiu-Shan Feng
- Department of Ob and Gyn, Fujian Medical University Union Hospital, Fuzhou, China.
| | - Hui-Lan Wang
- Department of Ob and Gyn, Fujian Medical University Union Hospital, Fuzhou, China.
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17
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Peritore L, Labbozzetta V, Maressa V, Casuscelli C, Conti G, Gembillo G, Santoro D. How to Choose the Right Treatment for Membranous Nephropathy. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1997. [PMID: 38004046 PMCID: PMC10673286 DOI: 10.3390/medicina59111997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 10/30/2023] [Accepted: 11/12/2023] [Indexed: 11/26/2023]
Abstract
Membranous nephropathy is an autoimmune disease affecting the glomeruli and is one of the most common causes of nephrotic syndrome. In the absence of any therapy, 35% of patients develop end-stage renal disease. The discovery of autoantibodies such as phospholipase A2 receptor 1, antithrombospondin and neural epidermal growth factor-like 1 protein has greatly helped us to understand the pathogenesis and enable the diagnosis of this disease and to guide its treatment. Depending on the complications of nephrotic syndrome, patients with this disease receive supportive treatment with diuretics, ACE inhibitors or angiotensin-receptor blockers, lipid-lowering agents and anticoagulants. After assessing the risk of progression of end-stage renal disease, patients receive immunosuppressive therapy with various drugs such as cyclophosphamide, steroids, calcineurin inhibitors or rituximab. Since immunosuppressive drugs can cause life-threatening side effects and up to 30% of patients do not respond to therapy, new therapeutic approaches with drugs such as adrenocorticotropic hormone, belimumab, anti-plasma cell antibodies or complement-guided drugs are currently being tested. However, special attention needs to be paid to the choice of therapy in secondary forms or in specific clinical contexts such as membranous disease in children, pregnant women and patients undergoing kidney transplantation.
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Affiliation(s)
- Luigi Peritore
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy; (V.L.); (V.M.); (C.C.)
| | - Vincenzo Labbozzetta
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy; (V.L.); (V.M.); (C.C.)
| | - Veronica Maressa
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy; (V.L.); (V.M.); (C.C.)
| | - Chiara Casuscelli
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy; (V.L.); (V.M.); (C.C.)
| | - Giovanni Conti
- Pediatric Nephrology Unit, AOU Policlinic “G Martino”, University of Messina, 98125 Messina, Italy;
| | - Guido Gembillo
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy; (V.L.); (V.M.); (C.C.)
| | - Domenico Santoro
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy; (V.L.); (V.M.); (C.C.)
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18
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Scully M, Rayment R, Clark A, Westwood JP, Cranfield T, Gooding R, Bagot CN, Taylor A, Sankar V, Gale D, Dutt T, McIntyre J, Lester W. A British Society for Haematology Guideline: Diagnosis and management of thrombotic thrombocytopenic purpura and thrombotic microangiopathies. Br J Haematol 2023; 203:546-563. [PMID: 37586700 DOI: 10.1111/bjh.19026] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 07/21/2023] [Accepted: 07/26/2023] [Indexed: 08/18/2023]
Abstract
The objective of this guideline is to provide healthcare professionals with clear, up-to-date and practical guidance on the management of thrombotic thrombocytopenic purpura (TTP) and related thrombotic microangiopathies (TMAs), including complement-mediated haemolytic uraemic syndrome (CM HUS); these are defined by thrombocytopenia, microangiopathic haemolytic anaemia (MAHA) and small vessel thrombosis. Within England, all TTP cases should be managed within designated regional centres as per NHSE commissioning for highly specialised services.
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Affiliation(s)
- M Scully
- Department of Haematology, UCLH and Haematology Programme, University College London Hospitals Biomedical Research Centre, National Institute for Health Research, London, UK
| | - R Rayment
- Department of Haematology, University Hospital of Wales, Cardiff, UK
| | - A Clark
- Department of Haematology, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | | | - T Cranfield
- Department of Haematology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - R Gooding
- Haematology Department, Belfast City Hospital, Belfast H&SC Trust, Belfast, UK
| | - C N Bagot
- Glasgow Royal Infirmary, Glasgow, UK
| | - A Taylor
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - V Sankar
- Department of Critical Care Medicine, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - D Gale
- Department of Renal Medicine, University College London, London, UK
| | - T Dutt
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | | | - W Lester
- Department of Haematology, University Hospitals Birmingham, Birmingham, UK
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19
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Farooq F, Brandt JS, Cardonick E, Polushkina E, Vose J, Ahmed S, Ramakrishnan Geethakumari P, Olszewski AJ, Yasin H, Farooq U, Hamad N, Lin Y, Maggen C, Fruscio R, Gziri MM, Steffensen KD, Amant F, Evens AM. An international real-world analysis of relapsed/refractory lymphoma occurring during pregnancy. Blood Adv 2023; 7:5480-5484. [PMID: 37259563 PMCID: PMC10515306 DOI: 10.1182/bloodadvances.2023010090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 04/07/2023] [Accepted: 04/30/2023] [Indexed: 06/02/2023] Open
Affiliation(s)
- Faheem Farooq
- Division of Blood Disorders, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Justin S. Brandt
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Elyce Cardonick
- Maternal-Fetal Medicine, Cooper University Hospital, Camden, NJ
| | - Evgeniya Polushkina
- National Medical Research Centre for Obstetrics, Gynaecology and Perinatology named after Academician V.I. Kulakov of the Ministry of Healthcare of the Russian Federation, Moscow, Russia
| | - Julie Vose
- Division of Hematology & Oncology, Department of Internal Medicine, University of Nebraska Medical Center, Fred and Pamela Buffett Cancer Center, Omaha, NE
| | | | - Praveen Ramakrishnan Geethakumari
- Division of Hematologic Malignancies and Cellular Therapy, Harold C. Simmons Comprehensive Cancer Center, The University of Texas Southwestern Medical Center, Dallas, TX
| | | | - Hesham Yasin
- Hematology/Oncology and Blood & Marrow Transplantation, University of Iowa, Iowa City, IA
| | - Umar Farooq
- Hematology/Oncology and Blood & Marrow Transplantation, University of Iowa, Iowa City, IA
| | - Nada Hamad
- Department of Haematology and Bone Marrow Transplantation, St Vincent’s Hospital, Sydney, Australia
| | - Yong Lin
- Division of Blood Disorders, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | | | - Robert Fruscio
- University of Milan – Bicocca, San Gerardo Hospital, Monza, Italy
| | - Mina Mhallem Gziri
- Department of Obstetrics, Cliniques Universitaires Saint-Luc, Woluwe-Saint-Lambert, Belgium
| | - Karina Dahl Steffensen
- Center for Shared Decsion Making, Lillebaelt University Hospital of Southern Denmark, Vejle, Denmark
| | - Frédéric Amant
- Center for Gynecological Oncology, University of Amsterdam, Amsterdam, The Netherlands
| | - Andrew M. Evens
- Division of Blood Disorders, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
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20
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Minoia C, Viviani S, Silvestris E, Palini S, Parissone F, De Palma G, Fedina A, Cormio G, Guarini A, Gini G, Montano L, Merli F, Peccatori FA. Fertility preservation and monitoring in adult patients diagnosed with lymphoma: consensus-based practical recommendations by the Fondazione Italiana Linfomi & Società Italiana della Riproduzione Umana. Front Oncol 2023; 13:1252433. [PMID: 37766870 PMCID: PMC10520955 DOI: 10.3389/fonc.2023.1252433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 08/21/2023] [Indexed: 09/29/2023] Open
Abstract
Introduction Fertility preservation (FP) and monitoring has considerable relevance in the multidisciplinary approach to cancer patients. In these consensus-based practical recommendations, the scientific societies Fondazione Italiana Linfomi (FIL) and Società Italiana della Riproduzione Umana (SIRU) reviewed the main aspects and identified the optimal paths which aim to preserve and monitor fertility in patients diagnosed with lymphoma at the different phases of the disease and during long-term survivorship. Methods For the Panel, eleven experts were selected for their expertise in research and clinical practice on onco-fertility and lymphoma. The Panel's activity was supervised by a chairman. A series of rank-ordering key questions were proposed according to their clinical relevance and discussed among the Panel, focusing on patients diagnosed with non-Hodgkin's lymphomas and Hodgkin lymphoma. Agreement among all the Panelists on the content and terminology of the statements was evaluated by a web-based questionnaire according to the Delphi methodology. Results From the literature review a total of 78 questions or sentences, divided into the 6 areas of interest, were identified. By applying the Gwet's AC, k was: Section 1: 0,934 (Very good); Section 2: 0,958 (Very good); Section 3: 0,863 (Very good); Section 4: 0,649 (Good); Section 5: 0,936 (Very good); Section 6 raw agreement 100%. Two rounds of Delphi allowed to provide the maximum agreement. All statements were newly discussed in a round robin way and confirmed for the drafting of the final recommendations. Discussion These recommendations would be useful for onco-hematologists, gynecologists, urologists, and general practice physicians who take care of young lymphoma patients to guarantee an evidence-based oncofertility assessment and treatment during the oncologic pathway.
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Affiliation(s)
- Carla Minoia
- Hematology Unit, IRCCS Istituto Tumori “Giovanni Paolo II”, Bari, Italy
| | - Simonetta Viviani
- Division of Onco-Hematology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Erica Silvestris
- Gynecologic Oncology Unit, IRCCS Istituto Tumori “Giovanni Paolo II”, Bari, Italy
| | - Simone Palini
- Physiopathology of Reproduction Unit, Cervesi Hospital, Cattolica, Italy
| | - Francesca Parissone
- Department of Obstetrics and Gynecology, Azienda Ospedaliera Universitaria Integrata di Verona, Università di Verona, Verona, Italy
| | - Giuseppe De Palma
- Institutional BioBank, Experimental Oncology and Biobank Management Unit, IRCCS Istituto Tumori “Giovanni Paolo II”, Bari, Italy
| | - Anna Fedina
- Data Office Fondazione Italiana Linfomi, Alessandria, Italy
| | - Gennaro Cormio
- IRCCS Istituto Tumori Departiment of Interdisciplinary Medicine (DIM), University of Bari, Bari, Italy
| | - Attilio Guarini
- Hematology Unit, IRCCS Istituto Tumori “Giovanni Paolo II”, Bari, Italy
| | - Guido Gini
- Clinic of Hematology Azienda Ospedaliera Universitaria (AOU) delle Marche, Ancona, Italy
| | - Luigi Montano
- Andrology Unit and Service of Lifestyle Medicine in UroAndrology, Local Health Authority (ASL), Salerno, Italy
| | - Francesco Merli
- Hematology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy
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21
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Liu C, Pace S, Bromley R, Dobson R. Exposure to medication for neurological disease in pregnancy - time to consider the long-term implications? EClinicalMedicine 2023; 63:102157. [PMID: 37662523 PMCID: PMC10474373 DOI: 10.1016/j.eclinm.2023.102157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 07/25/2023] [Accepted: 07/26/2023] [Indexed: 09/05/2023] Open
Abstract
A range of long-term neurological conditions may be diagnosed in young adulthood. These conditions are generally not curable, and most people need to take ongoing treatment for symptom control and/or disease modification. When chronic diseases are diagnosed before people have completed their families, there is a need to balance the potential benefits of treatment for the mother against potential risk(s) to the fetus from exposure to medications during pregnancy. Whilst available data regarding short-term fetal outcomes following treatment exposures during pregnancy is rapidly increasing, information regarding longer-term outcomes is more limited. The association of fetal exposure to valproate with serious long-term neurodevelopmental outcomes has highlighted the importance of capturing and evaluating long-term data. In this review we examine available evidence around the long-term effects of treatments used for the most common long-term neurological conditions diagnosed in early adulthood, namely epilepsy, migraine and neuroinflammatory disorders. We draw from existing literature across a range of diseases and discuss strategies to improve future knowledge.
