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Should we Recommend Hydroxychloroquine During Pregnancy in all Ro/La Positive Patients?
November 9 2015 1:10 AM ET — via RheumReports
We all know that hydroxychloroquine has been shown to prevent lupus flares during pregnancy. In Ro/La positive patients, it has been found to reduce the risk of neonatal congenital heart block by 20-30% in mothers who have had a previous child with heart block. In addition to congenital heart block, children born to mothers with Ro/La antibodies are at higher risk for cutaneous neonatal lupus lesions (cNL). Hydroxychloroquine has been found to be effective for the treatment of interface dermatitis in CTD, which is found on biopsy of patients with cNL. We don't have information on whether maternal use of hydroxychloroquine during pregnancy can delay or prevent the development of cutaneous neonatal lupus in women with Ro/La antibodies.
In an abstract presented at ACR today, Julie Barsalou from Sick Kids Hospital, along with colleagues from France and USA, tried to answer this question using data from their three respective registries. They identified 327 babies born with cNL and found those who were exposed to hydroxychloroquine in utero had numerically delayed onset of rash (median 6 weeks) compared to those whose mothers did not take hydroxychloroquine in utero (median time to rash 4.4 weeks). In addition, they found that mothers who received hydroxychloroquine were more likely to have a confirmed CTD diagnosis compared to those who did not. There was no difference in the anti-Ro and La antibody profile between groups.
Women in Canada are not routinely screened for Ro/La antibodies during pregnancy. We often see patients with incidental positive Ro/La antibodies who do not have an associated connective tissue disease. Even if we don't follow these women chronically, we usually advise them to have monitoring for fetal CHB during pregnancy. Based on this data, and the data on secondary prevention of CHB, should we also be discussing the use of prophylactic hydroxychloroquine (or Vitamin H) during pregnancy? Should we start to routinely screen all pregnant women for Ro/La antibodies? Although some would argue for this, I think it is premature. We need more robust, prospective data prior to adopting such a drastic change.
However, in patients with positive Ro/La antibodies who are already on hydroxychloroquine for rheumatoid arthritis or other connective tissue disease, I think this data is compelling to recommend continuing hydroxychloroquine through pregnancy. Not only can hydroxychloroquine prevent disease flare and reduce the risk of CHB, there may be a benefit on time of onset of neonatal lupus.
The real question that needs to be addressed, however, is not a delay in its onset, but rather, prevention altogether. More data is needed, but this is a great start. It is great to see successful international collaborations, particularly with involvement of our Canadian colleagues!
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About the Author
Dr. Shahin Jamal
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.
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