Immunology of pregnancy and reproductive health in autoimmune rheumatic diseases. Update from the 11th International Conference on Reproduction, Pregnancy and Rheumatic Diseases

Autoimmune rheumatic diseases (ARD) can affect women and men during fertile age, therefore reproductive health is a priority issue in rheumatology. Many topics need to be considered during preconception counselling: fertility, the impact of disease-related factors on pregnancy outcomes, the influence of pregnancy on disease activity, the compatibility of medications with pregnancy and breastfeeding. Risk stratification and individualized treatment approach elaborated by a multidisciplinary team minimize the risk of adverse pregnancy outcomes (APO). Research has been focused on identifying biomarkers that can be predictive of APO. Specifically, preeclampsia and hypertensive disorders of pregnancy tend to develop more frequently in women with ARD. Placental insufficiency can lead to intrauterine growth restriction and small-for-gestational age newborns. Such APO have been shown to be associated with maternal disease activity in different ARD. Therefore, a key message to be addressed to the woman wishing for a pregnancy and to her family is that treatment with compatible drugs is the best way to ensure maternal and fetal wellbeing. An increasing number of medications have entered the management of ARD, but data about their use in pregnancy and lactation are scarce. More information is needed for most biologic drugs and their biosimilars, and for the so-called small molecules, while there is sufficient evidence to recommend the use of TNF inhibitors if needed for keeping maternal disease under control. Other issues related to the reproductive journey have emerged as "unmet needs", such as sexual dysfunction, contraception, medically assisted reproduction techniques, long-term outcome of children, and they will be addressed in this review paper. Collaborative research has been instrumental to reach current knowledge and the future will bring novel insights thanks to pregnancy registries and prospective studies that have been established in several Countries and to their joint efforts in merging data.

OP0131 WHAT IS THE EFFECT OF METHOTREXATE ON SEMEN PARAMETERS OF MEN DIAGNOSED WITH IMMUNE-MEDIATED DISEASES? RESULTS OF A PROSPECTIVE COHORT STUDY (iFAME-MTX)

Background

Methotrexate (MTX) is one of the most frequently prescribed medications for the treatment of several immune-mediated diseases (IMD). MTX has well-established safety and efficacy profiles. Nonetheless, the available scientific evidence to support the decision whether men with an active desire to become a father should be treated with MTX is dubious (1). This knowledge gap is characterized by a lack of prospective studies evaluating the semen parameters before and after exposure to MTX (2).

Objectives

Our objective is to compare the semen parameters (sperm concentration, volume and progressive motility) between men diagnosed with IMD (pre and post exposure to MTX) and healthy controls.

Methods

This is a prospective cohort study. Men diagnosed with an IMD (RA, SpA, psoriasis) who were older than 18 years and received a medical indication to start therapy with MTX were invited to participate (naïve cases). These men were instructed to produce 2 semen samples (a pre-exposure sample before initiating MTX therapy and a post-exposure sample 12 weeks after initiating MTX therapy). Healthy men who were over 18 years old were invited to participate as healthy controls. Furthermore, to evaluate the semen parameters of men chronically exposed to MTX, men diagnosed with an IMD who had been exposed to MTX (≥15 mg/week) for at least 1 year were also invited to participate (chronic cases). These men produced one semen sample (post-exposure). All participants were proven fertile (fathered a child or their partner reported a positive pregnancy test). Continuous variables were compared using a paired t-test or a one-way analysis of variance.

Results

In total 18 naïve cases, 25 healthy controls and 5 chronic cases were included. Their demographic characteristics and the results of the conventional semen analysis are presented per group in Table 1. Compared to the semen parameters (sperm concentration, volume and progressive motility) from healthy controls, pre-exposure and post-exposure semen parameters from naïve cases were not statistically significant different (see Figure 1). The semen parameters of chronic cases were also not statistically significant different compared to pre-exposure samples from naïve cases and to healthy controls. Oligospermia (sperm concentration <15 10^6/mL) was identified in two samples from a naïve case (pre and post-exposure to MTX) and no cases of azoospermia were identified.

Table 1.

Demographic, clinical characteristics and semen parameters

MTX naïveControlsMTX chronicp valuePre-exposurePost-exposureTotal, n18255Age, mean (95% CI)36.52 (33.65-39.39)34.56(32.75-36.36)36.80(31.95 – 41.64)MTX dose mg/week, mean (95% CI)-16.52(14.54 – 18.49)-18.00(14.59 – 21.40)Sperm concentration, mean × 10^6/ mL (95% CI)84.27(44.27-123.83)64.31(42.55 – 86.35)92.56(60.45 –124.66)44.60(25.11 – 64.08)p=0.358*p=0.280**Progressive motility*, % (95% CI)63.20(55.44-70.95)60.11(49.56-70.67)56.95(51.05-62.85)50.40(34.82 – 65.97)p=0.562*p=0.456**Semen volume, mean mL,(95% CI)2.93(2.09-3.76)2.90(2.08-3.71)3.12(2.51-3.73)2.50(1.55-3.44)p=0.608*p=0.593**

*Comparisons between pre and post exposure samples were tested using a paired t-test,

**Comparisons between pre, post exposure and healthy controls were tested using a one way analysis of variance.

Conclusion

This is the largest prospective study ever conducted to evaluate the impact of MTX on semen parameters in men diagnosed with IMDs. We demonstrated that exposure to MTX did not result in statistically significant different semen parameters. Based on semen parameters, our findings suggest that MTX therapy can be continued in men diagnosed with an IMD and a wish to become a father.

References

[1]Sammaritano LR et al. Arthritis Care Res (Hoboken). 2020;72(4):461-88.

[2]Perez-Garcia LF et al. Human Reproduction Update. 2020.

Disclosure of Interests

None declared

POS0696 DOES PREDNISONE USE DURING PREGNANCY IN WOMEN WITH RHEUMATOID ARTHRITIS INDUCE INSULIN RESISTANCE IN THE OFFSPRING?

Background

The use of long-term corticosteroids during pregnancy has been growing over the past decades1. Corticosteroids can be given when an auto-inflammatory disease like rheumatoid arthritis (RA) is too active. Several studies have shown that long-term corticosteroids use in pregnancy is associated with maternal and fetal adverse outcomes, like preeclampsia, shorter gestational age, lower birth weight and rapid catch-up growth 1-3. These last two outcomes could influence the insulin resistance later in life4.

Objectives

Does prednisone use in pregnant women with RA induces insulin resistance in the offspring?

Methods

103 children were included after their mother had participated in a prospective cohort study on RA and pregnancy. 42 children were in utero exposed to prednisone and 61 were non-exposed. To assess insulin resistance, we measured Homeostasis Model of Assessment Insulin Resistance (HOMA-IR), serum adiponectin and lipid levels, corrected for body fat distribution.

Results

There was no difference in mean HOMA-IR (SD) between the children who were prednisone-exposed in utero (1.10 (0.84)) and those non-exposed (1.09 (0.49)). No difference was found in mean adiponectin (SD) level, 16.45 (4.06) µg/mL and 15.40 (3.59) µg/mL, respectively. Also no difference was found in body fat distribution or lipids such as total cholesterol, fasting triglyceride or high-density lipoprotein.

Conclusion

Children who are prednisone-exposed in utero have no increased risk for insulin resistance at the age of approximately 7-years. This findings are reassuring, but further research has to be performed to evaluate if prednisone-exposure in utero has no other negative effects on the long-term and if insulin resistance remains absent in the future.

References

[1]Cai E, Czuzoj-Shulman N, Abenhaim HA. Maternal and fetal outcomes in pregnancies with long-term corticosteroid use. J Matern Fetal Neonatal Med. 2021;34(11):1797-1804.

[2]de Man YA, Hazes JM, van der Heide H, et al. Association of higher rheumatoid arthritis disease activity during pregnancy with lower birth weight: results of a national prospective study. Arthritis Rheum. 2009;60(11):3196-3206.

[3]de Steenwinkel FD, Hokken-Koelega AC, de Ridder MA, Hazes JM, Dolhain RJ. Rheumatoid arthritis during pregnancy and postnatal catch-up growth in the offspring. Arthritis Rheumatol. 2014;66(7):1705-1711.

[4]Kerkhof GF, Willemsen RH, Leunissen RW, Breukhoven PE, Hokken-Koelega AC. Health profile of young adults born preterm: negative effects of rapid weight gain in early life. J Clin Endocrinol Metab. 2012;97(12):4498-4506.

