ObjectivesIn patients with rheumatoid arthritis (RA), high disease activity impairs fertility outcomes and increases the risk of adverse pregnancy outcomes. The aim of this study was to determine the feasibility of a modern treatment approach, including treat-to-target (T2T) and the prescription of tumour necrosis factor (TNF) inhibitors, in patients with RA with a wish to conceive or who are pregnant.MethodsPatients were derived from the Preconception Counseling in Active RA (PreCARA) cohort. Patients with a wish to conceive or who are pregnant were treated according to a modified T2T approach, in which the obvious restrictions of pregnancy were taken into account. Results of the PreCARA study were compared with results of the Pregnancy-induced Amelioration of Rheumatoid Arthritis (PARA) study, a historic reference cohort on RA during pregnancy. Patients in the PARA cohort were treated according to the standards of that time (2002–2010). Differences in disease activity over time between the two cohorts were tested using a linear mixed model.Results309 patients with RA were included in the PreCARA study, 188 children were born. 47.3% of the patients used a TNF inhibitor at any time during pregnancy. Mean disease activity over time in the PreCARA cohort was lower than in the reference cohort (p<0.001). In the PreCARA cohort, 75.4% of the patients were in low disease activity (LDA) or remission before pregnancy increasing to 90.4% in the third trimester, whereas in the PARA cohort, these percentages were 33.2% and 47.3%, respectively.ConclusionsThis first study on a modern treatment approach in pregnant patients with RA shows that LDA and remission are an attainable goal during pregnancy, with 90.4% of patients achieving this in the third trimester.
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 = 104MedicationBefore pregnancy (%)**1sttrimester (%)2ndtrimester (%)3rdtrimester (%)6 weeks post-partum (%)12 weeks post-partum (%)26 weeks post-partum (%)MTX0000183036Leflunomide0000012Hydroxychloroqine6222487Sulfasalazine34252726263029Prednisone42333636353632Azathioprine1000111Adalimumab0000235Infliximab0000011Etanercept0000365** patients seen before pregnancy = 124Conclusion: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 2007Disclosure 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
BackgroundInflammatory rheumatic diseases (RD) often affects women in their childbearing years. Despite extensive counselling, we noticed that in RD patients there is an increasing need of more information concerning pregnancy and parenting. This suggests that there are still unexplored information needs regarding pregnancy and parenting in women with RD. To our knowledge, there are no studies exploring these unidentified information needs.ObjectivesThe aim of this study was to evaluate the unmet needs of women diagnosed with RD that received highly specialized care in a tertiary Reproductive Rheumatology center.MethodsWomen (≥18 years) diagnosed with RD (such as rheumatoid arthritis, spondyloarthritis, psoriatic arthritis or juvenile idiopathic arthritis), who were followed-up by the Reproductive Rheumatology team from the Department of Rheumatology of the Erasmus University Medical Center were invited to complete an online questionnaire. The questionnaire was divided into different sections: pre-conception, pregnancy, post-partum, parenthood and support received/needed by informal caregivers such as family, friends, neighbors etc. The questions were related to the support and information provided by the team, problems experienced, unmet needs and the patient’s general characteristics. The patients were offered the possibility to give additional remarks (free text). Descriptive statistics were used to represent the outcomes.ResultsFrom a total of 181 women who were invited to fill out the online questionnaire, 95 women (52%) completed the questionnaire. It concerns women in the age between 22 and 45 (mean of 33yrs), with a RD, who received their first (n=56), second, or third baby between 2019 and 2021. Overall, the care of the rheumatology team was highly rated by the women (satisfaction score of 88 (scale 0-100) for the rheumatologist and 92 (scale 0-100) for the rheumatology nurses) (Table 1). 18 Women (19%) experienced any problem during the period around their delivery and/or post-partum. Six women indicated that their problems persisted. A lack of mental health support regarding disease coping (4 out 6) was the most frequently mentioned persisting problem. In addition 2 out of 6 women indicated a need for additional communication with the rheumatology team regarding information, indication and adjustment of their medication between the regular outpatient clinic visits.ConclusionThe care provided by the Reproductive Rheumatology team was highly rated by the majority of the women. Nevertheless, the following unmet needs were identified: a) mental health support regarding disease coping and, b) the opportunity to communicate about medication beyond the regular outpatient visits.Despite a very high satisfaction rate of patients treated by the Reproductive Rheumatology team some of them experience health problems that remain unsolved. This will help us to improve our patient-centered care as we aim at matching our care as appropriately as possible to patient needs. In the future, we want to identify the characteristics of the women who need more information, more mental support and, more contact between the regular consults, so we can help them solve their problems and fill their needs.REFERENCES:NIL.Acknowledgements:NIL.Disclosure of InterestsNone Declared.