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Affiliation(s)
- Chen Liu
- Preventive Neurology Unit, Wolfson Institute of Population Health, QMUL, UK
| | - Samuel Pace
- Department of Neurology, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Rebecca Bromley
- Division of Neuroscience, School of Biological Sciences, Faculty of Medicine, Biology and Health, University of Manchester, UK
- Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, UK
| | - Ruth Dobson
- Preventive Neurology Unit, Wolfson Institute of Population Health, QMUL, UK
- Department of Neurology, Royal London Hospital, Barts Health NHS Trust, London, UK
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22
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Yong HYF, Burton JM. A Clinical Approach to Existing and Emerging Therapeutics in Neuromyelitis Optica Spectrum Disorder. Curr Neurol Neurosci Rep 2023; 23:489-506. [PMID: 37540387 DOI: 10.1007/s11910-023-01287-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2023] [Indexed: 08/05/2023]
Abstract
PURPOSE OF REVIEW Neuromyelitis optica spectrum disorder (NMOSD) is a rare but highly disabling disease of the central nervous system. Unlike multiple sclerosis, disability in NMOSD occurs secondary to relapses that, not uncommonly, lead to blindness, paralysis, and death. Recently, newer, targeted immunotherapies have been trialed and are now in the treatment arsenal. We have endeavoured to evaluate the current state of NMOSD therapeutics. RECENT FINDINGS This review provides a pragmatic evaluation of recent clinical trials and post-marketing data for rituximab, inebilizumab, satralizumab, eculizumab, and ravalizumab, contrasted to older agents. We also review contemporary issues such as treatment in the context of SARS-CoV2 infection and pregnancy. There has been a dramatic shift in NMOSD morbidity and mortality with earlier and improved disease recognition, diagnostic accuracy, and the advent of more effective, targeted therapies. Choosing a maintenance therapy remains nuanced depending on patient factors and accessibility. With over 100 putative agents in trials, disease-free survival is now a realistic goal for NMOSD patients.
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Affiliation(s)
- Heather Y F Yong
- Division of Neurology, Department of Clinical Neurosciences, University of Calgary, Cummings School of Medicine, Calgary, AB, Canada
| | - Jodie M Burton
- Division of Neurology, Department of Clinical Neurosciences, University of Calgary, Cummings School of Medicine, Calgary, AB, Canada.
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada.
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23
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Pecher AC, Henes M, Henes JC. Optimal management of ANCA-associated vasculitis before and during pregnancy: current perspectives. Arch Gynecol Obstet 2023; 308:379-385. [PMID: 36104505 PMCID: PMC10293371 DOI: 10.1007/s00404-022-06744-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 08/12/2022] [Indexed: 11/02/2022]
Abstract
Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAV) are a group of systemic vasculitis characterized by autoantibodies against neutrophil cytoplasmic antigens (proteinase 3 PR3-ANCA and myeloperoxidase MPO-ANCA) and inflammation of small vessels. AAV include the diagnosis Granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA) and eosinophilic granulomatosis with polyangiitis (EGPA), which share many clinical and pathological features. Immunomodulatory therapies have significantly improved prognosis during the last decade. Nevertheless, especially in undiagnosed and thus uncontrolled AAV mortality due to renal impairment or pulmonary haemorrhages is still high. AAV are rare in fertile women, as the typical age of manifestation is above 50 years but there are women with AAV who are or want to become pregnant. This review focusses on how to manage patients with AAV planning to become pregnant and during their pregnancy.
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Affiliation(s)
- Ann-Christin Pecher
- Centre for Interdisciplinary Clinical Immunology, Rheumatology and Autoinflammatory Diseases and Department of Internal Medicine II, University Hospital Tuebingen, Otfried-Mueller-Strasse 10, 72076, Tuebingen, Germany
| | - Melanie Henes
- Department of Obstetrics and Gynaecology, University Hospital Tuebingen, Tuebingen, Germany
| | - Joerg Christoph Henes
- Centre for Interdisciplinary Clinical Immunology, Rheumatology and Autoinflammatory Diseases and Department of Internal Medicine II, University Hospital Tuebingen, Otfried-Mueller-Strasse 10, 72076, Tuebingen, Germany.
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Vakrakou AG, Karachaliou E, Chroni E, Zouvelou V, Tzanetakos D, Salakou S, Papadopoulou M, Tzartos S, Voumvourakis K, Kilidireas C, Giannopoulos S, Tsivgoulis G, Tzartos J. Immunotherapies in MuSK-positive Myasthenia Gravis; an IgG4 antibody-mediated disease. Front Immunol 2023; 14:1212757. [PMID: 37564637 PMCID: PMC10410455 DOI: 10.3389/fimmu.2023.1212757] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 07/05/2023] [Indexed: 08/12/2023] Open
Abstract
Muscle-specific kinase (MuSK) Myasthenia Gravis (MG) represents a prototypical antibody-mediated disease characterized by predominantly focal muscle weakness (neck, facial, and bulbar muscles) and fatigability. The pathogenic antibodies mostly belong to the immunoglobulin subclass (Ig)G4, a feature which attributes them their specific properties and pathogenic profile. On the other hand, acetylcholine receptor (AChR) MG, the most prevalent form of MG, is characterized by immunoglobulin (Ig)G1 and IgG3 antibodies to the AChR. IgG4 class autoantibodies are impotent to fix complement and only weakly bind Fc-receptors expressed on immune cells and exert their pathogenicity via interfering with the interaction between their targets and binding partners (e.g. between MuSK and LRP4). Cardinal differences between AChR and MuSK-MG are the thymus involvement (not prominent in MuSK-MG), the distinct HLA alleles, and core immunopathological patterns of pathology in neuromuscular junction, structure, and function. In MuSK-MG, classical treatment options are usually less effective (e.g. IVIG) with the need for prolonged and high doses of steroids difficult to be tapered to control symptoms. Exceptional clinical response to plasmapheresis and rituximab has been particularly observed in these patients. Reduction of antibody titers follows the clinical efficacy of anti-CD20 therapies, a feature implying the role of short-lived plasma cells (SLPB) in autoantibody production. Novel therapeutic monoclonal against B cells at different stages of their maturation (like plasmablasts), or against molecules involved in B cell activation, represent promising therapeutic targets. A revolution in autoantibody-mediated diseases is pharmacological interference with the neonatal Fc receptor, leading to a rapid reduction of circulating IgGs (including autoantibodies), an approach already suitable for AChR-MG and promising for MuSK-MG. New precision medicine approaches involve Chimeric autoantibody receptor T (CAAR-T) cells that are engineered to target antigen-specific B cells in MuSK-MG and represent a milestone in the development of targeted immunotherapies. This review aims to provide a detailed update on the pathomechanisms involved in MuSK-MG (cellular and humoral aberrations), fostering the understanding of the latest indications regarding the efficacy of different treatment strategies.
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Affiliation(s)
- Aigli G. Vakrakou
- First Department of Neurology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Eleni Karachaliou
- Second Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Elisabeth Chroni
- Department of Neurology, School of Medicine, University of Patras, Patras, Greece
| | - Vasiliki Zouvelou
- First Department of Neurology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Tzanetakos
- Second Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Stavroula Salakou
- Second Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Marianna Papadopoulou
- Second Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
- Department of Physiotherapy, University of West Attica, Athens, Greece
| | - Socrates Tzartos
- Tzartos NeuroDiagnostics, Athens, Greece
- Department of Neurobiology, Hellenic Pasteur Institute, Athens, Greece
- Department of Pharmacy, University of Patras, Patras, Greece
| | - Konstantinos Voumvourakis
- Second Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Constantinos Kilidireas
- First Department of Neurology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
- Department of Neurology, Henry Dunant Hospital Center, Athens, Greece
| | - Sotirios Giannopoulos
- Second Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Georgios Tsivgoulis
- Second Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
- Department of Neurology, The University of Tennessee Health Science Center, Memphis, TN, United States
| | - John Tzartos
- Second Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
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Wickenheisser NE, Craig AM, Kuller JA, Dotters-Katz SK. The Risks and Benefits of Monoclonal Antibody Therapy During Pregnancy and Postpartum: Maternal, Obstetric, and Neonatal Considerations. Obstet Gynecol Surv 2023; 78:429-437. [PMID: 37480293 DOI: 10.1097/ogx.0000000000001155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/24/2023]
Abstract
Importance Autoimmune and rheumatologic conditions can lead to multiple adverse maternal, obstetric, and neonatal outcomes, especially if they flare during pregnancy. Although many medications to control these conditions exist, concerns regarding their safety often unnecessarily limit their use. Objective We aim to review the current evidence available describing the use of monoclonal antibody (mAb) therapeutics in pregnancy and postpartum and understand the impact of their use on the developing fetus and neonate. Evidence Acquisition Original research articles, review articles, case series and case reports, and pregnancy guidelines were reviewed. Results Multiple retrospective (including 1924 patients) and prospective studies (including 899 patients) of anti-tumor necrosis factor (TNF) agent use in pregnancy found no significant increase in rates of miscarriage, preterm birth, or congenital anomalies compared with controls. Most societies, including American College of Obstetricians and Gynecologists and Society for Maternal-Fetal Medicine, recommend initiation or continuation of TNF-α inhibitors during pregnancy for patients with autoimmune diseases. An increased risk of mild infections in newborns has been reported, although infections requiring hospitalizations are rare. Data suggest that breastfeeding while taking anti-TNF agents is safe for neonates. Less data exist for the use of other mAbs including anticytokine, anti-integrin, and anti-B-cell agents during pregnancy and postpartum. Conclusions and Relevance Current evidence suggests that the use of mAbs, particularly anti-TNF agents, is safe in pregnancy and postpartum, without significant adverse effects on the pregnant patient or infant. The benefits of ongoing disease control in pregnant patients result in favorable maternal and neonatal outcomes.