Disclosure of Interests

None declared

OP0129 REPORTED CONGENITAL MALFORMATIONS AFTER EXPOSURE TO NON-TNF-Α INHIBITORS: A RETROSPECTIVE COMPARATIVE STUDY IN EUDRAVIGILANCE DATABASE

Background

Tumor necrosis factor-α inhibitors (TNFis) such as certolizumab pegol (CZP), are a subgroup of biologics, which have shown no increase in risk of congenital malformations (CMs) after use during pregnancy. (1) However, for the subgroup of non-TNFis, very scarce data is available.

Objectives

To evaluate the number and nature of reported CMs after intrauterine exposure to non-TNFis compared to CZP, in Eudravigilance database.

Methods

A retrospective comparative study in EudraVigilance database was conducted. Reports of all pregnancies exposed to non-TNFis and CZP, were extracted. Multiple versions of a unique case, pregnancies with unknown outcome, paternal exposures, CMs due to known genetic abnormalities, and cases exposed only via breast milk were excluded. Odd ratios for CMs were calculated for each non-TNFi, with CZP as reference group. Due to limitations of pharmacovigilance databases, such as possibility of under-reporting normal outcomes and information bias (2), in consultation with a clinical geneticist, CM patterns were compared between non-TNFi and CZP groups.

Results

In total 851 non-TNFi and 1179 CZP exposed pregnancy reports were included. Numerical differences for CMs after exposure to non-TNFis were not statistically significant except for belimumab and vedolizumab (Table 1).

Table 1.

Reported number, crude and adjusted ORs [95%CIs] for major and minor CMs and TOPFAs after intrauterine exposure to non-TNFis compared to CZP

MedicationReported CMs and TOPFAs, n/N (%)Crude ORs [95%CIs],Adjusted ORs (for maternal age) [95%CIs],Stratified ORs (teratogen unexposed cases only) [95%CIs] *Certolizumab pegol95/1179 (8.05)ReferenceReferenceReferenceAbatacept2/64 (3.12)0.36 [0.08, 1.52]0.35 [0.08, 1.47]0.69 [0.16, 2,96]Anakinra3/20 (15.00)2.01 [0.57, 6.99]2.81 [0.77, 10.20]3.39 [0.91, 12.63]Belimumab17/93 (18.27)2.55 [1.44, 4.49]2.63 [1.40, 4.93]2.65 [1.35, 5.20]Ixekizumab1/29 (3.44)0.40 (0.05, 3.02]0.39 [0.05, 2.96]0.42 [0.05, 3.16]Rituximab8/57 (14.03)1.86 [0.85, 4.04]2.47 [1.05, 5.80]2.55 [0.94, 6.95]Secukinumab4/128 (3.12)0.36 [0.13, 1.01]0.34 [0.10, 1.11]0.37 [0.11, 1.19]Tocilizumab10/124 (8.06)1.00 [0.50, 1.97]0.79 [0.37, 1.68]0.62 [0.22, 1.76]Ustekinumab19/215 (8.83)1.10 [0.66, 1.85]0.92 [0.51, 1.66]1.01 [0.56, 1.82]Vedolizumab23/113 (20.35)2.91 [1.76, 4.82]2.66 [1.53, 4.61]2.27 [1.24, 4.15]

OR: odds ratio; CI: confidence interval; CM: congenital malformation; TOPFA: termination of pregnancy due to foetal anomaly anomaly.

*After adjusting for maternal age, stratified ORs are presented for patients who had no reported teratogen exposure during pregnancy.

Pattern of CMs were reviewed by a clinical geneticist. Except for vedolizumab, no specific CM patterns were observed. For vedolizumab four cases of corpus callosum agenesis (CCA) were reported (versus null in CZP and other investigated non-TNFis). Three of the CCA cases were associated with other neurological CMs such as a neural tube defect, microcephaly and polymicrogyria. This indicates that the reported CCAs may have been related to undiagnosed genetic alterations or were associated with underlying maternal disease, although a definite relationship cannot be ruled out.

Conclusion

Except for vedolizumab, no special safety signal was identified regarding occurrence of CMs after exposure to non-TNFis. Based on available information, no firm conclusions can be made regarding observed CCA cases in vedolizumab group.

References

[1]EuropeanMedicinesAgency, Summary of Product Characteristics (SmPC) Certolizumab pegol (Cimzia). European Medicines Agency 2021. http://www.ema.europa.eu/docs/en_GB/document_library/EPAR_-_Product_Information/human/001037/WC500069763.pdf.

[2]Klein K, Scholl JHG, De Bruin ML, van Puijenbroek EP, Leufkens HGM, Stolk P. When More Is Less: An Exploratory Study of the Precautionary Reporting Bias and Its Impact on Safety Signal Detection. Clin Pharmacol Ther. 2018;103(2):296-303.

Acknowledgements

We would like to thank C. Zaccaria and L. Piccolo for their contributions to access and interpreting data from EudraVigilance database. The views expressed in this article are the personal views of the author(s) and may not be understood or quoted as being made on behalf of or reflecting the position of the regulatory agency/agencies or organizations with which the author(s) is/are employed/affiliated.

Disclosure of Interests

Nafise Ghalandari: None declared, Hubertina Johanna Maria Josephina Crijns: None declared, Jorieke Bergman: None declared, Radboud Dolhain Speakers bureau: UCB, Roche, Abbvie, Genzyme, Novartis, Lilly, Grant/research support from: RJEM. Dolhain, MD, PhD received an unrestricted grant from UCB Pharma B.V, Dutch Arthritis Association and Galapagos., Eugène van Puijenbroek: None declared, Johanna Hazes: None declared

POS0705 DILEMMA OF BELIMUMAB THERAPY (DIS) CONTINUATION DURING PREGNANCY: RESULTS OF A RETROSPECTIVE STUDY IN EUDRAVIGILANCE

Background

Active systemic lupus erythematosus (SLE) and nephritis due to SLE contribute to poor pregnancy outcomes. (1, 2) A meta-analysis has shown a relative risk of 1.51 for miscarriage in SLE patients compared to women without SLE. (3) The risk is even higher if the disease is active during pregnancy (around 3-fold increase in pregnancy loss). (4) Corticosteroids, azathioprine, hydroxychloroquine, ciclosporine and tacrolimus are considered safe treatments. (5) However, these treatment options may still not be sufficient in patients poorly responsive to conventional therapies or patients who suffer from nephritis. (6) The only biologic authorized for SLE up to this date, belimumab, is currently not recommended for use during pregnancy due to lack of data.

Provided that the health of the child begins with the health of the mother, pregnant patients, face the dilemma of cessation or continuation of belimumab. If belimumab is stopped there will be a risk of SLE flare and its consequences for mother and foetus. Continuation is also not optimal because the lack of knowledge on safety for use during pregnancy.

Objectives

To compare the reported foetal outcomes in SLE patients who stopped scheduled belimumab within the first trimester (group A) and who continued scheduled belimumab during the first trimester or thereafter (group B).

Methods

All belimumab-exposed pregnancy-related reports, were extracted from the EudraVigilance (EV) database until March 11th 2021. After case review, repeated cases, uninformative reports, non-medical elective abortions and foetal chromosomal abnormalities were excluded. Included pregnancies were divided into two groups (group A and B, as described above). Foetal outcomes were divided into live birth or foetal death (due to miscarriage or still birth) and were compared between both groups. Furthermore, neonatal outcomes, such as reporting rates of pre-term birth, low birth weight and major congenital malformations (CMs) were compared.

Results

No statistical difference in foetal death was observed between group A and B (reporting rates: 46.4% and 52.4%, respectively; p-value>0.05). Occurrence of major CMs, pre-term birth and low birth weight was higher - though not statistically different- in group A (Table 1).

Table 1.

Neonatal characteristics of live born children (including twin pregnancies)

Live birthsStopped (group A); (n=37)Continued (group B); (n =10)Total; (n=47)Gestational age at birth, median (IQR), weeks37.1 (35.5, 40.0)38.2 (36.4, 39.1)37.6 (36.0, 39.4)Weight, median (IQR), grams2749 (2268, 3200)2975 (2700, 3175)2835 (2406-3175)Preterm birth*; n (%)16 (43.2)4 (40.0)20 (42.5)Low birth weight*; n (%)9 (24.3)0 (0.0)9 (19.4)

Conclusion

Based on our data belimumab continuation during first trimester or thereafter does not result in higher reporting of foetal death. Therefore, continuation might be even preferable if the pregnancy is already exposed to belimumab. Since the analysis is based on spontaneous reports / retrospective data, additional studies are needed to confirm the results.

