Management of rheumatic diseases during pregnancy update

The management of pregnant women with rheumatic diseases is evolving, with medication continuance now an increasing practise for some drug classes, the ISR 2018 Autumn Meeting heard.

Dr Ian Giles, Consultant Rheumatologist, University College Hospital London, UK, and lead author of the British Society for Rheumatology (BSR) 2016 guidelines on prescribing anti-rheumatic drugs in pregnancy and breastfeeding, addressed the meeting on changing practise in the area.

He noted the management of these patients is complicated by several factors, including an increased burden of pregnancy morbidity compared to the general population, which is partly due to increased disease activity. Some studies have shown an increased risk of adverse pregnancy outcomes in the presence of elevated levels of TNF-alfa.

Dr Giles also maintained that pregnancy does not induce remission in as many rheumatic patients as commonly believed, showing some recent data to support this.

He also commented that pain and discomfort during pregnancy is normal and it is important to remember this when trying to distinguish normal aches and stiffness from actual arthritis activity.

While traditionally, women have been advised to discontinue their medications prior to conception and during pregnancy, this is now changing as discontinuing biologics, for example, can have potentially worse outcomes for the pregnancy than continuing them.

Now, many patients continue biologic therapy for at least a portion of pregnancy, ie, first trimester at least, and international guidelines are changing to reflect this, with recent data showing supportive and reassuring results for some biologics, noted Dr Giles. He pointed out that certolizumab pegol (CZP), a novel anti-TNF agent that is used for patients with moderate-to-severe active rheumatoid arthritis (RA), recently had its EU approval extended to include women who are pregnant or breastfeeding following a number of positive studies showing a lack of adverse pregnancy outcomes.

However, there remains a general lack of data on medication usage during pregnancy, with most data looking at foetal as opposed to maternal health, while very few drugs are specifically licensed for usage during pregnancy. Thus, safety concerns around some drugs persist, while in others, not enough is known about the long-term safety profile. As a result, many potentially beneficial drugs are still being unnecessarily withdrawn in pregnancy due to a mistaken belief that the drugs themselves may be harmful, thus allowing an increase in disease activity, which is itself more harmful to the pregnancy.

Careful pre-conception planning with rheumatic patients is key and some medications, such as methotrexate, remain contraindicated, while dosage and compliance are also very important, said Dr Giles.

The BSR guidelines advise stopping methotrexate, leflunomide, mycophenolate mofetil and cyclophosphamide pre-conception, and during pregnancy, switching patients on warfarin to low molecular-weight heparin and starting aspirin in lupus patients. In the second and third trimesters, the guidelines say to consider stopping anti-TNF therapies, Dr Giles summarised.

Prompt post-partum care and appropriate re-initiation of rheumatic therapies are also key, as flare risk is high, but if mothers are breastfeeding, therapies must be compatible, he concluded.