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Affiliation(s)
| | | | | | - Sarah K Dotters-Katz
- Associate Professor of Obstetrics and Gynecology, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC
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Romano A, Mastrangelo S, Attina G, Maurizi P, Ruggiero A. Pregnancy-associated Cancer and Chemotherapy during Pregnancy. BIOMEDICAL AND PHARMACOLOGY JOURNAL 2023; 16:705-714. [DOI: 10.13005/bpj/2652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
The diagnosis of pregnancy-associated cancer, although rare, is a condition of great human and social significance and difficult clinical management. A pregnancy-associated neoplasm is defined as a cancer diagnosis made during pregnancy or within 12 months after delivery/abortion. The most common cancers in pregnancy occur most frequently in women of reproductive age with an incidence overall like that observed in non-pregnant women of the same age. This incidence is likely to increase in view of both the expected increase in certain malignancies among young women (particularly breast cancer and melanoma) and the increasing frequency of pregnancies undertaken later in life (fourth and fifth decades of life) that is characterizing modern society. Chemotherapy is generally contraindicated before 12 weeks of pregnancy due to the increased risk of congenital anomalies while exposure in the second and third trimester of pregnancy to chemotherapy has been associated with more growth restriction and preterm delivery. Clinical decisions about the optimal management should consider maternal and fetal characteristics with the involvement of a multidisciplinary team.
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Affiliation(s)
- Alberto Romano
- Pediatric Oncology Unit, Fondazione Policlinico Universitario A.Gemelli IRCCS, Universita’ Cattolica Sacro Cuore, Rome, Italy
| | - Stefano Mastrangelo
- Pediatric Oncology Unit, Fondazione Policlinico Universitario A.Gemelli IRCCS, Universita’ Cattolica Sacro Cuore, Rome, Italy
| | - Giorgio Attina
- Pediatric Oncology Unit, Fondazione Policlinico Universitario A.Gemelli IRCCS, Universita’ Cattolica Sacro Cuore, Rome, Italy
| | - Palma Maurizi
- Pediatric Oncology Unit, Fondazione Policlinico Universitario A.Gemelli IRCCS, Universita’ Cattolica Sacro Cuore, Rome, Italy
| | - Antonio Ruggiero
- Pediatric Oncology Unit, Fondazione Policlinico Universitario A.Gemelli IRCCS, Universita’ Cattolica Sacro Cuore, Rome, Italy
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Pirosa MC, Peccatori FA. Lymphomas in pregnancy. Hematol Oncol 2023; 41 Suppl 1:70-74. [PMID: 37294956 DOI: 10.1002/hon.3150] [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: 03/28/2023] [Accepted: 03/28/2023] [Indexed: 06/11/2023]
Abstract
Lymphoma in pregnancy is an uncommon occurrence. This diagnosis is challenging, and a multidisciplinary team of specialists in obstetrics, anesthesiology, neonatology, hematology psychology should participate in the management of this condition. The choice of treatment regimen depends on the histotype and the gestational age. In Hodgkin lymphoma, ABVD is safe if administered after the thirteenth week of pregnancy. In indolent non-Hodgkin Lymphomas (NHL) a watchful waiting approach is reasonable; in case of aggressive NHLs, if the diagnosis occurs in the first gestational weeks, a termination of the pregnancy might be considered or if it occurs after the thirteenth week of pregnancy, a standard R-CHOP regimen is safe. Regarding new anti-lymphoma drugs, available data on the potential fetotoxicity of these agents are limited. Data collection regarding the use of new drugs in pregnant patients is mandatory in order to learn more about their safety and facilitating clinical decision making in this setting of patients.
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Affiliation(s)
- Maria Cristina Pirosa
- Clinic of Medical Oncology, Oncology Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
- Faculty of Biomedical Science, Università della Svizzera italiana, Lugano, Switzerland
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28
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Mills GS, Chadwick V, Tang C, Perram J, Anderson MA, Anazodo A, Kidson-Gerber G, Shand A, Lavee O, Withers B, Milliken S, Di Ciaccio PR, Hamad N. Immunochemotherapy for life-threatening haematological malignancies in pregnancy: a systematic review of the literature and cross-sectional analysis of clinical trial eligibility. Lancet Haematol 2023; 10:e458-e467. [PMID: 37263722 DOI: 10.1016/s2352-3026(23)00059-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 03/01/2023] [Accepted: 03/03/2023] [Indexed: 06/03/2023]
Abstract
The management of potentially life-threatening malignancies in pregnancy is complicated by a lack of robust safety and efficacy evidence. This data shortage stems from a historical exclusion of women of childbearing potential from prospective clinical trials due to concerns around potential teratogenicity and toxicity of investigational agents. We conducted a systematic review of published data on immunochemotherapeutic treatment of life-threatening haematological malignancies in pregnancy between 2010 and 2022, and the maternal and neonatal outcomes. We then performed a cross-sectional observational study of clinical trial protocols on ClinicalTrials.gov, between 2016 and 2022, recruiting women of childbearing potential with potentially life-threatening haematological malignancies, collecting trial demographic data, and documenting whether pregnant or lactating women were explicitly excluded, along with the type and duration of contraception required for women of childbearing potential. We included 17 studies for analysis in our systematic review. A total of 595 women were treated with immunochemotherapy during pregnancy, with a median age of 29 years (range 14-48). Of these, 81 women (14%) were treated in the first trimester, and 514 (86%) were treated in the second and third trimesters collectively. In total, 68 trials for acute myeloid leukaemia, acute lymphocytic leukaemia, high-grade non-Hodgkin lymphoma, and Hodgkin lymphoma (40%, 26%, 21%, and 13%, respectively) were included in our ClinicalTrials.gov analysis. Most protocols (66 [97%]) explicitly excluded pregnant women, with 40 (69%) not providing a rationale for exclusion. The potential harm to the fetus from anti-cancer therapy has historically been given greater moral precedence than a pregnant woman's autonomy. This pattern is reflected in the lack of rigorous evidence for immunochemotherapy in pregnancy and a universal exclusion of pregnant and lactating women from clinical trial protocols in this study. Nonetheless, the administration of systemic chemotherapy in the second and third trimesters was not associated with an increased rate of congenital malformations or perinatal mortality in our systematic review cohort, with maternal outcomes broadly comparable to those of the non-pregnant population.
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Affiliation(s)
- Georgia S Mills
- Department of Haematology, Northern Beaches Hospital, Frenchs Forest, NSW, Australia; Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia; Faculty of Medicine, Macquarie University, North Ryde, NSW, Australia.
| | - Verity Chadwick
- Department of Haematology and Bone Marrow Transplant, St Vincent's Hospital, Darlinghurst, NSW, Australia
| | - Catherine Tang
- Department of Haematology, Gosford Hospital, Gosford, NSW, Australia
| | - Jacinta Perram
- Department of Haematology and Bone Marrow Transplant, St Vincent's Hospital, Darlinghurst, NSW, Australia; Department of Haematology and Bone Marrow Transplant, Westmead Hospital, Westmead, NSW, Australia
| | - Mary Ann Anderson
- Department of Clinical Haematology, The Royal Melbourne Hospital and Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; Division of Blood Cells and Blood Cancer, The Walter and Eliza Hall Institute, Parkville, VIC, Australia
| | - Antoinette Anazodo
- Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia; Kids Cancer Centre, Sydney Children's Hospital, Randwick, NSW, Australia
| | - Giselle Kidson-Gerber
- Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia; Department of Maternal Fetal Medicine, Royal Hospital for Women, Randwick, NSW, Australia; Department of Haematology, Prince of Wales Hospital, Randwick, NSW, Australia
| | - Antonia Shand
- Department of Maternal Fetal Medicine, Royal Hospital for Women, Randwick, NSW, Australia; Faculty of Medicine, University of Sydney, Sydney, NSW, Australia
| | - Orly Lavee
- Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia; Department of Haematology and Bone Marrow Transplant, St Vincent's Hospital, Darlinghurst, NSW, Australia
| | - Barbara Withers
- Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia; Department of Haematology and Bone Marrow Transplant, St Vincent's Hospital, Darlinghurst, NSW, Australia
| | - Sam Milliken
- Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia; Department of Haematology and Bone Marrow Transplant, St Vincent's Hospital, Darlinghurst, NSW, Australia
| | - Pietro R Di Ciaccio
- Department of Haematology, Sydney Adventist Hospital, Sydney, NSW, Australia; College of Health and Medicine, Australian National University, Canberra, ACT, Australia
| | - Nada Hamad
- Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia; Department of Haematology and Bone Marrow Transplant, St Vincent's Hospital, Darlinghurst, NSW, Australia; Faculty of Medicine, University of Notre Dame, Sydney, NSW, Australia
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29
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Sorouri K, Loren AW, Amant F, Partridge AH. Patient-Centered Care in the Management of Cancer During Pregnancy. Am Soc Clin Oncol Educ Book 2023; 43:e100037. [PMID: 37220323 DOI: 10.1200/edbk_100037] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
The management of cancer during pregnancy requires a patient-centered, multidisciplinary approach to balance maternal and fetal well-being given the rarity of this clinical scenario and lack of substantial data. Involvement of oncology and nononcology medical specialists and ethical, legal, and psychosocial supports, as needed, is instrumental in navigating the complexities of care for this patient population. Critical periods of fetal development and physiological changes in pregnancy must be considered when planning diagnostic and therapeutic approaches during pregnancy. The complexity of symptom recognition and interventional approaches contributes to diagnostic delays of cancers during pregnancy. Ultrasound and whole-body diffusion-weighted magnetic resonance imaging are safe throughout pregnancy. Surgery can be safely performed throughout pregnancy, with the early second trimester preferred for intra-abdominal surgery. Chemotherapy can be safely administered after 12-14 weeks of gestation until 1-3 weeks before the anticipated delivery. Most targeted and immunotherapeutic agents are contraindicated during pregnancy because of limited data. Pelvic radiation during pregnancy is absolutely contraindicated, while if radiation to the upper body is needed, administration should only be considered early in pregnancy. To ensure that the total cumulative fetal exposure to ionizing radiation does not exceed 100 mGy, early inclusion of the radiology team in the care plan is required. Closer prenatal monitoring is recommended for maternal and fetal treatment-related toxicities. Delivery before 37 weeks of gestation should be avoided if possible, and vaginal delivery is preferred unless obstetrically indicated or specific clinical scenarios. Postpartum, breastfeeding should be discussed, and the neonate should receive blood work to assess for acute toxicities with follow-up arranged for long-term monitoring.