References

[1]Bremme K, Honkanen S, Gunnarsson I, Chaireti R. The presence of lupus nephritis additionally increases the risk of preeclampsia among pregnant women with systemic lupus erythematosus. Lupus. 2021;30(7):1031-8.

[2]Østensen M, Cetin I. Autoimmune connective tissue diseases. Best Pract Res Clin Obstet Gynaecol. 2015;29(5):658-70.

[3]Bundhun PK, Soogund MZ, Huang F. Impact of systemic lupus erythematosus on maternal and fetal outcomes following pregnancy: A meta-analysis of studies published between years 2001-2016. J Autoimmun. 2017;79:17-27.

[4]Clowse MEB, Magder LS, Witter F, Petri M. The impact of increased lupus activity on obstetric outcomes. Arthritis & Rheumatism. 2005;52(2):514-21.

[5]Moroni G, Ponticelli C. Pregnancy in women with systemic lupus erythematosus (SLE). Eur J Intern Med. 2016;32:7-12.

[6]Goldblatt F, Isenberg DA. New therapies for systemic lupus erythematosus. Clin Exp Immunol. 2005;140(2):205-12.

Acknowledgements

We would like to thank C. Zaccaria and L. Piccolo for their contributions to access and interpreting data from EudraVigilance database. The views expressed in this article are the personal views of the author(s) and may not be understood or quoted as being made on behalf of or reflecting the position of the regulatory agency/agencies or organizations with which the author(s) is/are employed/affiliated.

Disclosure of Interests

Nafise Ghalandari: None declared, Hubertina Johanna Maria Josephina Crijns: None declared, Radboud Dolhain Speakers bureau: UCB, Roche, Abbvie, Genzyme, Novartis, Lilly, Grant/research support from: unrestricted research grants from: Dutch Arthritis Association, UCB Pharma, Galapagos, Johanna Hazes: None declared, Eugène van Puijenbroek: None declared

POS0541 LOW PREVALENCE OF SSA (anti-Ro) AND SSB (anti-La) AUTOANTIBODIES IN FEMALE RHEUMATOID ARTHRITIS PATIENTS WITH A WISH TO CONCEIVE

Background:

The presence of SSA (anti-Ro) and SSB (anti-La) autoantibodies has important clinical implications for female patients with a wish to conceive. The association between maternal levels of these autoantibodies and complete congenital heart block and neonatal Lupus syndrome is well established. Currently guidelines advise to test for these antibodies in all Rheumatoid Arthritis (RA) patients with a wish to conceive (1).

Objectives:

The objective was to determine the prevalence and titers of SSA and SSB autoantibodies in female patients with rheumatoid arthritis and a wish to conceive or who are pregnant.

Methods:

Patients were derived from 2 large prospective cohorts on RA and pregnancy (PARA-cohort and PreCARA-cohort). The presence and titers of SSA and SSB were tested using Phadia, an automated system which uses fluorescence enzyme immunoassays (FEIA) (Thermo-Fisher Scientific).

Results:

We included a total of 647 patients with RA and a wish to conceive, 417 (64.5%) conceived during the follow-up period. A detailed description of the study population, stratified for the presence of SSA and SSB antibodies autoantibodies is presented in table 1. A total of 25 out of 647 patients had detectable SSA or SSB antibodies: SSA n = 25 (SSA-52 n = 17, SSA-60 n = 19), SSB n = 7. This corresponds with a prevalence of 3.9% for SSA antibodies and 1.1% for SSB antibodies. 13 (52% of the SSA positive patients, 2.0% of the total population) patients had a titer of >240 units/ml of SSA antibodies, and 3 (42.9% of the SSB positive patients, 0.46% of the total population) patients had a titers >340 units/ml of SSB antibodies. The percentage of patients positive for RF antibodies was higher in SSA and/or SSB positive patients (p = 0.01).

Table 1.

Clinical and demographic features from 647 patients with rheumatoid arthritis and a wish to conceive.

VariableSSA and SSB antibodies [-], n = 622Positive SSA and/or SSB antibodies [+], n = 25p-valueAge at inclusion in the cohort (y, SD)32.3 (4.0)32.3 (4.4)0.98Median disease duration at first visit, years (IQR)5.2 (2.2 – 9.8)4.9 (2.1 – 11.4)0.77ACPA positive, n (%)408/614 (66.5)16 (69.6)0.75Rheumatoid Factor positive, n (%)426/617 (69.0)23 (92.0)0.01

Conclusion:

Our study shows an overall low prevalence of SSA and SSB autoantibodies in female RA patients with a wish to conceive. Moreover, about half of the patients positive for SSA or SSB had, based on literature, moderate or low titers of these antibodies (2). Especially for RF negative patients, the current advise to test for SSA and SSB antibodies in all RA patients with a wish to conceive should be reconsidered.

References:

[1]Sammaritano LR et al. 2020 American College of Rheumatology Guideline for the Management of Reproductive Health in Rheumatic and Musculoskeletal Diseases. Arthritis Care Res (Hoboken). 2020 Apr; 72(4):461-488.

[2]Jaeggi E et al. The Importance of the Level of Maternal Anti-Ro/SSA Antibodies as a Prognostic Marker of the Development of Cardiac Neonatal Lupus Erythematosus: A Prospective Study of 186 Antibody-Exposed Fetuses and Infants. Journal of the American College of Cardiology. 2010 2010/06/15/; 55(24):2778-2784

Disclosure of Interests:

Hieronymus TW Smeele: None declared, Luis Fernando Perez-Garcia Consultant of: Yes, Galapagos, J.M.J. Cornette: None declared, Marco WJ Schreurs: None declared, Radboud Dolhain Speakers bureau: Yes UCB, Roche, Abbvie, Genzyme, Novartis, Consultant of: Yes, Galapagos, Grant/research support from: Yes, UCB

POS0542 DISEASE ACTIVITY IN PREGNANT WOMEN WITH RHEUMATOID ARTHRITIS: IMPACT ON THE SOLUBLE FMS-LIKE TYROSINE KINASE-1 TO PLACENTAL GROWTH FACTOR RATIO

Background:

An elevated sFlt-1 indicates soluble Fms-like tyrosine kinase-1 (sFlt-1)/ placental growth factor (PlGF) ratio has recently been validated as significant predictor of preeclampsia (PE)(1). However, raised sFlt-1 levels due to inflammation are observed in patients with rheumatoid arthritis (RA)(2). The use of the sFlt-1/PlGF ratio for the prediction of PE has not been evaluated in pregnant women with diseases that are characterized by high levels of inflammation, such as RA

Objectives:

We investigated whether sFlt-1 and/or PlGF are altered in pregnant women with RA according to disease activity, and evaluated whether a sFlt-1/PlGF ratio of ≤38 could be used to predict the absence of PE in pregnant RA-patients.

Methods:

This study was embedded in a nationwide, observational, prospective cohort study on pregnant women with RA (PARA-study). sFlt-1 and PlGF levels were measured, using automated analyzer (Cobas-6000, e-module; Roche-Diagnostics), in the third trimester of pregnancy.

Results:

A total of 221 women, aged 21–42 years, were included. Values of sFlt-1, PlGF and sFlt-1/PlGF ratio were not significantly correlated with the DAS28-CRP (Figure 1). CRP correlated weakly with PlGF (r=-0.14, p=0.03), while no correlation was found with sFlt-1 or the sFlt-1/PlGF ratio.

Preeclampsia occurred in four out of 214 women with a ratio ≤38 (2%) in contrast to three out of seven women with a ratio >38 (43%), p<0.001 (Table 1). When stratified to a sFlt-1/PlGF ratio of ≤38 only 2% of women developed preeclampsia, compared to 43% of the women with a ratio >38. The observed sensitivity and specificity for a sFlt-1/PlGF ratio cut-off of ≤38 were 42.1% and 98.1%, respectively, with a negative predictive value (NPV) of 98%. All women that developed PE, developed PE >4 weeks after collecting of blood samples in the 3rd trimester, therefore the observed NPV could be even higher.

Table 1.

Pregnancy Outcome according to sFlt-1/PlGF ratio with a cut-off value of 38.

