We know that RA tends to go into remission in pregnancy and flare in the post-partum period. Over the past few years, we have learned that remission rates are likely not quite as good as we previously thought (60-70% of patients). First trimester flares can predict those patients who will flare in the third trimester. Over the course of EULAR 2015, there were multiple small abstracts on pregnancy outcomes with and without treatment in RA.
From the RABBIT Registry (2001-2014), 95 pregnancy outcomes from 78 patients were reported. There were 51 patients who were exposed to biologics at conception (mostly etanercept but also others) and 44 without recent biologic exposure. The majority of those exposed at conception stopped their biologic at some point during the study. Results of this study showed no increase in risk of malformations or other harmful consequences to infants of mothers exposed to biologics at conception compared to those who were not exposed. However, mothers who needed biologics at conception were more likely to flare in the third trimester and require treatment with steroids. Use of steroids in the third trimester was associated with a higher rate of preterm birth.
Saturday morning, a group from Germany reported similar findings. They compared the frequency of RA flares in women who discontinued their TNFi at conception to those on conventional therapy. Of the 46 RA pregnancies followed, 18 occurred in women on TNFi at conception, and 24 in women on conventional therapy. Those who were on TNFi at conception and stopped their TNFi during pregnancy were more likely to have a flare than those who continued their TNFi or who did not require TNFi to begin with. The majority of those who flared required prednisone. Cumulative prednisone doses throughout pregnancy were significantly associated with prematurity (p=0.04).
The above two studies support the rationale that patients who have severe enough RA to require biologic therapy should be maintained on some sort of biologic throughout pregnancy to prevent third trimester flares. Both studies (and others not presented at EULAR) showed that prednisone use in the third trimester is a marker of prematurity and preterm birth, which could have their own complications.
The big question remains, “Should we change our paradigm of stopping biologics during pregnancy?” In my opinion, certolizumab pegol and etanercept should be continued through pregnancy. Prior to recommending this routinely with ALL biologics, we need to understand both the short-term safety (birth and pregnancy outcomes) of exposure during pregnancy AND the long-term outcomes in exposed children.
Dr. Jamal is a Clinical Associate Professor at the University of British Columbia and an active staff physician at Vancouver Coastal Health. Her interests include diagnosis and prognosis of early inflammatory arthritis, and timely assessment and access to care for patients with rheumatoid arthritis.View Full Bio