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Pregnancy in RA Patients: How do we decide when to taper therapy?
June 10 2016 11:25 AM ET — via RheumReports
We know that rheumatoid arthritis disease activity usually improves during pregnancy. Based on data from recent years, remission rates are not quite as high as we used to previously think and a study by de Man et al in 2008 showed around 50% of RA patients have active disease in the 3rd trimester. Furthermore, we know that corticosteroid use is associated with pregnancy-related morbidity and should be avoided if possible, especially in the 3rd trimester. This has led many experts to recommend ongoing DMARD therapy through pregnancy. On the other hand, patients are often keen to taper and discontinue DMARDs if possible.
On Thursday at EULAR 2016, researchers from The Netherlands presented data on factors that can identify patients in whom DMARDs can be safely tapered using data from the PARA (Pregnancy induced Amelioration of Rheumatoid Arthritis) Study, a nationwide prospective cohort study. Using data from 190 pregnancies followed from 1st trimester to delivery, they built a multivariate regression model using DAS28 in the 3rd trimester.
Results showed that prednisone use in the 1st trimester and seropositivity were independent factors associated with higher 3rd trimester disease activity. Based on the results, the authors concluded that DMARD taper in pregnancy could be considered in seronegative patients who don’t require prednisone in the 1st trimester.
While these data are interesting, I don’t find the results particularly surprising and I am not sure that I agree with the authors’ conclusions. Furthermore, before making treatment recommendations based on these observations, I think we need to prospectively evaluate these results. I have had many seropositive women with RA successfully taper DMARDs during pregnancy without issues and have had the opposite as well.
In my opinion, more data with varying DMARD tapering strategies in pregnancy are needed before recommending changes to clinical practice.
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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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