ParameterRatio ≤38Ratio >38P-valueN2147GA at birth, weeks39 (38 - 40)37 (36 - 40)0.05<342 (1)0(0)1.0034 - 3718 (8)2 (29)0.12Male, n (%)113 (53)5 (71)0.45Birth weight, grams3420 (2998 - 3800)2620 (2360 - 2850)<0.01Maternal OutcomeGestational Hypertension15 (7)2 (29)0.09Preeclampsia4 (2)3 (43)<0.001Time to delivery, days66 (52 - 75)52 (44 - 66)0.08Fetal OutcomeBirth weight percentile <1033 (15)5 (71)<0.01Fetal/Neonatal Death1 (1)0 (0)1.00

Data are reported as median (interquartile range) or number (percentage). sFlt-1 indicates soluble Fms-like tyrosine kinase-1; PlGF, placental growth factor; GA, gestational age. Time to delivery is defined as the amount of days between blood sampling and delivery.

Conclusion:

Our study shows that in pregnant women with RA, the sFlt-1/PlGF ratio is not altered due to disease activity, and a cut-off of ≤38 of this ratio can be used to exclude preeclampsia.

References:

[1]H. Zeisler et al. Predictive Value of the sFlt-1:PlGF Ratio in Women with Suspected Preeclampsia. N Engl J Med 2016; 374: 13-22. DOI 10.1056/NEJMoa1414838.

[2]S. Ballara et al. Paleolog. Raised serum vascular endothelial growth factor levels are associated with destructive change in inflammatory arthritis. Arthritis Rheum 2001; 44: 2055-2064. DOI 10.1002/1529-0131(200109)44:9<2055::AID-ART355>3.0.CO;2-2.

Figure 1.

Correlations between sFlt-1, PlGF and sFlt-1/PlGF ratio with DAS28-CRP and CRP. Correlation coefficients for sFlt-1 (A-B), PlGF (C-D) and sFlt-1/PlGF ratio (E-F) with DAS28-CRP and CRP.

Acknowledgements:

The kits for measurement of sFlt-1/PlGF ratio were a kind gift from Roche Diagnostics, Germany. We thank all participants of the PARA study. Additionally, we extend our gratitude to the laboratory workers, in particular Nadine Davelaar and Priyanka Bangoer, and research assistants for their contribution to the data collection. We thank ReumaNederland (LLP project number: LLP-26) for their financial support.

Disclosure of Interests:

Hieronymus TW Smeele: None declared, R.I. Neuman: None declared, A.H.J. Danser: None declared, Radboud Dolhain Speakers bureau: Yes UCB, Roche, Abbvie, Genzyme, Novartis, Consultant of: Yes, Galapagos, Grant/research support from: Yes, UCB, W. Visser: None declared

OP0212 MEN DIAGNOSED WITH INFLAMMATORY ARTHRITIS BEFORE THE AGE OF 40 YEARS HAVE A LOWER FERTILITY RATE THAN THOSE DIAGNOSED AFTER THE AGE OF 40 YEARS: RESULTS OF A LARGE MULTICENTER STUDY (IFAME-FERTILITY)

Background:

The effect of inflammatory arthritis (IA) on fertility has been mainly studied in women. Multiple factors associated with lower fertility rate in women can also be present in male patients with IA (1). The fertility rate in men with IA, however, has never been studied.

Objectives:

To describe the fertility rate (number of biological children per individual) of men with IA.

Methods:

We performed a multicenter cross-sectional retrospective study conducted in eight Dutch hospitals. Men with IA (Rheumatoid Arthritis (RA), Juvenile Idiopathic Arthritis (JIA) and Spondyloarthritis (SpA)) who were over 40 years old and indicated that their family size was complete were invited to participate. Men who were still planning on having biological children were excluded. Participants completed a digital questionnaire that included fertility-related questions and questions regarding their demographic and clinical information. To analyze the impact of IA on male fertility rate, patients were divided into groups according to the age at the time of their diagnosis: age<30 years, age 31-40 years and age>41 years.

Results:

In total 628 participants diagnosed with IA were included. The response rate 34.87%. Information regarding their age, age at diagnosis, clinical diagnosis and number of children is presented per group in Table 1. Regarding the total number of children per man, there was a statistically significant difference between the three groups (p=<0.005). The mean total number of children was significantly lower in men diagnosed at age<30 years (1.39 {SD 1.41}) and at age 31-40 years (1.60 {SD 1.35}) compared to those diagnosed after at age>41 years (1.88 {SD 1.14}). Compared to men from the general population of the Netherlands, the total number of children of men diagnosed at age>41 years was not statistically different (1.88 vs 1.80, respectively).

Table 1.

Participants’ basic demographic and clinical characteristics, including the number of biological children per men.

All patientsIA diagnosed at age <30 yearsIA diagnosed at age 31-40 yearsIA diagnosed at age >41 yearsTotal, n (%)628137 (21.82)149 (23.73)342 (54.46)Age, mean (SD)57.17 (9.98)53.01 (9.96)52.76 (7.35)61.06 (9.47)Diagnosis, n (%)•iRA297 (47.29)42 (30.66)67 (44.97)188 (55.32)•AJIA10 (1.59)10 (6.25)0 (0)0 (0)•ISpA (incl. PsA)320 (50.96)90 (65.69)83 (55.70)147 (42.98)Age at diagnosis, mean (SD)41.29 (13.08)26.27 (9.15)36.99 (5.66)49.98 (9.70)Disease duration, mean (SD)15.89 (11.88)26.48 (12.57)15.70 (8.52)11.30 (9.87)Number of biological children, mean (95% CI)1.71 (1.60-1.81)1.39 (1.15-1.63)a,b1.60 (1.38-1.82)a1.88 (1.75 -2.01)

a p< 0.05 compared to those diagnosed age >41 years

b p< 0.05 compared to those diagnosed age >31-40 years

Conclusion:

This is the largest study ever conducted to evaluate the impact of IA on male fertility. We demonstrated that men diagnosed with IA before and during their reproductive years have a lower fertility rate than those men diagnosed with IA after their reproductive years. Multiple mechanisms (biological and non-biological) can be responsible for this association. More research is needed to identify the causes of these lower fertility rates in men with IA.

References:

[1]Perez-Garcia LF, Te Winkel B, Carrizales JP, Bramer W, Vorstenbosch S, van Puijenbroek E, et al. Sexual function and reproduction can be impaired in men with rheumatic diseases: A systematic review. Semin Arthritis Rheum. 2020;50(3):557-73.

Figure 1.

Total number of biological children (mean and SD) per group.

Acknowledgements:

The authors would like to acknowledge Ron Buijs, data manager of the Department of Rheumatology of the Erasmus MC, for his technical support with regards to data collection.

Disclosure of Interests:

Luis Fernando Perez-Garcia Consultant of: Galapagos, Esther Röder: None declared, Robbert Goekoop: None declared, Johanna Hazes: None declared, Marc R Kok Consultant of: Novartis, Grant/research support from: Novartis, Petra Kok: None declared, Hieronymus TW Smeele: None declared, Ilja Tchetverikov: None declared, J.H. van der Kaap: None declared, Annette van der Helm - van Mil: None declared, Bouwe Krijthe: None declared, Radboud Dolhain Speakers bureau: UCB, Roche, Abbvie, Genzyme, Novartis, Consultant of: Galapagos, Grant/research support from: UCB

AB0020 ACPA ILLUSTRATING THE IMPACT OF IGG FAB-GLYCOSYLATION ON TRANSPLACENTAL TRANSFER OF ANTIBODIES AND THEIR BINDING TO THE NEONATAL FC-RECEPTOR (FCRN)

Background:

Fc neonatal receptor (FcRn) is crucial for IgG half-life and transplacental transport. Different sites of IgG carry glycans which may affect binding to FcRn. While the effect of Fc-glycans has been investigated, the impact of Fab-glycosylation (~14% IgG) on IgG-FcRn interaction remains unclear. Anti-citrullinated protein antibodies (ACPA) of rheumatoid arthritis patients exhibit remarkably high Fab-glycosylation (~90%). This makes ACPA an ideal model to investigate how Fab-glycosylation influences IgG-FcRn interaction.

Objectives:

To investigate the potential impact of IgG Fab-glycosylation on IgG transplacental transfer and interaction with FcRn.

Methods:

To investigate transplacental transport of ACPA and total IgG, serum of ACPA-positive RA patients (mothers) as well as of healthy mothers and their respective newborns was analyzed. IgG Fab- and Fc-glycosylation was investigated with liquid chromatography and mass-spectrometry. Furthemore, ACPA monoclonal IgG were produced and glycoengineered to acquire several variants of the same monoclonal antibody differing only in their glycosylation profile. These glycovariants were then used to investigate the impact of Fab-glycans on the affinity of IgG for FcRn. Surface plasmon resonance (SPR) and affinity chromatography were implemented.