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Affiliation(s)
- Kimia Sorouri
- Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | - Alison W Loren
- Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA
| | - Frédéric Amant
- Netherlands Cancer Institute, Amsterdam, the Netherlands
- KU Leuven, Leuven, Belgium
- University of Amsterdam, Amsterdam, the Netherlands
| | - Ann H Partridge
- Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
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30
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Deer E, Herrock O, Campbell N, Cornelius D, Fitzgerald S, Amaral LM, LaMarca B. The role of immune cells and mediators in preeclampsia. Nat Rev Nephrol 2023; 19:257-270. [PMID: 36635411 PMCID: PMC10038936 DOI: 10.1038/s41581-022-00670-0] [Citation(s) in RCA: 41] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2022] [Indexed: 01/14/2023]
Abstract
Preeclampsia is a hypertensive disorder of major concern in pregnancy than can lead to intrauterine growth restriction, placental abruption and stillbirth. The pathophysiology of preeclampsia is multifactorial, including not only kidney dysfunction but also endothelial dysfunction, as the maternal endothelium becomes exposed to placental factors that are released into the circulation and increase systemic levels of vasoconstrictors, oxidative stress, anti-angiogenic factors and inflammatory mediators. Importantly, inflammation can lead to insufficient placental perfusion and low birthweight in offspring. Various innate and adaptive immune cells and mediators have been implicated in the development of preeclampsia, in which oxidative stress is associated with activation of the maternal inflammatory response. Immune cells such as regulatory T cells, macrophages, natural killer cells, and neutrophils are known to have major causative roles in the pathology of preeclampsia, but the contributions of additional immune cells such as B cells, inflammatory cytokines and anti-angiotensin II type 1 receptor autoantibodies are also now recognized. Immunological interventions, therefore, have therapeutic potential in this disease. Here, we provide an overview of the immune responses that are involved in the pathogenesis of preeclampsia, including the role of innate and adaptive immune cells and mediators.
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Affiliation(s)
- Evangeline Deer
- Department of Pharmacology & Toxicology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Owen Herrock
- Department of Pharmacology & Toxicology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Nathan Campbell
- Department of Pharmacology & Toxicology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Denise Cornelius
- Emergency Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Sarah Fitzgerald
- Department of Pharmacology & Toxicology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Lorena M Amaral
- Department of Pharmacology & Toxicology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Babbette LaMarca
- Department of Pharmacology & Toxicology, University of Mississippi Medical Center, Jackson, MS, USA.
- Department of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson, MS, USA.
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31
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Bruzzese A, Vigna E, Martino EA, Mendicino F, Lucia E, Olivito V, Mazzulla R, De Rose S, Cozza PP, Bova C, Filippelli G, Zinno F, Morelli M, Morabito F, Gentile M. Safety and efficacy of caplacizumab in a case of thrombotic thrombocytopenic purpura in the postpartum period. Blood Coagul Fibrinolysis 2023; 34:215-217. [PMID: 36730001 DOI: 10.1097/mbc.0000000000001186] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a rare and life-threatening disease for which pregnancy and the postpartum period represent risk factors. Here, we present the case of a 39-year-old woman at the 31st week of gestation, who presented with cutaneous haemorrhagic symptoms. The complete blood count showed anaemia, thrombocytopenia, increase in haemolysis indices and undetectable ADAMTS13 activity. Acquired TTP was diagnosed, and she started daily plasma exchange (PEX) and methylprednisolone. After 5 days, an emergency caesarean section was performed with success because of pathologic cardiotocographic findings. After 7 days of PEX, the patient showed an initial laboratoristic improvement; unfortunately, 3 days later, she had a recurrence of disease and started daily PEX, caplacizumab and steroid, obtaining a haematological improvement. No literature data about caplacizumab use in pregnant or breastfeeding patients are available. In the present study, we describe that caplacizumab in the postpartum period could be well tolerated and effective.
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Silver R, Craigo S, Porter F, Osmundson SS, Kuller JA, Norton ME. Society for Maternal-Fetal Medicine Consult Series #64: Systemic lupus erythematosus in pregnancy. Am J Obstet Gynecol 2023; 228:B41-B60. [PMID: 36084704 DOI: 10.1016/j.ajog.2022.09.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Systemic lupus erythematosus (SLE) is a chronic, multisystem, inflammatory autoimmune disease characterized by relapses (commonly called "flares") and remission. Many organs may be involved, and although the manifestations are highly variable, the kidneys, joints, and skin are commonly affected. Immunologic abnormalities, including the production of antinuclear antibodies, are also characteristic of the disease. Maternal morbidity and mortality are substantially increased in patients with systemic lupus erythematosus, and an initial diagnosis of systemic lupus erythematosus during pregnancy is associated with increased morbidity. Common complications of systemic lupus erythematosus include nephritis, hematologic complications such as thrombocytopenia, and a variety of neurologic abnormalities. The purpose of this document is to examine potential pregnancy complications and to provide recommendations on treatment and management of systemic lupus erythematosus during pregnancy. The following are the Society for Maternal-Fetal Medicine recommendations: (1) we recommend low-dose aspirin beginning at 12 weeks of gestation until delivery in patients with systemic lupus erythematosus to decrease the occurrence of preeclampsia (GRADE 1B); (2) we recommend that all patients with systemic lupus erythematosus, other than those with quiescent disease, either continue or initiate hydroxychloroquine (HCQ) in pregnancy (GRADE 1B); (3) we suggest that for all other patients with quiescent disease activity who are not taking HCQ or other medications, it is reasonable to engage in shared decision-making regarding whether to initiate new therapy with this medication in consultation with the patient's rheumatologist (GRADE 2B); (4) we recommend that prolonged use (>48 hours) of nonsteroidal antiinflammatory drugs (NSAIDs) generally be avoided during pregnancy (GRADE 1A); (5) we recommend that COX-2 inhibitors and full-dose aspirin be avoided during pregnancy (GRADE 1B); (6) we recommend discontinuing methotrexate 1-3 months and mycophenolate mofetil/mycophenolic acid at least 6 weeks before attempting pregnancy (GRADE 1A); (7) we suggest the decision to initiate, continue, or discontinue biologics in pregnancy be made in collaboration with a rheumatologist and be individualized to the patient (GRADE 2C); (8) we suggest treatment with a combination of prophylactic unfractionated or low-molecular-weight heparin and low-dose aspirin for patients without a previous thrombotic event who meet obstetrical criteria for antiphospholipid syndrome (APS) (GRADE 2B); (9) we recommend therapeutic unfractionated or low-molecular-weight heparin for patients with a history of thrombosis and antiphospholipid (aPL) antibodies (GRADE 1B); (10) we suggest treatment with low-dose aspirin alone in patients with systemic lupus erythematosus and antiphospholipid antibodies without clinical events meeting criteria for antiphospholipid syndrome (GRADE 2C); (11) we recommend that steroids not be routinely used for the treatment of fetal heart block due to anti-Sjögren's-syndrome-related antigen A or B (anti-SSA/SSB) antibodies given their unproven benefit and the known risks for both the pregnant patient and fetus (GRADE 1C); (12) we recommend that serial fetal echocardiograms for assessment of the PR interval not be routinely performed in patients with anti-SSA/SSB antibodies outside of a clinical trial setting (GRADE 1B); (13) we recommend that patients with systemic lupus erythematosus undergo prepregnancy counseling with both maternal-fetal medicine and rheumatology specialists that includes a discussion regarding maternal and fetal risks (GRADE 1C); (14) we recommend that pregnancy be generally discouraged in patients with severe maternal risk, including patients with active nephritis; severe pulmonary, cardiac, renal, or neurologic disease; recent stroke; or pulmonary hypertension (GRADE 1C); (15) we recommend antenatal testing and serial growth scans in pregnant patients with systemic lupus erythematosus because of the increased risk of fetal growth restriction (FGR) and stillbirth (GRADE 1B); and (16) we recommend adherence to the Centers for Disease Control and Prevention medical eligibility criteria for contraceptive use in patients with systemic lupus erythematosus (GRADE 1B).
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Ejaz A, O’Doherty C, Sharpley FA, Curry N, Shapiro S, Desborough MJR. Acquired haemophilia A diagnosed during pregnancy. Obstet Med 2023; 16:56-58. [PMID: 37139513 PMCID: PMC10150309 DOI: 10.1177/1753495x211049987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 08/28/2021] [Accepted: 09/08/2021] [Indexed: 11/16/2022] Open
Abstract
Pregnancy-associated haemophilia A is an uncommon, acquired bleeding disorder which usually presents post-partum; very rarely it may present during pregnancy. No consensus guidelines exist on the management of this condition in pregnancy and very few cases have been reported in the literature. Here we describe the case of a woman presenting with acquired haemophilia A during pregnancy and outline the management of her bleeding disorder. We contrast her case with that of two other women, presenting to the same tertiary referral centre, with acquired haemophilia A presenting post-partum. These cases highlight the heterogeneous management of this condition and how it may be successfully managed in pregnancy.
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Affiliation(s)
- Ayesha Ejaz
- Oxford Haemophilia and Thrombosis
Centre, Oxford, UK
| | | | | | - Nicola Curry
- Oxford Haemophilia and Thrombosis
Centre, Oxford, UK
- NIHR Oxford Biomedical Research Centre,
Oxford, UK
| | - Susan Shapiro
- Oxford Haemophilia and Thrombosis
Centre, Oxford, UK
- NIHR Oxford Biomedical Research Centre,
Oxford, UK
| | - Michael J R Desborough
- NIHR Oxford Biomedical Research Centre,
Oxford, UK
- Department of Haematology, John Radcliffe Hospital, Oxford UK
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34
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Graham EL. Neuroimmunological Disorders. Neurol Clin 2023; 41:315-330. [PMID: 37030960 DOI: 10.1016/j.ncl.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
Multiple sclerosis is a disease that tends to affect women during their childbearing years. Although relapse risk decreases during pregnancy, patients should still be optimized on disease-modifying therapy before and after pregnancy to minimize gaps in treatment. Exclusive breastfeeding may reduce the chances of disease relapse postpartum, and many disease-modifying therapies are considered to be safe while breastfeeding. Treatments for other neuroimmunologic disorders such as neuromyelitis optica spectrum disorder, myelin oligodendrocyte glycoprotein antibody-associated disease, neurosarcoidosis, and central nervous system vasculitis may require rituximab before and prednisone or intravenous immunoglobulin therapy during pregnancy.
