It Is Time to Modify Treatment to Enable More Women with Rheumatoid Arthritis to Have Successful Pregnancies

Clowse, Megan E.B.

doi:10.3899/jrheum.181036

Cited by 4 publications

(4 citation statements)

References 17 publications

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“…Prolonged time to pregnancy, concerns about the well-being of pregnancy and disability contributed to a decrease in the number of pregnancies conceived in women with RA. 18 Regarding the potential effect of exposure to immunosuppressants, recently a systematic literature review evaluated the impact of conventional synthetic DMARDs, including MTX, on fertility in RA. 4 The authors concluded, based on retrieved evidence, that MTX use did not negatively affect fertility, contrary to what is traditionally believed.…”

Section: Discussionmentioning

confidence: 99%

Impact of rheumatoid arthritis and methotrexate on pregnancy outcomes: retrospective cohort study of the Italian Society for Rheumatology

et al. 2022

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ObjectiveTo evaluate the impact of rheumatoid arthritis (RA) and methotrexate (MTX) on the probability of becoming pregnant, pregnancy losses, elective termination of pregnancy (TOP) and congenital malformations.MethodsA retrospective cohort study on administrative healthcare databases was conducted. Three patients’ cohorts were enrolled among childbearing-age women. The first cohort included patients with RA starting MTX between July 2004 and December 2011. The second cohort included patients with RA without MTX treatment randomly selected from the same population (ratio 1:1). Finally, a cohort of subjects without RA was identified (ratio 1:4). Multivariate logistic regression models were implemented, ORs and 95% CI were reported.ResultsThe two matched RA cohorts included 3564 patients with MTX and without MTX. The cohort without RA included 14 256 subjects. In the three cohorts, the proportion of women achieving pregnancy during follow-up was 6.3%, 9.1% and 11.9%, respectively. Congenital malformations were very rare in all cohorts. RA women treated with MTX at any time before conception showed significantly higher risks of pregnancy losses than non-RA women (OR (95% CI) 2.22 (1.40 to 3.45)). We observed a significant positive relationship between the exposure to MTX in the 3 months window before conception and increased risk of elective TOP (OR (95% CI) 4.77 (1.08 to 19.40)).ConclusionMTX-treated patients appeared to be the cohort with the highest risk of pregnancy losses. The positive association with elective TOP and exposure to MTX in the three months window before conception in patients with RA reinforces the need for adequate preconception counselling to avoid unplanned pregnancies.

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Section: Discussionmentioning

confidence: 99%

Impact of rheumatoid arthritis and methotrexate on pregnancy outcomes: retrospective cohort study of the Italian Society for Rheumatology

et al. 2022

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“…In addition, in the period covered by the RECORD study (January 1, 2004 to December 31, 2013), there were sparse data on bDMARD use in pregnancy, and the European League Against Rheumatism (EULAR) and the British Society for Rheumatology had not yet published guidelines for the prescription of pregnancy-compatible medications. The scant data on bDMARD exposure in pregnancy reflects the attitude at the time the study was conducted, but the scenario will likely change as the use of bDMARDs during pregnancy will consolidate (1).…”

Section: Discussionmentioning

confidence: 99%

“…The management of pregnancy in women with rheumatoid arthritis (RA) has substantially changed in the past few decades, along with the milestones in RA treatment, such as biologic and targeted synthetic agents and treat-to-target strategies (1). With the improvement in the management of RA, patients with severe disease have been able to reach remission more frequently and live normal lives, including starting a family.…”

Section: Introductionmentioning

confidence: 99%

Improved Pregnancy Outcome in Patients With Rheumatoid Arthritis Who Followed an Ideal Clinical Pathway