ObjectivesPrevious research has demonstrated that patients with rheumatoid arthritis (RA) are less likely to breast feed their offspring. Treatment options for RA during lactation have expanded and the importance of counselling is recognised. The aim of the current research was to study breast feeding among women with RA who benefit from these developments.MethodsPatients were derived from the Preconceptional Counselling in Active Rheumatoid Arthritis (PreCARA) cohort. Patients were treated according to a modified treat-to-target approach aimed at remission and received pregnancy counselling, including counselling on breast feeding. Postpartum visits were scheduled at 4–6, 12 and 26 weeks post partum. Prevalence of breast feeding at each postpartum visit was compared with a historical reference cohort (Pregnancy-induced Amelioration of Rheumatoid Arthritis cohort) and the general population.ResultsData on 171 pregnancies were available for the current analysis. 120 (70.2%) patients with RA initiated breast feeding. 103/171 (60.2%), 68/171 (39.8%) and 45/171 (26.3%) patients with RA breast fed their offspring at 4–6, 12 and 26 weeks post partum, respectively. These percentages were higher at all postpartum visits compared with the historical reference cohort (p<0.001). In comparison with the general population, the rates were similar at each time point.ConclusionPatients with RA in the PreCARA cohort were more likely to breast feed their offspring compared with patients with RA in the historical reference cohort. The breastfeeding rates observed were similar to breastfeeding rates among women in the general population. The increase in breast feeding among patients with RA may be due to the extension of lactation-compatible medication and pregnancy counselling.
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BackgroundFor patients with a rheumatic disease (RD), self-management is the effort to find a balance between the demands of the disease and the activities of daily life. Self-management is an important aspect in the care for patients with a RD, in which they are expected to take an active role. Over the past decade, new technologies have been developed to support self-management, including smartphone apps. These apps perfectly fit the idea that patients prefer an active role in self-management. Therefore, a smartphone application (app) was developed.ObjectivesThis study 1) investigates whether the use of an app improved patients’ self-management, 2) explores patients’ experiences with this RD-app, 3) investigates which factors are associated with the use of the RD-app.MethodsWe performed a prospective before-after study among patients with a RD. The primary outcome was patients’ self-management behavior measured with the Partners in Health scale (PIH), a generic validated 12 item self-rated scale, which indicates higher scores for better self-management behavior (1). A paired t-test was used to evaluate changes in the PIH-scale score after three months. To measure the user-experience with the app, survey questions addressed whether the RD-app had contributed to get more grip (or not) on the disease and how (why not). Logistic regression analyses served to investigate variables that are important for using the RD-app.ResultsOf the 1511 eligible patients, 397 completed both the baseline and the follow-up surveys. Participants who completed both questionnaires were most frequently diagnosed with RA, 65% was female and the mean age was 52.0 (SD 15.6) years. Hundred-fourteen participants used the RD-app. Self-management behavior did not improve according to the PIH score in the app-users group after 3 months. However, 42% of the app-users perceived that use of the RD-App had contributed to get more grip on the disease. Receiving tips, information on exercises and gaining insight on self-reported disease activity contributed to get more grip on the disease. However, the other app-users whom did not get more grip on the disease indicated the following reasons: information was not useful, no need for information or additional help, technical issues and too little usage of the app itself. Almost all users would recommend the app to others. To investigate who did use the RD-app, univariate analysis revealed a role for female patients, positive expectations of the RD-app, help needed to get more grip on the disease and a higher VAS global as associated factors with actually using the RD-app. In the multivariate analysis only positive expectations of the RD-app remained significantly associated with actually using the RD-app (p=<0.001).ConclusionAlmost one third used the RD-app. Although the PIH-score did not change, 42 percent of the participants thought the app helped them to get more grip on the disease. Therefore, the RD-app may be useful for additional self-management support in a clinical practice. Participants seemed ...
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