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Dobson R, Rog D, Ovadia C, Murray K, Hughes S, Ford HL, Pearson OR, White S, Bonham N, Mathews J, Nelson-Piercy C, Brex P. Anti-CD20 therapies in pregnancy and breast feeding: a review and ABN guidelines. Pract Neurol 2023; 23:6-14. [PMID: 35803727 DOI: 10.1136/pn-2022-003426] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2022] [Indexed: 02/02/2023]
Abstract
Neurologists increasingly use anti-CD20 therapies, including for women of childbearing age, despite these medications being unlicensed for use in pregnancy. Current evidence suggests that women can safely conceive while taking anti-CD20 therapy. Women should not be denied treatment during pregnancy when it is clinically indicated, although they should be counselled regarding live vaccinations for their infant. Women receiving regular ocrelizumab for multiple sclerosis should preferably wait 3 months before trying to conceive. There are few data around ofatumumab in pregnancy, and while there is probably a class effect across all anti-CD20 therapies, ofatumumab may need to be continued during pregnancy to maintain efficacy. We recommend that anti-CD20 therapies can be safely given while breast feeding. It is important to make time to discuss treatments with women of childbearing age to help them choose their most suitable treatment. Outcomes should be monitored in pregnancy registries.
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Affiliation(s)
- Ruth Dobson
- Preventive Neurology Unit, Wolfson Institute of Population Health, Queen Mary University, London, UK .,Department of Neurology, The Royal London Hospital, London, UK
| | - David Rog
- Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Salford, UK
| | - Caroline Ovadia
- Department of Women and Children's Health, King's College London, London, UK
| | - Katy Murray
- Anne Rowling Regenerative Neurology Clinic, The University of Edinburgh, Edinburgh, UK.,Department of Neurology, Forth Valley Royal Hospital, Larbert, UK
| | - Stella Hughes
- Department of Neurology, Belfast Health and Social Care Trust, Belfast, UK
| | - Helen L Ford
- Department of Neurology, Leeds Teaching Hospitals NHS Trust, Leeds, UK.,Department of Neurosciences, University of Leeds Faculty of Medicine and Health, Leeds, UK
| | - Owen R Pearson
- Department of Neurology, Morriston Hospital, Swansea, UK
| | - Sarah White
- Department of Neurology, St George's Hospitals NHS Trust, London, UK
| | - Nicola Bonham
- Department of Neurology, Forth Valley Royal Hospital, Larbert, UK
| | - Joela Mathews
- Department of Neurology, The Royal London Hospital, London, UK
| | - Catherine Nelson-Piercy
- Department of Obstetrics, Guy's and St Thomas' Hospitals NHS Trust, London, UK.,Department of Obstetrics, King's College Hospital NHS Foundation Trust, London, UK
| | - Peter Brex
- Department of Neurology, King's College Hospital NHS Foundation Trust, London, UK
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Liu XG, Hou Y, Hou M. How we treat primary immune thrombocytopenia in adults. J Hematol Oncol 2023; 16:4. [PMID: 36658588 PMCID: PMC9850343 DOI: 10.1186/s13045-023-01401-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 01/11/2023] [Indexed: 01/20/2023] Open
Abstract
Primary immune thrombocytopenia (ITP) is an immune-mediated bleeding disorder characterized by decreased platelet counts and an increased risk of bleeding. Multiple humoral and cellular immune abnormalities result in accelerated platelet destruction and suppressed platelet production in ITP. The diagnosis remains a clinical exclusion of other causes of thrombocytopenia. Treatment is not required except for patients with active bleeding, severe thrombocytopenia, or cases in need of invasive procedures. Corticosteroids, intravenous immunoglobulin, and anti-RhD immunoglobulin are the classical initial treatments for newly diagnosed ITP in adults, but these agents generally cannot induce a long-term response in most patients. Subsequent treatments for patients who fail the initial therapy include thrombopoietic agents, rituximab, fostamatinib, splenectomy, and several older immunosuppressive agents. Other potential therapeutic agents, such as inhibitors of Bruton's tyrosine kinase and neonatal Fc receptor, are currently under clinical evaluation. An optimized treatment strategy should aim at elevating the platelet counts to a safety level with minimal toxicity and improving patient health-related quality of life, and always needs to be tailored to the patients and disease phases. In this review, we address the concepts of adult ITP diagnosis and management and provide a comprehensive overview of current therapeutic strategies under general and specific situations.
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Affiliation(s)
- Xin-Guang Liu
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yu Hou
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Ming Hou
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China. .,Shandong Provincial Key Laboratory of Immunohematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.
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Vukusic S, Marignier R, Ciron J, Bourre B, Cohen M, Deschamps R, Guillaume M, Kremer L, Pique J, Carra-Dalliere C, Michel L, Leray E, Guennoc AM, Laplaud D, Androdias G, Bensa C, Bigaut K, Biotti D, Branger P, Casez O, Daval E, Donze C, Dubessy AL, Dulau C, Durand-Dubief F, Hebant B, Kwiatkowski A, Lannoy J, Maarouf A, Manchon E, Mathey G, Moisset X, Montcuquet A, Roux T, Maillart E, Lebrun-Frenay C. Pregnancy and neuromyelitis optica spectrum disorders: 2022 recommendations from the French Multiple Sclerosis Society. Mult Scler 2023; 29:37-51. [PMID: 36345839 DOI: 10.1177/13524585221130934] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND In 2020, the French Multiple Sclerosis (MS) Society (SFSEP) decided to develop a national evidence-based consensus on pregnancy in MS. As neuromyelitis optica spectrum disorders (NMOSD) shares a series of commonalities with MS, but also some significant differences, specific recommendations had to be developed. OBJECTIVES To establish recommendations on pregnancy in women with NMOSD. METHODS The French Group for Recommendations in Multiple Sclerosis (France4MS) reviewed PubMed and universities databases (January 1975 through June 2021). The RAND/UCLA appropriateness method, which was developed to synthesise the scientific literature and expert opinions on health care topics, was used to reach a formal agreement. Fifty-six MS experts worked on the full-text review and initial wording of recommendations. A sub-group of nine NMOSD experts was dedicated to analysing available data on NMOSD. A group of 62 multidisciplinary healthcare specialists validated the final proposal of summarised evidence. RESULTS A strong agreement was reached for all 66 proposed recommendations. They cover diverse topics, such as pregnancy planning, follow-up during pregnancy and postpartum, delivery routes, loco-regional analgesia or anaesthesia, prevention of postpartum relapses, breastfeeding, vaccinations, reproductive assistance, management of relapses, and disease-modifying treatments. CONCLUSION Physicians and patients should be aware of the new and specific evidence-based recommendations of the French MS Society for pregnancy in women with NMOSD. They should help harmonise counselling and treatment practise, allowing for better individualised choices.
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Affiliation(s)
- Sandra Vukusic
- Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro-Inflammation, Hospices Civils de Lyon, Hôpital Neurologique Pierre Wertheimer, Bron, France/INSERM 1028 et CNRS UMR 5292, Observatoire Français de la Sclérose en Plaques, Centre de Recherche en Neurosciences de Lyon, Lyon, France/Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France/Eugène Devic EDMUS Foundation against Multiple Sclerosis, State-Approved Foundation, Bron, France
| | - Romain Marignier
- Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France/Hospices Civils de Lyon, Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro-Inflammation, and Centre de Référence des Maladies Inflammatoires Rares du Cerveau et de la Moelle (MIRCEM), Hôpital Neurologique Pierre Wertheimer, Bron, France/FORGETTING Team, INSERM 1028 et CNRS UMR5292, Centre des Neurosciences de Lyon, Lyon, France
| | - Jonathan Ciron
- Centre Ressources et Compétences Sclérose en Plaques (CRC-SEP) et Service de Neurologie B4, Hôpital Pierre-Paul Riquet, CHU Toulouse Purpan, Toulouse, France/INSERM UMR1291 - CNRS UMR5051, Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity), Université Toulouse III, Toulouse, France
| | | | - Mikael Cohen
- CRCSEP Côte d'Azur, CHU de Nice Pasteur 2, Nice, France/UR2CA-URRIS, Université Nice Côte d'Azur, Nice, France
| | - Romain Deschamps
- CRC-SEP, Neurology Department, Hôpital Fondation Adolphe de Rothschild, Paris, France
| | | | - Laurent Kremer
- CRC-SEP, Service de Neurologie, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Julie Pique
- Hospices Civils de Lyon, Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro-Inflammation, and Centre de Référence des Maladies Inflammatoires Rares du Cerveau et de la Moelle (MIRCEM), Hôpital Neurologique Pierre Wertheimer, Bron, France
| | - Clarisse Carra-Dalliere
- CRC-SEP, Neurology Department, Hôpital Gui de Chauliac, CHU de Montpellier, Montpellier, France
| | - Laure Michel
- CIC_P1414 INSERM, Neurology Department, Rennes University Hospital, Rennes, France
| | - Emmanuelle Leray
- EHESP, CNRS, Inserm, Arènes - UMR 6051, RSMS (Recherche sur les Services et Management en Santé), Université de Rennes, Rennes, France
| | | | - David Laplaud
- INSERM, Center for Research in Transplantation and Translational Immunology, Nantes Université, Nantes, France/CIC INSERM 1413, CRC-SEP Pays de la Loire, CHU Nantes, Nantes, France
| | - Géraldine Androdias
- Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro-Inflammation, Hospices Civils de Lyon, Hôpital Neurologique Pierre Wertheimer, Bron, France/Ramsay Santé, Clinique de la Sauvegarde, Lyon, France
| | - Caroline Bensa
- CRC-SEP, Neurology Department, Hôpital Fondation Adolphe de Rothschild, Paris, France
| | - Kevin Bigaut
- CRC-SEP, Service de Neurologie, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Damien Biotti
- Centre Ressources et Compétences Sclérose en Plaques (CRC-SEP) et Service de Neurologie B4, Hôpital Pierre-Paul Riquet, CHU Toulouse Purpan, Toulouse, France/INSERM UMR1291 - CNRS UMR5051, Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity), Université Toulouse III, Toulouse, France
| | - Pierre Branger
- Service de Neurologie, CHU de Caen Normandie, Caen, France
| | - Olivier Casez