Results:

When measured in mothers’ serum and cord blood samples, Fab-glycosylation of IgG antibodies was ~20% lower in newborns compared to their mothers, which was observed for ACPA IgG, non-ACPA IgG in RA patients and total IgG of healthy controls (Figure 1). This may indicate that transplacental transfer of Fab-glycosylated antibodies is impaired. SPR results suggested that presence of Fab-glycans slightly lowered the affinity of IgG for FcRn. However, presence of Fab-glycans did not have a significant effect on the results of FcRn affinity chromatography. Together, these results suggest that Fab-glycans may impair association of IgG with FcRn, while dissociation likely stays intact.

Conclusion:

Our results suggest that Fab-glycans inhibit IgG-FcRn binding which negatively affects the transplacental transfer of Fab-glycosylated IgG. The impact of Fab-glycosylation on IgG half-life requires further investigation.

Figure 1.

Disclosure of Interests:

Mikhail Volkov: None declared, Karin van Schie: None declared, Albert Bondt: None declared, Theresa Kissel: None declared, Maximilian Brinkhaus Grant/research support from: argenx, Arthur Bentlage: None declared, Carolien Koeleman: None declared, Steven de Taeye Grant/research support from: Genmab, Radboud Dolhain: None declared, Manfred Wuhrer: None declared, Rene Toes: None declared, Gestur Vidarsson: None declared, Diane van der Woude: None declared

AB0052 INFLAMMATORY PROTEOMIC SIGNATURE RELATED TO DECREASED FERTILITY IN WOMEN WITH RHEUMATOID ARTHRITIS

Background:

Fertility issues are common in women with rheumatoid arthritis (RA). Decreased fertility in these patients is associated with high disease activity and the use of certain medication [1]. However, immunological mechanisms behind this phenomenon remain unresolved.

Objectives:

This study aims to identify inflammation-related proteins associated with decreased fertility in women with rheumatoid arthritis and a wish to conceive.

Methods:

Patients were derived from the PARA-study, a prospective cohort on RA and pregnancy. High-multiplex immunoassay technology with qPCR readout (Olink Proteomics, Uppsala, Sweden) was used to assess 92 inflammation-related proteins in serum obtained before pregnancy of 186 women with RA and a wish to conceive. Measured protein levels were imputed into multivariable cox regression models with time to pregnancy (TTP) as dependent variable. This model was corrected for known confounders age, nulliparity, NSAID use, prednisone use and past methotrexate use [2].

Results:

Our analyses show prolonged TTP to be associated with increased expression of pro-inflammatory cytokines (TNF, IL-6, IL-18), chemokines (CCL23, CCL19, CXCL10, MCP-3, CXCL9) and T cell stimulating factors (TNFRSF9, CDCP-1). Furthermore, increased factors associated with angiogenesis (VEGF-A) and bone and collagen damage (RANKL, MMP-1) were found. Lastly, decreased fertility is associated with increased immune regulatory factors (IL-10, IL10RB, PD-L1). After false discovery rate (FDR) correction for multiple testing, IL-10, CCL23, MCP-3 and CDCP-1 remained statistically significant (adjusted P<0.05). Results are depicted in table 1.

Conclusion:

This study shows a pro-inflammatory proteomic signature, including a counterbalance of increased immune regulatory proteins, to be associated with prolonged TTP. These findings provide more insight into the immunological pathways involved in fertility in RA patients.

References:

[1]Smeele HTW, Dolhain R. Current perspectives on fertility, pregnancy and childbirth in patients with Rheumatoid Arthritis. Semin Arthritis Rheum. 2019;49(3S):S32-S5.

[2]Brouwer J, Hazes JM, Laven JS, Dolhain RJ. Fertility in women with rheumatoid arthritis: influence of disease activity and medication. Ann Rheum Dis. 2015;74(10):1836-41.

Table 1.

Significant multivariable cox regression results with time to pregnancy as dependent variable, corrected for age, nulliparity, NSAID use, prednisone use and past MTX use. HR = hazard ratio, FDR = false discovery rate.

ProteinHRPP FDR adjustedFunctionIL-100,640,0010,026Immune regulatoryCCL230,510,0010,026T cell/monocyte migrationMCP-30,740,0010,026Monocyte migrationCDCP10,560,0020,039T cell migrationCCL190,770,0050,077DC/T cell/B cell migrationTNFRSF90,630,0070,090T cell costimulatorVEGF-A0,70,0140,154AngiogenesisCXCL100,820,0210,185T cell/monocyte/NK/DC migrationRANKL0,760,0220,185Osteoclast activation, DC survivalIL-60,880,0240,185Pro-inflammatory cytokine, stimulation of acute phase responsePD-L10,550,0270,189Immune suppressionIL-180,70,0350,193Type 1 response activatorIL-70,690,0380,208Lymphocyte maturationIL-10RB0,480,0390,208IL-10 receptorMMP-10,730,0450,208Collagen breakdownTNF0,440,0480,208Pro-inflammatory cytokine, necrosisCXCL90,260,0490,208Th1 polarization

Acknowledgements:

The authors are grateful to all patients who participated in the PARA study. Additionally, they thank Yaël de Man, Fleur van de Geijn, Esther Gasthuis, Florentien de Steenwinkel, Jenny Brouwer and all laboratory workers and research assistants for their contribution to the data collection.

Disclosure of Interests:

Margot Bongenaar: None declared, Hieronymus TW Smeele: None declared, Erik Lubberts Grant/research support from: CHDR, Galapagos, Radboud Dolhain Speakers bureau: Yes, for UCB, Roche, Abbvie, Genzyme, Novartis, Consultant of: Yes, Galapagos, Grant/research support from: Yes, UCB

POS0526 SEXUAL FUNCTION IN MALE AND FEMALE PATIENTS WITH RHEUMATOID ARTHRITIS: A POST-HOC ANALYSIS OF THE FINCH STUDIES

Background:

While sexual function is impaired in a high proportion of patients with rheumatoid arthritis (RA), it is often neglected in patient care.1 FINCH 1 (NCT02889796), FINCH 2 (NCT02873936) and FINCH 3 (NCT02886728) were Phase 3 studies to assess the safety and efficacy of filgotinib (FIL) for moderate-to-severe RA; patient-reported sexual function was also evaluated.

Objectives:

To analyse disease characteristics associated with sexual function and explore the effect of FIL and adalimumab (ADA) on sexual function in males and females in the FINCH studies.

Methods:

Post-hoc analyses included data from patients who were randomised and received ≥1 dose of study drug in the FINCH studies. Male and female subgroup analyses were performed to describe the correlation between baseline disease characteristics and baseline visual analogue scale (VAS) sexual function score (using Pearson correlation coefficient) and to assess the treatment effect on the change from baseline in VAS sexual function (mm) up to Week 52 (FINCH 1 and 3) or Week 24 (FINCH 2). Patients indicated how RA affected their ability to have sex during the last week using an exploratory 0–100 VAS (0: no effect; 100: complete inhibition). Changes from baseline were analysed with a mixed-effects model for repeated measures. All P values are nominal for exploratory purposes.

Results:

Baseline characteristics are shown in the Table 1. Univariate analyses revealed significant positive correlations (P<0.05) between disease duration and baseline VAS sexual function score in male and female subgroups in FINCH 1; no significant correlations were seen in male and female subgroups of FINCH 2 and 3. In all studies, significant correlations (P<0.05) were observed between baseline VAS sexual function score and baseline disease characteristics (swollen/tender joint count 28, Disease Activity Score-28, Health Assessment Questionnaire Disability Index, 36-Item Short Form Survey, patient global VAS, pain VAS or fatigue) in males or females. In all studies, analysis of least-squares mean changes from baseline in VAS sexual function revealed improvements in both males and females on FIL as early as Week 2, until Week 52 (Week 24 in FINCH 2). Figure 1 shows data for FINCH 1.

Conclusion:

Sexual function should be considered as an important patient outcome in RA treatment. At baseline in the FINCH studies, disease activity negatively impacted sexual function in both male and female patients. Active treatment with FIL or ADA resulted in early and sustained improvements from baseline in sexual function.

References:

[1]Tristano AG. World J Orthop 2014;5:107–11

Table 1.