Bortoluzzi

Andréoli

Carrara

et al. 2021

Arthritis Care & Research

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Objective To assess the effect of optimal management of pregnancy on a composite outcome of miscarriage and complicated birth among women with rheumatoid arthritis (RA). Methods Data were extracted from health care databases of the Lombardy Region, Italy (2004–2013) as a part of the Record‐Linkage on Rheumatic Diseases Study. Analyses included women with RA identified through a copayment exemption code (International Classification of Diseases, Ninth Revision, Clinical Modification code 714.0) and controls from the general population, ages 18–50 years. Seven health care quality indicators (HCQI) were constructed and summarized in 3 pathway indicators: diagnostic, therapeutic, and prenatal follow‐up. Complicated birth or miscarriage were used to identify the adverse pregnancy outcome (APO). The relationship between HCQI and APO was analyzed using logistic models, and the results were presented as odds ratios (ORs) and 95% confidence intervals (95% CIs). Results Data from the study cohort included the first pregnancy observed in 443 patients with RA compared with 6,097 women belonging to the general population. In the RA population, patients who followed the 3 pathway indicators had a reduced risk of overall APO, with an OR of 0.60 (95% CI 0.39–0.94), and reduced risk of miscarriage/perinatal death, with an OR of 0.40 (95% CI 0.24–0.69), compared to those who did not follow the pathway indicators. Compared with the general population, patients with RA who met all HCQI during pregnancy displayed a risk of APO with an OR of 0.92 (95% CI 0.61–1.38) and miscarriage/perinatal death with an OR of 0.77 (95% CI 0.47–1.29). Conclusion The adherence to an ideal clinical pathway of pregnancy management in women with RA restored the risk of APO to that expected for the general population.

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“…For patients with RA who wish to become pregnant, there is growing evidence on the safety of anti-rheumatic medications in pregnancy and breastfeeding. 41 Among biologics, anti-TNFs have been most extensively studied and appear reasonably safe with first and second trimester use. 42 As there is limited evidence for the safe use of rituximab, tocilizumab and abatacept in pregnancy, and JAKi are contraindicated in pregnancy, these agents should be replaced with a more suitable agent prior to conception.…”

Section: Potential Selection Criteria For Treatment Following First-l...mentioning

confidence: 99%

Managing inadequate response to initial anti-TNF therapy in rheumatoid arthritis: optimising treatment outcomes

Taylor

Matucci‐Cerinic

Alten

et al. 2022

Therapeutic Advances in Musculoskeletal

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Anti-tumour necrosis factors (anti-TNFs) are established as first-line biological therapy for rheumatoid arthritis (RA) with over two decades of accumulated clinical experience. Anti-TNFs have well established efficacy/safety profiles along with additional benefits on various comorbidities. However, up to 40% of patients may respond inadequately to an initial anti-TNF treatment because of primary non-response, loss of response, or intolerance. Following inadequate response (IR) to anti-TNF treatment, clinicians can consider switching to an alternative anti-TNF (cycling) or to another class of targeted drug with a different mechanism of action, such as Janus kinase inhibitors, interleukin-6 receptor blockers, B-cell depletion agents, and co-stimulation inhibitors (swapping). While European League Against Rheumatism recommendations for pharmacotherapeutic management of RA, published in 2020, are widely regarded as helpful guides to clinical practice, they do not provide any clear recommendations on therapeutic choices following an IR to first-line anti-TNF. This suggests that both cycling and swapping treatment strategies are of equal value, but that the treating physician must take the patient’s individual characteristics into account. This article considers which patient characteristics influence clinical decision-making processes, including the reason for treatment failure, previous therapies, comorbidities, extra-articular manifestations, pregnancy, patient preference and cost-effectiveness, and what evidence is available to support decisions made by the physician.

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It Is Time to Modify Treatment to Enable More Women with Rheumatoid Arthritis to Have Successful Pregnancies

Cited by 4 publications

References 17 publications

Impact of rheumatoid arthritis and methotrexate on pregnancy outcomes: retrospective cohort study of the Italian Society for Rheumatology

Impact of rheumatoid arthritis and methotrexate on pregnancy outcomes: retrospective cohort study of the Italian Society for Rheumatology

Improved Pregnancy Outcome in Patients With Rheumatoid Arthritis Who Followed an Ideal Clinical Pathway

Managing inadequate response to initial anti-TNF therapy in rheumatoid arthritis: optimising treatment outcomes

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