- Neurologie, Pathologies Inflammatoires du Système Nerveux, CHU Grenoble Alpes, Grenoble, France/TIMC-IMAG, T-RAIG (Translational Research in Autoimmunity and Inflammation Group), Université de Grenoble Alpes, Grenoble, France
| | - Elodie Daval
- Service de Neurologie, CHU de Besançon, Besançon, France
| | - Cécile Donze
- Faculté de Médecine et de Maïeutique de Lille, Groupement des Hôpitaux de l'Institut Catholique de Lille, Hôpital Saint Philibert, Lille, France
| | - Anne-Laure Dubessy
- APHP-6, Department of Neurology, Saint-Antoine Hospital, Paris, France/Sorbonne University, Paris, France
| | - Cécile Dulau
- CRC-SEP, Hôpital Pellegrin, CHU de Bordeaux, Bordeaux, France
| | - Françoise Durand-Dubief
- Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro-Inflammation, Hospices Civils de Lyon, Hôpital Neurologique Pierre Wertheimer, Bron, France
| | | | - Arnaud Kwiatkowski
- Department of Neurology, Lille Catholic Hospitals, Lille Catholic University, Lille, France
| | - Julien Lannoy
- Service de Neurologie, Centre Hospitalier de Lens, Lens, France
| | - Adil Maarouf
- CNRS, CRMBM, UMR 7339, Aix-Marseille Université, Marseille, France/APHM, Hôpital de la Timone, Marseille, France
| | - Eric Manchon
- Department of Neurology, Gonesse Hospital, Gonesse, France
| | - Guillaume Mathey
- Service de Neurologie, Hôpital Central, Centre Hospitalier Régional Universitaire de Nancy, Nancy, France
| | - Xavier Moisset
- Inserm, Neuro-Dol, Université Clermont Auvergne, Clermont-Ferrand, France/Department of Neurology et CRC-SEP, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | | | - Thomas Roux
- CRC-SEP, Neurology Department, Pitié-Salpêtrière Hospital, Paris, France
| | - Elisabeth Maillart
- CRC-SEP, Neurology Department, Pitié-Salpêtrière Hospital, Paris, France
| | - Christine Lebrun-Frenay
- CRCSEP Côte d'Azur, CHU de Nice Pasteur 2, Nice, France/UR2CA-URRIS, Université Nice Côte d'Azur, Nice, France
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Vukusic S, Carra-Dalliere C, Ciron J, Maillart E, Michel L, Leray E, Guennoc AM, Bourre B, Laplaud D, Androdias G, Bensa C, Bigaut K, Biotti D, Branger P, Casez O, Cohen M, Daval E, Deschamps R, Donze C, Dubessy AL, Dulau C, Durand-Dubief F, Guillaume M, Hebant B, Kremer L, Kwiatkowski A, Lannoy J, Maarouf A, Manchon E, Mathey G, Moisset X, Montcuquet A, Pique J, Roux T, Marignier R, Lebrun-Frenay C. Pregnancy and multiple sclerosis: 2022 recommendations from the French multiple sclerosis society. Mult Scler 2023; 29:11-36. [PMID: 36317497 DOI: 10.1177/13524585221129472] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE The objective of this study was to develop evidence-based recommendations on pregnancy management for persons with multiple sclerosis (MS). BACKGROUND MS typically affects young women in their childbearing years. Increasing evidence is available to inform questions raised by MS patients and health professionals about pregnancy issues. METHODS The French Group for Recommendations in Multiple Sclerosis (France4MS) reviewed PubMed and university databases (January 1975 through June 2021). The RAND/UCLA appropriateness method was developed to synthesise the scientific literature and expert opinions on healthcare topics; it was used to reach a formal agreement. Fifty-six MS experts worked on the full-text review and initial wording of recommendations. A group of 62 multidisciplinary healthcare specialists validated the final proposal of summarised evidence. RESULTS A strong agreement was reached for all 104 proposed recommendations. They cover diverse topics, such as pregnancy planning, follow-up during pregnancy and postpartum, delivery routes, locoregional analgesia or anaesthesia, prevention of postpartum relapses, breastfeeding, vaccinations, reproductive assistance, management of relapses and disease-modifying treatments. CONCLUSION The 2022 recommendations of the French MS society should be helpful to harmonise counselling and treatment practice for pregnancy in persons with MS, allowing for better and individualised choices.
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Affiliation(s)
- Sandra Vukusic
- Sclérose en Plaques, Pathologies de la Myéline et Neuro-Inflammation, Service de Neurologie, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Bron, France/INSERM 1028 et CNRS UMR 5292, Observatoire Français de la Sclérose en Plaques, Centre de Recherche en Neurosciences de Lyon, Bron, France/Université Claude Bernard Lyon 1, Université de Lyon, Lyon, France/Eugène Devic EDMUS Foundation against Multiple Sclerosis, State-approved Foundation, Bron, France
| | | | - Jonathan Ciron
- Centre Ressources et Compétences sclérose en plaques (CRC-SEP) et Service de Neurologie B4, Hôpital Pierre-Paul Riquet, CHU Toulouse Purpan, Toulouse, France INSERM UMR1291 - CNRS UMR5051, Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity), Université Toulouse 3, Toulouse, France
| | - Elisabeth Maillart
- Neurology Department, Pitié-Salpêtrière Hospital, CRC-SEP, Paris, France
| | - Laure Michel
- Neurology Department, CIC_P1414 INSERM, Rennes University Hospital, Rennes, France
| | - Emmanuelle Leray
- EHESP, CNRS, Inserm, Arènes - UMR 6051, RSMS (Recherche sur les Services et Management en Santé) - U 1309, Université de Rennes, Rennes, France
| | | | | | - David Laplaud
- Center for Research in Transplantation and Translational Immunology, UMR 1064, Nantes Université and INSERM, Nantes, France/CIC INSERM 1413, CRC-SEP Pays de la Loire, CHU Nantes, Nantes, France
| | - Géraldine Androdias
- Sclérose en Plaques, Pathologies de la Myéline et Neuro-Inflammation, Service de Neurologie, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Bron, France/Clinique de la Sauvegarde, Ramsay Santé, Lyon, France
| | - Caroline Bensa
- CRC-SEP, Neurology Department, Hôpital Fondation Adolphe de Rothschild, Paris, France
| | - Kevin Bigaut
- CRC-SEP, Service de Neurologie, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Damien Biotti
- Centre Ressources et Compétences sclérose en plaques (CRC-SEP) et Service de Neurologie B4, Hôpital Pierre-Paul Riquet, CHU Toulouse Purpan, Toulouse, France INSERM UMR1291 - CNRS UMR5051, Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity), Université Toulouse 3, Toulouse, France
| | - Pierre Branger
- Service de Neurologie, CHU de Caen Normandie, Caen, France
| | - Olivier Casez
- Pathologies Inflammatoires du Système Nerveux, Neurologie, CHU Grenoble Alpes, Grenoble, France/Translational Research in Autoimmunity and Inflammation Group (T-RAIG), TIMC-IMAG, Université de Grenoble Alpes, Grenoble, France
| | - Mikael Cohen
- CRCSEP Côte d'Azur, CHU de Nice Pasteur 2, Nice, France/Université Nice Côte d'Azur UR2CA-URRIS, Nice, France
| | - Elodie Daval
- Service de Neurologie, CHU de Besançon, Besançon, France
| | - Romain Deschamps
- CRC-SEP, Neurology Department, Hôpital Fondation Adolphe de Rothschild, Paris, France
| | - Cécile Donze
- Hôpital saint Philibert, Groupement des Hôpitaux de l'Institut Catholique de Lille, Faculté de médecine et de maïeutique de Lille, Lomme, France
| | - Anne-Laure Dubessy
- Department of Neurology, Saint-Antoine Hospital, APHP-6, Paris, France/Sorbonne University, Paris, France
| | - Cécile Dulau
- CRC-SEP, Hôpital Pellegrin, CHU de Bordeaux, Bordeaux, France
| | - Françoise Durand-Dubief
- Sclérose en Plaques, Pathologies de la Myéline et Neuro-Inflammation, Service de Neurologie, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Bron, France
| | | | | | - Laurent Kremer
- CRC-SEP, Service de Neurologie, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Arnaud Kwiatkowski
- Department of Neurology, Lille Catholic Hospitals, Lille Catholic University, Lille, France
| | - Julien Lannoy
- Service de Neurologie, Centre Hospitalier de Lens, Lens, France
| | - Adil Maarouf
- CRMBM, UMR 7339, CNRS, Aix-Marseille Université, Marseille, France/APHM Hôpital de la Timone, Marseille, France
| | - Eric Manchon
- Department of Neurology, Gonesse Hospital, Gonesse, France
| | - Guillaume Mathey
- Service de neurologie, Centre Hospitalier Régional Universitaire de Nancy - Hôpital Central, Nancy, France
| | - Xavier Moisset
- Neuro-Dol, Inserm, Université Clermont Auvergne, Clermont-Ferrand, France/Department of neurology et CRC-SEP, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | | | - Julie Pique
- Sclérose en Plaques, Pathologies de la Myéline et Neuro-Inflammation, Service de Neurologie, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Bron, France/INSERM 1028 et CNRS UMR 5292, Centre de Recherche en Neurosciences de Lyon, Bron, France/Université Claude Bernard Lyon 1, Lyon, France
| | - Thomas Roux
- Neurology Department, Pitié-Salpêtrière Hospital, CRC-SEP, Paris, France
| | - Romain Marignier
- Sclérose en Plaques, Pathologies de la Myéline et Neuro-Inflammation, Service de Neurologie, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Bron, France/INSERM 1028 et CNRS UMR 5292, Centre de Recherche en Neurosciences de Lyon, Lyon, France/Université Claude Bernard Lyon 1, Université de Lyon, Lyon, France
| | - Christine Lebrun-Frenay
- Service de Neurologie, CHU de Besançon, Besançon, France/Université Nice Côte d'Azur UR2CA-URRIS, Nice, France
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de Sèze J, Maillart E, Gueguen A, Laplaud DA, Michel L, Thouvenot E, Zephir H, Zimmer L, Biotti D, Liblau R. Anti-CD20 therapies in multiple sclerosis: From pathology to the clinic. Front Immunol 2023; 14:1004795. [PMID: 37033984 PMCID: PMC10076836 DOI: 10.3389/fimmu.2023.1004795] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 02/13/2023] [Indexed: 04/11/2023] Open
Abstract
The immune system plays a significant role in multiple sclerosis. While MS was historically thought to be T cell-mediated, multiple pieces of evidence now support the view that B cells are essential players in multiple sclerosis pathogenic processes. High-efficacy disease-modifying therapies that target the immune system have emerged over the past two decades. Anti-CD20 monoclonal antibodies selectively deplete CD20+ B and CD20+ T cells and efficiently suppress inflammatory disease activity. These monotherapies prevent relapses, reduce new or active magnetic resonance imaging brain lesions, and lessen disability progression in patients with relapsing multiple sclerosis. Rituximab, ocrelizumab, and ofatumumab are currently used in clinical practice, while phase III clinical trials for ublituximab have been recently completed. In this review, we compare the four anti-CD20 antibodies in terms of their mechanisms of action, routes of administration, immunological targets, and pharmacokinetic properties. A deeper understanding of the individual properties of these molecules in relation to their efficacy and safety profiles is critical for their use in clinical practice.