Mean (standard deviation) baseline characteristics

FINCH 1FINCH 2FINCH 3Male n=258Female n=990Malen=79Female n=270Male n=233Female n=691Duration of RA, yr6.8 (7.38)8.0 (7.63)11.3 (8.53)12.7 (9.35)2.1 (5.35)2.2 (4.85)SJC2811 (5.0)11 (5.1)13 (6.2)12 (6.1)11 (5.4)11 (5.7)TJC2814 (6.5)15 (6.4)15 (7.5)16 (7.0)14 (6.6)15 (6.7)HAQ-DI1.35 (0.614)1.64 (0.601)1.41 (0.689)1.73 (0.634)1.37 (0.651)1.62 (0.617)DAS28 (CRP)5.6 (0.95)5.8 (0.90)5.8 (1.08)5.9 (0.92)5.7 (1.00)5.7 (0.99)SF-36 PCS34.3 (7.72)33.0 (7.34)31.7 (8.48)30.9 (7.75)34.4 (7.72)33.4 (7.47)SF-36 MCS45.9 (10.15)43.6 (10.65)43.7 (11.20)44.5 (11.71)46.2 (11.75)43.0 (10.89)FACIT-fatigue30.0 (10.00)26.8 (10.49)26.3 (11.15)24.0 (11.64)30.7 (10.93)26.6 (10.89)Patient global VAS (mm)64 (19.8)67 (19.0)66 (20.0)70 (19.5)65 (22.4)66 (20.3)Pain VAS (mm)61 (20.6)66 (19.5)62 (22.3)68 (20.6)64 (22.3)66 (20.9)VAS sexual function score44 (30.2)49 (32.3)48 (34.6)49 (36.8)42 (34.4)48 (35.1)

Variables in bold significantly correlated with VAS sexual function score (P<0.05)

DAS28 (CRP), Disease Activity Score-28 using C-reactive protein; FACIT, Functional Assessment of Chronic Illness Therapy; HAQ-DI, Health Assessment Questionnaire Disability Index; MCS, mental component summary; PCS, physical component summary; RA, rheumatoid arthritis; SF-36, 36-Item Short Form Survey; S/TJC28, swollen/tender joint count based on 28 joints; VAS, visual analogue scale

Acknowledgements:

The FINCH studies were funded by Gilead Sciences, Inc (Foster City, CA, USA). Medical writing/editorial support was provided by Debbie Sherwood, BSc, CMPP (Aspire Scientific, Bollington, UK), funded by Galapagos NV (Mechelen, Belgium).

Disclosure of Interests:

Luis Fernando Perez-Garcia Consultant of: Galapagos, Grant/research support from: CONACYT, ReumaNederland, and ZonMw, Mihaela Micu Speakers bureau: AbbVie, Angelini, Eli Lilly, Ewopharma, Novartis, UCB, Consultant of: Galapagos, Lien Gheyle Shareholder of: Galapagos, Employee of: Galapagos, Zhaoyu Yin Shareholder of: Gilead, Employee of: Gilead, YingMeei Tan Shareholder of: Gilead, Employee of: Gilead, Kun Chen Shareholder of: Gilead, Employee of: Gilead, Patrick Papazian Speakers bureau: Amgen, Gilead, Janssen, MSD, Consultant of: Gilead, Janssen, MSD, Employee of: Galapagos, part-time employee since Sept 2020, Katrien Van Beneden Shareholder of: Galapagos, Employee of: Galapagos, Radboud Dolhain Speakers bureau: AbbVie, Genzyme, Novartis, Roche, UCB, Consultant of: Galapagos, Grant/research support from: UCB, Rene Westhovens Speakers bureau: Celltrion, Galapagos/Gilead, Consultant of: Celltrion, Galapagos/Gilead

OP0211 PATERNAL INFLAMMATORY ARTHRITIS IS ASSOCIATED WITH A HIGHER RISK OF MISCARRIAGES: RESULTS OF A LARGE MULTICENTER STUDY (IFAME-FERTILITY)

Background:

The effect of inflammatory arthritis (IA) on pregnancy outcomes has been studied mainly in women. Paternal older age, sperm DNA integrity and certain genetic defects have been associated with worse pregnancy outcomes (1). However, pregnancy outcomes of partners of men with IA have never been studied.

Objectives:

To describe the pregnancy characteristics and outcomes of partners of men diagnosed with IA.

Methods:

We performed a multicenter cross-sectional retrospective study conducted in eight Dutch hospitals. Men with IA (Rheumatoid Arthritis (RA), Juvenile Idiopathic Arthritis (JIA) and Spondyloarthritis (SpA)) who were over 40 years old and indicated that their family size was complete were invited to participate. Participants completed a digital questionnaire that included pregnancy-related questions and questions regarding their demographic and clinical information. To analyze the impact of IA on pregnancy outcomes, pregnancies were classified into two groups; pregnancies that occurred after diagnosis of IA and before the diagnosis of IA.

Results:

In total 628 male participants diagnosed with IA were included. 408 men reported 897 singleton pregnancies that resulted in 794 live births. Regarding pregnancy characteristics, pregnancies conceived after diagnosis of IA had a higher mean paternal and maternal age at conception and a lower rate of spontaneous pregnancies (90.91 vs 96.60%, p=<0.005) (See Table 1). With regards to pregnancy outcomes, pregnancies conceived after receiving the diagnosis of IA had a lower rate of live births (86.36% and 89.22%, p=0.053) and a significant higher rate of miscarriages (12.27 vs 7.53%, p=<0.05). After correcting for maternal age and year of pregnancy, pregnancies conceived after the diagnosis of IA had a higher risk of miscarriages (OR 1.71 [CI 1.04-2.81], p<0.05). No statistically significant differences between the two groups were reported for the rates of abortions, preterm births and pregnancy complications.

Table 1.

Pregnancy characteristics and outcomes.

AllpregnanciesPregnancy afterdiagnosis of IAPregnancy before diagnosis of IAP valuePregnancy characteristicsTotal number of pregnancies897220677Maternal age at conception, mean (SD)29.00 (5.00)30.69 (5.16)28.45 (4.83)p<0.005Paternal age at conception, mean (SD)31.31 (5.72)34.27 (6.08)30.49 (5.34)p<0.005Spontaneous pregnancy, n (%)854 (95.21)200 (90.91)654 (96.60)p<0.005Pregnancy duration-months, median (IQR)39 (38-40)39 (38-40)39 (38-40)p=0.928Pregnancy outcomesLive births, n (%)794 (88.52)190 (86.36)604 (89.22)p=0.053Miscarriage, n (%)78 (8.70)27 (12.27)51 (7.53)p<0.05Abortion, n (%)25 (2.78)3 (1.36)22 (3.25)p=0.128*Medical indication5 (20.00)0 (0)5 (22.73)*Personal reasons20 (80.00)3 (100.00)17 (77.27)Pre-term birth149 (16.61)31 (14.09)118 (17.43)p=0.248Pregnancy complicationsNo complications during pregnancy, n (%)754 (84.34)184 (83.64)570 (84.57)p=0.741Hypertensive disorders(hypertension, pre/eclampsia), n (%)41 (4.57)8 (3.64)33 (4.87)p=0.445Gestational Diabetes Mellitus11 (1.28)2 (0.94)9 (1.38)p=0.619Growth restriction12 (1.34)1 (0.45)11 (1.65)p=0.193

Conclusion:

This is the largest study to describe the pregnancy characteristics and outcomes of partners of men diagnosed with IA and the first to demonstrate that paternal IA is associated with a higher risk of miscarriage. Prospective studies are needed to corroborate these findings.

References:

[1]Ibrahim Y, Johnstone E. The male contribution to recurrent pregnancy loss. Translational andrology and urology. 2018;7(Suppl 3):S317-S27.

Acknowledgements:

The authors would like to acknowledge Ron Buijs, data manager of the Department of Rheumatology of the Erasmus MC, for his technical support with regards to data collection.

Disclosure of Interests:

Luis Fernando Perez-Garcia Consultant of: Galapagos, Esther Röder: None declared, Robbert Goekoop: None declared, Marc R Kok Consultant of: Roche, Grant/research support from: Roche, Petra Kok: None declared, Hieronymus TW Smeele: None declared, Ilja Tchetverikov: None declared, Annette van der Helm - van Mil: None declared, J.H. van der Kaap: None declared, Bouwe Krijthe: None declared, Radboud Dolhain Speakers bureau: Abbvie, UCB, Genzyme, Novartis, Consultant of: Galapagos, Grant/research support from: UCB

POS0202 ANALYZING CORD BLOOD LEVELS OF TNF INHIBITORS TO VALIDATE THE EULAR POINTS-TO-CONSIDER FOR TNF INHIBITOR USE DURING PREGNANCY

Background:

Increasing evidence suggests that TNF inhibitors (TNFi) are safe to use during pregnancy1. A drawback of TNFi use during pregnancy is active transport across the placenta, which is affected by the structure of the TNFi1. The European League Against Rheumatism (EULAR) defined points to consider (PtC) on the use of TNFi during pregnancy2: to prevent placental transfer, etanercept should be discontinued at gestational age (GA) 30-32 weeks, and both adalimumab and infliximab should be discontinued at GA 20 weeks. Certolizumab pegol can be conditionally continued throughout pregnancy.

Objectives:

The aim of this research is to validate the EULAR PtC by measuring the level of TNFi in cord blood.

Methods:

Patients were derived from the PreCARA study, an ongoing prospective cohort study on inflammatory rheumatic diseases and pregnancy in the Netherlands. Patients were treated according to a treat-to-target approach, which included the use of TNFi. TNFi were, if possible, discontinued at recommended stop time points. Maternal blood samples were collected in each trimester. Cord blood was analyzed for the presence of certolizumab pegol, etanercept, adalimumab and infliximab. Levels of TNFi in the cord blood were compared between patients that stopped at the advised GA and patients who did not.

Results:

Data from 111 patients with inflammatory rheumatic diseases were used for the current analysis. Most patients stopped treatment before the recommended GA (table 1). Certolizumab pegol (n = 68) was measured in a low number of cord blood samples (5.9%) and in low concentrations (median, (IQR): 0.25 µg/ml (0.15 – 1.3)). Etanercept was not detected in any cord blood samples (n = 28). Adalimumab (n = 24) and infliximab (n = 13) were measured more often in cord blood (in 50.0% and 61.5% of patients, respectively), this also was observed in patients that stopped before the recommended GA (in 47.7% for adalimumab and 60.0% for infliximab). However, the observed concentrations were low: the maximum observed concentrations in cord blood were 2.1 µg/ml (stopped at GA 19.4 weeks) for adalimumab and 4.5 µg/ml (stopped at GA 21.1 weeks) for infliximab.

Conclusion:

Stopping TNFi around the GA recommended by the EULAR PtC resulted in no measurable levels or low concentrations of TNF inhibitor in the cord blood in a majority of patients.

References:

[1]Smeele HTW, Dolhain RJEM. Current perspectives on fertility, pregnancy and childbirth in patients with Rheumatoid Arthritis. Semin Arthritis Rheum. 2019;49(3S):S32-S35. doi:10.1016/j.semarthrit.2019.09.010

[2]Götestam Skorpen C, Hoeltzenbein M, Tincani A, et al. The EULAR points to consider for use of antirheumatic drugs before pregnancy, and during pregnancy and lactation. Ann Rheum Dis. 2016;75(5):795-810. doi:10.1136/annrheumdis-2015-208840

Table 1.

TNF inhibitor use during pregnancy and TNF inhibitor concentrations in mother’s blood and cord blood.

Certolizumab pegol (n = 68)Etanercept (n = 28)Adalimumab (n = 24)Infliximab (n = 13)Stop time point as recommended by EULARN/AGA 30-32GA 20GA 20Gestational age at time of stopping TNFi, median±IQR37.29 (32.79 – 38.29)25.43 (18.71 – 28.36)18.79 (8.93 – 19.86)18.86 (14.57 – 20.00)Measurable TNFi in cord blood, n (%)4 (5.9%)0 (0%)12 (50.0%)8 (61.5%)Maternal concentration of TNFi in the 1st trimester, median±IQR (µg/ml)24.55 (19 – 31)2.1 (0.8 – 2.5)8.2 (1.5 – 10)14 (7.98 – 21)Maternal concentration of TNFi in the 2nd trimester, median±IQR (µg/ml)22.52 (13 – 30.72)1.4 (0.89 – 2.7)6 (4.5 – 7.5)6.37 (4.2 – 20)Maternal concentration of TNFi in the 3rd trimester, median±IQR (µg/ml)20.5 (13 – 29.58)0.2 (0.2 – 0.67)0.85 (0.1 – 1.4)1.4 (0.09 – 1.9)Concentration of TNFi in the cord blood if measurable, median±IQR (µg/ml)0.25 (0.15 – 1.3)-0.45 (0.15 – 0.65)0.4 (0.12 – 1.15)

Disclosure of Interests:

Erik Kemper: None declared, Nafise Ghalandari: None declared, Hubertina Johanna Maria Josephina Crijns: None declared, Hieronymus TW Smeele: None declared, Radboud Dolhain Speakers bureau: UCB, Roche, Abbvie, Genzyme, Novartis, Consultant of: Galapagos, Grant/research support from: UCB

OP0303-HPR IT IS NOT JUST ABOUT THE SEX: VIEWPOINTS OF DUTCH ADULT MEN WITH INFLAMMATORY ARTHRITIS REGARDING THE IMPACT OF THE DISEASE ON THEIR SEXUAL HEALTH

Background:

Sexual health (SH) can be impaired in men with inflammatory arthritis (IA) (1). In addition to biological factors, such as inflammation, subjective factors such as personal beliefs can also impair SH. The Q methodology combines aspects of qualitative and quantitative approaches to systematically study subjectivity, and has been applied successfully in other medical fields.

Objectives:

To describe the viewpoints of adult men with IA on the impact of IA on their SH using the Q methodology.

Methods:

Men, 18 years and older, diagnosed with RA or JIA were invited by their rheumatologist. Participants ranked 34 opinion statements about potential impacts of IA on their SH on an agreement scale. A by-person factor analysis identified common patterns in the rankings. These patterns represent the different viewpoints among the men. Data from interviews, in which the men explained their ranking, was used to further interpret the viewpoints. A Q-methodology study usually consists of 30-40 participants.

Results:

30 men with IA were included. Their mean age was 43.2 (range 22–77) years. The analysis revealed three viewpoints:

1.“I am satisfied with my sex life”

Men with viewpoint 1 experience no significant impact of IA on their SH. However, most men indicated that when their disease was active, IA had a negative impact on their SH.

2.“Arthritis has a negative influence on my sex life”

Men with viewpoint 2 experience a dramatic impact, due to pain, fatigue and gloom. Their relationship worsened and they feel guilty towards their partner. Discussing their problems is not difficult.

3.“I am keeping up appearances”

Men with viewpoint 3 experience SH impairment mainly as a result of pain. IA impairs them physically, makes them feel less of a man, less attractive and reduces their self-confidence. Due to problems with accepting their disease and communicating their problems, these men tend to hide their problems.

Conclusion:

We identified 3 viewpoints on the impact of IA on male SH, 2 of them revealing a negative influence that goes beyond the physical act of sex. IA can also affect relationships, self-confidence and manhood. Future research will focus on identifying men with SH problems in the clinic and the best counseling approach.

References:

[1]Perez-Garcia LF, Te Winkel B, Carrizales JP, Bramer W, Vorstenbosch S, van Puijenbroek E, et al. Sexual function and reproduction can be impaired in men with rheumatic diseases: A systematic review. Semin Arthritis Rheum. 2020;50(3):557-73.

Disclosure of Interests:

Luis Fernando Perez-Garcia Consultant of: Galapagos, Esther Röder: None declared, Hester Pastoor: None declared, Hanneke Bolt: None declared, Job van Exel: None declared, Radboud Dolhain Speakers bureau: Abbvie, UCB, Genzyme, Consultant of: Galapagos, Grant/research support from: UCB.

Male Sexual Health and Reproduction in Cutaneous Immune-Mediated Diseases: A Systematic Review

INTRODUCTION

Information about the possible effects of cutaneous immune-mediated diseases (cIMDs) on male sexual function and reproduction is scarce. Factors known to impair sexual health and reproduction, such as inflammation, medication use, and hypogonadism, can be present in a significant proportion of male patients with cIMD.

OBJECTIVES

To systematically review the literature for the influence of paternal cIMD on many aspects of male sexual and reproductive health, such as sexual function, reproductive hormones, fertility, and pregnancy and offspring outcomes.

METHODS

A systematic literature search was performed. The searches combined keywords regarding male sexual function and fertility, pregnancy outcomes, and offspring's health with a list of cIMDs.

RESULTS

The majority of the identified studies included patients with psoriasis (22 of 27), and sexual function was the most common outcome of interest (20 of 27). For patients diagnosed with psoriasis, the prevalence of male sexual dysfunction reported in these studies ranged from 34 to 81%. Hypogonadism in patients with psoriasis was reported in 2 of 3 studies. Sperm analysis abnormalities in patients with psoriasis were reported in 3 of 4 studies. No information about the effect of paternal disease on pregnancy and offspring outcomes was identified.