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Affiliation(s)
- Jérôme de Sèze
- Department of Neurology, Hôpital de Hautepierre, Clinical Investigation Center, Institut National de la Santé et de la Recherche Médicale (INSERM), Strasbourg, France
- Fédération de Médecine Translationelle, Institut National de la Santé et de la Recherche Médicale (INSERM), Strasbourg, France
- *Correspondence: Jérôme de Sèze,
| | - Elisabeth Maillart
- Department of Neurology, Pitié Salpêtrière Hospital, Paris, France
- Centre de Ressources et de Compétences Sclérose en Plaques, Paris, France
| | - Antoine Gueguen
- Department of Neurology, Rothschild Ophthalmologic Foundation, Paris, France
| | - David A. Laplaud
- Department of Neurology, Centre Hospitalier Universitaire (CHU) Nantes, Nantes Université, Institut National de la Santé et de la Recherche Médicale (INSERM), Centre d’Investigation Clinique (CIC), Center for Research in Transplantation and Translational Immunology, UMR, UMR1064, Nantes, France
| | - Laure Michel
- Clinical Neuroscience Centre, CIC_P1414 Institut National de la Santé et de la Recherche Médicale (INSERM), Rennes University Hospital, Rennes University, Rennes, France
- Microenvironment, Cell Differentiation, Immunology and Cancer Unit, Institut National de la Santé et de la Recherche Médicale (INSERM), Rennes I University, French Blood Agency, Rennes, France
- Neurology Department, Rennes University Hospital, Rennes, France
| | - Eric Thouvenot
- Department of Neurology, Centre Hospitalier Universitaire (CHU) Nîmes, University of Montpellier, Nîmes, France
- Institut de Génomique Fonctionnelle, UMR, Institut National de la Santé et de la Recherche Médicale (INSERM), University of Montpellier, Montpellier, France
| | - Hélène Zephir
- University of Lille, Institut National de la Santé et de la Recherche Médicale (INSERM) U1172, Centre Hospitalier Universitaire (CHU), Lille, France
| | - Luc Zimmer
- Université Claude Bernard Lyon 1, Hospices Civils de Lyon, Institut National de la Santé et de la Recherche Médicale (INSERM), CNRS, Lyon Neuroscience Research Center, Lyon, France
| | - Damien Biotti
- Centre Ressources et Compétences Sclérose En Plaques (CRC-SEP) and Department of Neurology, Centre Hospitalier Universitaire (CHU) Toulouse Purpan – Hôpital Pierre-Paul Riquet, Toulouse, France
| | - Roland Liblau
- Toulouse Institute for Infectious and Inflammatory Diseases (Infinity), University of Toulouse, CNRS, Institut National de la Santé et de la Recherche Médicale (INSERM), UPS, Toulouse, France
- Department of Immunology, Toulouse University Hospital, Toulouse, France
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40
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Differentiating and Managing Rare Thrombotic Microangiopathies During Pregnancy and Postpartum. Obstet Gynecol 2023; 141:85-108. [PMID: 36455925 DOI: 10.1097/aog.0000000000005024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 08/04/2022] [Indexed: 12/05/2022]
Abstract
The most common thrombotic microangiopathy (TMA) of pregnancy is the well-recognized syndrome of preeclampsia with hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome. However, rare TMAs, including thrombotic thrombocytopenic purpura, complement-mediated hemolytic-uremic syndrome, and catastrophic antiphospholipid syndrome, may occur during pregnancy or postpartum and present with features similar to those of preeclampsia with severe features. Early recognition and treatment of these infrequently encountered conditions are key for avoiding serious maternal morbidities with long-term sequelae and possible maternal or fetal death. Differentiating between preeclampsia with severe features and these rare TMAs is diagnostically challenging as there is significant overlap in their clinical and laboratory presentation. Given the rarity of these TMAs, high-quality evidence-based recommendations on diagnosis and management during pregnancy are lacking. Using current objective information and recommendations from working groups, this report provides practical clinical approaches to diagnose and manage these rare TMAs. This report also discusses how to manage individuals with a history of these rare TMAs who are planning to conceive. To optimize favorable outcomes, a multidisciplinary approach including obstetricians, maternal-fetal medicine specialists, hematologists, and nephrologists alongside close clinical and laboratory monitoring is vital.
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Ly S, Nedosekin D, Wong HK. Review of an Anti-CD20 Monoclonal Antibody for the Treatment of Autoimmune Diseases of the Skin. Am J Clin Dermatol 2023; 24:247-273. [PMID: 36630066 PMCID: PMC9838371 DOI: 10.1007/s40257-022-00751-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2022] [Indexed: 01/12/2023]
Abstract
Biologic therapies targeting B-cells are emerging as an effective strategy to treat a variety of immune-mediated diseases. One of the most studied B-cell-targeted therapies is rituximab, an anti-CD20 monoclonal antibody that exemplifies B-cell depletion therapy and has served as the prototype for other anti-CD20 monoclonal antibodies and the development of biosimilars. While there are multiple studies on the use of rituximab in dermatology, a comprehensive review of rituximab therapy in autoimmune skin conditions is lacking. In this literature review, we summarize indications, treatment efficacy, and safety of rituximab among common autoimmune diseases of the skin: pemphigus vulgaris, cutaneous lupus erythematous, dermatomyositis, systemic sclerosis, thyroid dermopathy, autoimmune pemphigoid diseases, and cutaneous vasculitis diseases. Existing data on rituximab support the approach of rituximab, biosimilars, and newer B-cell-targeting therapies in immune-mediated cutaneous diseases. Overall, rituximab, which targets CD20, provides an effective alternative or concomitant option to traditional immunosuppressants in the management of various autoimmune diseases of the skin. Further studies are necessary to expand the understanding and possible utility of B-cell-targeted therapies among autoimmune skin diseases.
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Affiliation(s)
- Sophia Ly
- grid.241054.60000 0004 4687 1637College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR USA
| | - Dmitry Nedosekin
- grid.241054.60000 0004 4687 1637College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR USA
| | - Henry K. Wong
- grid.241054.60000 0004 4687 1637Department of Dermatology, University of Arkansas for Medical Sciences, 4301 W. Markham St., Slot #576, Little Rock, AR 72205 USA
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Thrombocytopenia in pregnancy. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2022; 2022:303-311. [PMID: 36485110 PMCID: PMC9820693 DOI: 10.1182/hematology.2022000375] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Hematologists are often consulted for thrombocytopenia in pregnancy, especially when there is a concern for a non-pregnancy-specific etiology or an insufficient platelet count for the hemostatic challenges of delivery. The severity of thrombocytopenia and trimester of onset can help guide the differential diagnosis. Hematologists need to be aware of the typical signs of preeclampsia with severe features and other hypertensive disorders of pregnancy to help distinguish these conditions, which typically resolve with delivery, from other thrombotic microangiopathies (TMAs) (eg, thrombotic thrombocytopenic purpura or complement-mediated TMA). Patients with chronic thrombocytopenic conditions, such as immune thrombocytopenia, should receive counseling on the safety and efficacy of various medications during pregnancy. The management of pregnant patients with chronic immune thrombocytopenia who are refractory to first-line treatments is an area that warrants further research. This review uses a case-based approach to discuss recent updates in diagnosing and managing thrombocytopenia in pregnancy.
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On S, Chang A. Treatment of lymphoma with rituximab and chemotherapy during pregnancy. Leuk Lymphoma 2022; 63:2897-2904. [PMID: 35856478 DOI: 10.1080/10428194.2022.2100368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Safety of chemoimmunotherapy during pregnancy for treatment of Non-Hodgkin's lymphoma (NHL) is controversial. We review 37 cases of mothers with high grade NHL treated with rituximab and concurrent chemotherapy during pregnancy. Majority (95%) of mothers were treated in their second and third trimester, and a median of 4 cycles of combination therapy was administered. Complete remission occurred in 14/17 (82%) mothers whose disease outcomes were reported. There were 2 spontaneous abortions and 1 trimester fetal death that occurred in 3 mothers who received treatment in their first and second trimesters. Among the 34 (92%) live births, there were 6 cases of respiratory/cardiac complications requiring intervention and 5 cases of hematologic abnormalities reported. This review highlights the efficacy and safety of chemoimmunotherapy for mothers treated in second and third trimester. Further data is needed to establish recommendations for management of mothers with aggressive NHL in their first trimester of pregnancy.
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Affiliation(s)
- Sandy On
- Department of Pharmacy, Stanford Health Care, Palo Alto, CA, USA
| | - Abraham Chang
- Department of Pharmacy, Stanford Health Care, Palo Alto, CA, USA
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Russell MD, Dey M, Flint J, Davie P, Allen A, Crossley A, Frishman M, Gayed M, Hodson K, Khamashta M, Moore L, Panchal S, Piper M, Reid C, Saxby K, Schreiber K, Senvar N, Tosounidou S, van de Venne M, Warburton L, Williams D, Yee CS, Gordon C, Giles I, Roddy E, Armon K, Astell L, Cotton C, Davidson A, Fordham S, Jones C, Joyce C, Kuttikat A, McLaren Z, Merrison K, Mewar D, Mootoo A, Williams E. British Society for Rheumatology guideline on prescribing drugs in pregnancy and breastfeeding: immunomodulatory anti-rheumatic drugs and corticosteroids. Rheumatology (Oxford) 2022; 62:e48-e88. [PMID: 36318966 PMCID: PMC10070073 DOI: 10.1093/rheumatology/keac551] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 09/15/2022] [Indexed: 11/07/2022] Open
Affiliation(s)
- Mark D Russell
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Mrinalini Dey
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Julia Flint
- Department of Rheumatology, Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Shropshire, UK
| | - Philippa Davie
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Alexander Allen
- Clinical Affairs, British Society for Rheumatology, London, UK
| | | | - Margreta Frishman
- Rheumatology, North Middlesex University Hospital NHS Trust, London, UK
| | - Mary Gayed
- Rheumatology, Sandwell and West Birmingham Hospitals, Birmingham, UK
| | | | - Munther Khamashta
- Lupus Research Unit, Division of Women's Health, King's College London, London, UK
| | - Louise Moore
- Rheumatic and Musculoskeletal Disease Unit, Our Lady's Hospice and Care Service, Dublin, Ireland
| | - Sonia Panchal
- Department of Rheumatology, South Warwickshire NHS Foundation Trust, Warwickshire, UK
| | - Madeleine Piper
- Royal National Hospital for Rheumatic Diseases, Royal United Hospital, Bath, UK
| | | | - Katherine Saxby
- Pharmacy, University College London Hospitals NHS Foundation Trust, London, UK
| | - Karen Schreiber
- Thrombosis and Haemostasis, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Department of Rheumatology, Danish Hospital for Rheumatic Diseases, Sonderborg, Denmark.,Department of Regional Health Research (IRS), University of Southern Denmark, Odense, Denmark
| | - Naz Senvar
- Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Sofia Tosounidou
- Lupus UK Centre of Excellence, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | | | | | - David Williams
- Obstetrics, University College London Hospitals NHS Foundation Trust, London, UK
| | - Chee-Seng Yee
- Department of Rheumatology, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, Doncaster, UK
| | - Caroline Gordon
- Rheumatology Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Ian Giles
- Centre for Rheumatology, Division of Medicine, University College London, London, UK
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A comprehensive guide for managing the reproductive health of patients with vasculitis. Nat Rev Rheumatol 2022; 18:711-723. [PMID: 36192559 PMCID: PMC9529165 DOI: 10.1038/s41584-022-00842-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2022] [Indexed: 11/08/2022]
Abstract
Vasculitides and their therapies affect all areas of the reproductive life cycle. The ACR, EULAR and the Drugs and Lactation database offer guidance on the management of the reproductive health of patients with rheumatic diseases; however, these guidelines do not address patients with vasculitis specifically. This Review discusses the guidance from multiple expert panels and how these recommendations might apply to men and women with vasculitis, including the safety of contraception, use of assisted reproductive technology, preservation of fertility during cyclophosphamide therapy, disease management in pregnancy and the use of medications compatible with pregnancy and lactation. These discussions are augmented by the existing literature on vasculitis in pregnancy to enable physicians to provide comprehensive, precise and high quality care to patients with vasculitis. The contents of this Review, in conjunction with educational tools, serve to empower patients and physicians to participate in shared decision-making regarding pregnancy prevention, planning and management. This Review discusses how best to manage the reproductive health of patients with vasculitis, including the safety of contraception, the use of assisted reproductive technology, preservation of fertility during therapy, disease management in pregnancy and the use of medications compatible with pregnancy and lactation. Rheumatologists have the opportunity to initiate discussions with patients with vasculitis regarding family planning to make proactive decisions leading to improved pregnancy planning, management and outcomes. Birth control options and infertility interventions for women with vasculitis depend on their risk of thrombosis, serological profile and comorbid conditions. The majority of pregnancies in patients with vasculitis can be successful with the use of advanced family planning, medications compatible with pregnancy and lactation, and multidisciplinary collaboration among specialists. Vasculitis exacerbations and pregnancy complications can present with similar and overlapping clinical manifestations. Multiple expert panels provide guidelines and risk stratification regarding medication use in pregnancy and breastfeeding that can be applied to patients with vasculitis.
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Hui EX, Huang X, Oon HH. Review of Dermatologic Medications and Impact on Male Fertility, Sexual Dysfunction and Teratogenicity. Andrology 2022; 10:1272-1285. [PMID: 35876714 DOI: 10.1111/andr.13236] [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: 04/22/2022] [Revised: 07/04/2022] [Accepted: 07/17/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Dermatologic medications have been linked to issues with safety during pregnancy and lactation. Despite this, limited research, often with conflicting findings, has been published on the association between dermatologic medications, male infertility, sexual dysfunction, and teratogenicity following paternal exposure. OBJECTIVE This review seeks to provide evidence-based guidance for physicians who are prescribing dermatologic medications to male patients who are trying to conceive. METHODS Common medications used in the largest outpatient specialist dermatologic centre in Singapore were the focus of this review. A PubMed search using MeSH terms from inception to April 22, 2021, was conducted. A secondary search was conducted to include common non-dermatologic medications. Drug information from various online clinical resources and the Tenth Edition of Drugs in Pregnancy and Lactation were also used as a reference. RESULTS In this review of 234 studies, 131 medications were covered. A total of 34 medications were associated with male infertility and sexual dysfunction, while 16 medications were implicated with concerns of teratogenicity. DISCUSSION AND CONCLUSION Physicians are advised to discuss the potential impact on male fertility and teratogenicity with males who are trying to conceive, while taking into consideration the clinical efficacy and tolerability of these medications and alternative treatments. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Edward Xw Hui
- National Skin Centre, 1 Mandalay Rd, Singapore, 308205, Singapore
| | - Xiaoling Huang
- National Skin Centre, 1 Mandalay Rd, Singapore, 308205, Singapore
| | - Hazel H Oon
- National Skin Centre, 1 Mandalay Rd, Singapore, 308205, Singapore
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Pregnancy outcomes in women with pemphigus exposed to rituximab before or during pregnancy. Int J Womens Dermatol 2022; 8:e038. [PMID: 35837335 PMCID: PMC9276145 DOI: 10.1097/jw9.0000000000000038] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 06/14/2022] [Indexed: 01/03/2023] Open
Abstract
Rituximab (RTX) is an effective treatment for pemphigus; however, the drug labeling recommends not to use RTX within 1 year before conception.
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Grant-Orser A, Metcalfe A, Pope JE, Johannson KA. Pregnancy Considerations for Patients With Interstitial Lung Disease. Chest 2022; 162:1093-1105. [PMID: 35779609 DOI: 10.1016/j.chest.2022.06.024] [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: 02/19/2022] [Revised: 06/16/2022] [Accepted: 06/22/2022] [Indexed: 12/29/2022] Open
Abstract
Advances in our understanding of interstitial lung disease (ILD) pathophysiology and natural history have led to the development of guidelines for the diagnosis and management of several of these complex diseases. The demographics of patients with ILD indicate the disease is not restricted to older adults. Connective tissue disease-associated ILD, familial pulmonary fibrosis, and post-COVID-19 fibrosis may affect women of child-bearing age. Recent trials have excluded pregnant women, thereby limiting the applicability of contemporary therapeutic advances to these patients. This review synthesizes the current knowledge of pregnancy outcomes in those with ILD, with a focus on connective tissue disease-associated ILD, and potential treatment implications for patients with ILD who are pregnant or considering pregnancy. Pregnancy considerations for patients with ILD include the need for preconception counseling and planning to ensure disease stability, medication and vaccination optimization, and multidisciplinary involvement of a patient's pulmonologist, obstetrician, and, when indicated, rheumatologist and genetic counselor. Evidence to date suggests that women with ILD can have safe and healthy pregnancies but that complications may occur in those with severe ILD.
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Affiliation(s)
- Amanda Grant-Orser
- Division of Respirology, Department of Medicine, University of Calgary, Calgary, AB, Canada.
| | - Amy Metcalfe
- Department of Obstetrics and Gynecology, University of Calgary, Calgary, AB, Canada; Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Janet E Pope
- Division of Rheumatology, Department of Medicine, University of Western Ontario, St. Joseph's Health Care, London, ON, Canada
| | - Kerri A Johannson
- Division of Respirology, Department of Medicine, University of Calgary, Calgary, AB, Canada; Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada; Snyder Institute for Chronic Diseases, University of Calgary, Calgary, AB, Canada
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Transplacental Passage and Fetal Effects of Antineoplastic Treatment during Pregnancy. Cancers (Basel) 2022; 14:cancers14133103. [PMID: 35804875 PMCID: PMC9264939 DOI: 10.3390/cancers14133103] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 06/07/2022] [Accepted: 06/20/2022] [Indexed: 11/16/2022] Open
Abstract
Simple Summary In this paper we perform an introduction about pregnancy-associated cancer (PAC) and transplacental passage of antineoplastic agents. Furthermore, we describe therapeutic use and potential toxic effects of chemotherapeutic drug (alkylating agents, antimetabolites agents, anthracyclines, topoisomerase inhibitors, antimitotic agents, actinomycin-D, bleomycin) and targeted agents during pregnancy. This manuscript may be a useful and practical guide for the management of PAC, which is a challenge for clinicians that have to consider alike maternal benefits and fetal potential risks correlated to the antineoplastic treatment. Abstract The incidence of PAC is relatively infrequent among pregnant women. However, it has gradually increased in recent years, becoming a challenging area for clinicians that should take into account in the same way maternal benefits and fetal potential risks correlated to the antineoplastic treatment. None of the antineoplastic drugs is completely risk-free during the pregnancy, the timing of exposure and transplacental transfer properties influence the toxicity of the fetus. Despite the lack of guidelines about the management of PAC, several studies have described the use and the potential fetal and neonatal adverse events of antineoplastic drugs during pregnancy. We provide a review of the available literature about the transplacental passage and fetal effects of chemotherapy and targeted agents, to guide the clinicians in the most appropriate choices for the management of PAC.
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Maristany S, DuVall AS, Stock W, Adeleye AJ. Primary ovarian insufficiency secondary to chemotherapy with inotuzumab ozogamicin and other agents. J Assist Reprod Genet 2022; 39:1733-1738. [PMID: 35727422 PMCID: PMC9209836 DOI: 10.1007/s10815-022-02548-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 06/09/2022] [Indexed: 11/25/2022] Open
Abstract
Recent advances in targeted therapy with monoclonal antibodies have significantly improved outcomes for people with cancer, sometimes allowing patients to avoid ovotoxic agents altogether. The current understanding is that monoclonal antibody cancer therapies that are not targeted to ovarian antigens should not impact ovarian reserve or increase the risk of primary ovarian insufficiency (POI). We present a case of rapid onset POI in a 23-year-old patient following chemotherapy for relapse/refractory B-cell acute lymphoblastic leukemia with a monoclonal antibody drug-conjugate, inotuzumab ozogamicin, that targets CD22. She was also treated with intrathecal methotrexate, cytarabine, and vincristine which are typically considered low risk for ovotoxicity. She was ovulatory with an AMH of 1.0 ng/mL prior to treatment and 2 months later was found to have an undetectable AMH. The patient experienced a canceled fertility preservation cycle due to an absent response to gonadotropins during ovarian stimulation. Consideration should be given to potential gonadal effects of monoclonal antibody therapies that may not have previously been explored.
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Affiliation(s)
- Sumiko Maristany
- The University of Chicago Pritzker School of Medicine, Chicago, IL, USA.
| | - Adam S DuVall
- Department of Medicine, University of Chicago Medicine, Chicago, IL, USA
| | - Wendy Stock
- Department of Medicine, University of Chicago Medicine, Chicago, IL, USA
| | - Amanda J Adeleye
- Section of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, The University of Chicago, Chicago, IL, USA
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