CONCLUSIONS

Disease activity in psoriasis might play an important role in the development of sexual dysfunction, hypogonadism, and abnormal sperm quality. For the other cIMD included in this review, there is insufficient information regarding male sexual and reproductive health to draw firm conclusions. More research is needed to understand the association between cIMD and impaired male sexual and reproductive health. Perez-Garcia LF, Dolhain R, te Winkel B, et al. Male Sexual Health and Reproduction in Cutaneous Immune-Mediated Diseases: A Systematic Review. Sex Med Rev 2021;9:423-433.

AB1197 TREAT-TO-TARGET IS FEASIBLE IN RHEUMATOID ARTHRITIS PATIENTS DURING PREGNANCY, FIRST RESULTS OF THE PreCARA COHORT

Background:

A treat-to-target approach results in better outcomes for Rheumatoid Arthritis (RA) patients [1]. Well controlled disease is important for pregnant RA patients and patients with a wish to conceive too. Not only for the welfare of the mother, but also because active disease is associated with a prolonged time to pregnancy and adverse pregnancy outcomes [2]. This is this first study to examine a treat-to-target approach during pregnancy.

Objectives:

To determine the feasibility of a treat-to-target approach in RA patients with a wish to conceive or pregnant.

Methods:

Patients were derived from the PreCARA cohort (first inclusion 2011, data shown up to November 2019). The PreCARA cohort is an ongoing, single center, prospective study on RA and pregnancy. Patients in this cohort were treated according to a treat-to-target approach, in which the obvious restrictions of pregnancy were taken into account. Study visits were scheduled before, during and after pregnancy and disease activity (DAS28CRP) was measured. Results of the PreCARA study were compared with results of the PARA study [3], a historic reference cohort on RA during pregnancy, with a similar study design (inclusion 2002 – 2010). Patients in the PARA cohort were treated according to the standards of that time. The PARA cohort represents the natural course of RA during pregnancy with limited treatment options.

Results:

263 RA patients were included in the PreCARA cohort, up to now 154 children were born in this ongoing cohort. Mean age at inclusion was 32.3 (4.3 SD), 83.2 % was Rheumatoid Factor positive and/or ACPA positive. Mean disease activity in the PreCARA cohort is statistically significant lower than in the PARA cohort at every time-point: mean DAS28CRP in 3rdtrimester in the PreCARA cohort 2.22 (0.73 SD), in the PARA cohort 3.35 (1.12 SD) P < 0.001 (figure 1). In the PreCARA cohort 73.3% of the patients were in low disease activity or remission before pregnancy increasing to 90.4 % in the third trimester, whereas in the PARA cohort these percentages were 32.2 % and 47.3% respectively (P < 0.001) (figure 2). Medication use in the PreCARA cohort is shown in table 1 and in the PARA cohort in table 2.

MedicationBefore pregnancy (%)*1sttrimester (%)2ndtrimester (%)3rdtrimester (%)6 weeks post-partum (%)12 weeks post-partum (%)26 weeks post-partum (%)MTX5000151915Leflunomide0000112Abatacept0000111Hydroxychloroqine63515150494331Sulfasalazine70565857544736Prednisone43403942383427Azathioprine1211011Certolizumab25212628262418Adalimumab10500334Infliximab5830111Etanercept13109310119Golimumab0000001Tocilizumab3100323

* patients seen before pregnancy = 104

MedicationBefore pregnancy (%)**1sttrimester (%)2ndtrimester (%)3rdtrimester (%)6 weeks post-partum (%)12 weeks post-partum (%)26 weeks post-partum (%)MTX0000183036Leflunomide0000012Hydroxychloroqine6222487Sulfasalazine34252726263029Prednisone42333636353632Azathioprine1000111Adalimumab0000235Infliximab0000011Etanercept0000365

** patients seen before pregnancy = 124

Conclusion:

This first study on a treat-to-target approach in pregnant RA patients shows that low disease activity and remission are an attainable goal during pregnancy, with over 90% of patients achieving this in the 3rdtrimester. The effect of this approach on fertility and pregnancy outcomes should be the focus of further studies.

References:

[1]Smolen et al. Rheumatoid arthritis. Lancet 2016

[2]Smeele et al. Current perspectives on fertility, pregnancy and childbirth in patients with Rheumatoid Arthritis. Semin Arthritis Rheum 2019

[3]de Man et al. Measuring disease activity and functionality during pregnancy in patients with rheumatoid arthritis. A&R 2007

Disclosure of Interests:

Hieronymus TW Smeele: None declared, Esther Röder: None declared, Hetty Wintjes: None declared, Laura JC Kranenburg - van Koppen: None declared, Johanna Hazes: None declared, Radboud Dolhain Grant/research support from: unrestricted grant from UCB Pharma

The EULAR points to consider for use of antirheumatic drugs before pregnancy, and during pregnancy and lactation

A European League Against Rheumatism (EULAR) task force was established to define points to consider on use of antirheumatic drugs before pregnancy, and during pregnancy and lactation. Based on a systematic literature review and pregnancy exposure data from several registries, statements on the compatibility of antirheumatic drugs during pregnancy and lactation were developed. The level of agreement among experts in regard to statements and propositions of use in clinical practice was established by Delphi voting. The task force defined 4 overarching principles and 11 points to consider for use of antirheumatic drugs during pregnancy and lactation. Compatibility with pregnancy and lactation was found for antimalarials, sulfasalazine, azathioprine, ciclosporin, tacrolimus, colchicine, intravenous immunoglobulin and glucocorticoids. Methotrexate, mycophenolate mofetil and cyclophosphamide require discontinuation before conception due to proven teratogenicity. Insufficient documentation in regard to fetal safety implies the discontinuation of leflunomide, tofacitinib as well as abatacept, rituximab, belimumab, tocilizumab, ustekinumab and anakinra before a planned pregnancy. Among biologics tumour necrosis factor inhibitors are best studied and appear reasonably safe with first and second trimester use. Restrictions in use apply for the few proven teratogenic drugs and the large proportion of medications for which insufficient safety data for the fetus/child are available. Effective drug treatment of active inflammatory rheumatic disease is possible with reasonable safety for the fetus/child during pregnancy and lactation. The dissemination of the data to health professionals and patients as well as their implementation into clinical practice may help to improve the management of pregnant and lactating patients with rheumatic disease.

State of the art: Reproduction and pregnancy in rheumatic diseases

Throughout the last decade, increasing awareness has been raised on issues related to reproduction in rheumatic diseases including basic research to clarify the important role of estrogens in the etiology and pathophysiology of immune/inflammatory diseases. Sub- or infertility is a heterogeneous condition that can be related to immunological mechanisms, to pregnancy loss, to disease burden, to therapy, and to choices in regard to family size. Progress in reproductive medicine has made it possible for more patients with rheumatic disease to have children. Active disease in women with rheumatoid arthritis (RA) affects their children's birth weight and may have long-term effects on their future health status. Pregnancy complications as preeclampsia and intrauterine growth restriction are still increased in patients with systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS), however, biomarkers can monitor adverse events, and several new therapies may improve outcomes. Pregnancies in women with APS remain a challenge, and better therapies for the obstetric APS are needed. New prospective studies indicate improved outcomes for pregnancies in women with rare diseases like systemic sclerosis and vasculitis. TNF inhibitors hold promise for maintaining remission in rheumatological patients and may be continued at least in the first half of pregnancy. Pre-conceptional counseling and interdisciplinary management of pregnancies are essential for ensuring optimal pregnancy outcomes.

Influence of antiidiotypic antibody activity on renal transplant outcome

The presence of cytotoxic HLA antibodies (Ab1) against donor lymphocytes in pretransplant sera is almost always associated with rapid rejection of the renal transplant. We have investigated the possibility that antiidiotypic antibodies (Ab2) to cytotoxic HLA antibodies might modulate the immune response and favorably influence renal allograft outcome. The role of antibodies (Ab3) which potentiate the cytotoxic effect of Ab1 was also studied. Pretransplant sera from 63 patients were tested for inhibitory or potentiating activity in the short antiidiotypic assay. Inhibitory activity was detected in 30 patients and in 28 the transplant survived more than a year. Of patients without antibody activity 11 of 17 had grafts surviving more than one year, and of those showing potentiating activity 11 of 16 were functioning at a year. The difference in transplant survival between the first group and the other two groups was statistically significant (P less than 0.05). There was no significant difference in survival rates between the latter two groups. Potentiating activity is therefore not an independent predictor of transplant failure, whereas the presence of antiidiotypic antibody activity did correlate with improved allograft survival.