https://doi.org/10.4081/reumatismo.2024.1781
Treatment of spondyloarthritis with disease-modifying anti-rheumatic drugs during pregnancy and breastfeeding: comparing the recommendations and guidelines of the principal societies of rheumatology
Published: 11 September 2024
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All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.
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Objective. This paper aims to provide an overview of the use of treatments available for axial spondyloarthritis (axSpA) and psoriatic arthritis (PsA) during pregnancy and breastfeeding, according to current national recommendations and international guidelines, as well as data on the impact on pregnancy outcomes of paternal exposure to treatment.
Methods. We performed a narrative review of national and international recommendations and guidelines on the reproductive health of patients suffering from rheumatic diseases. The last updated recommendations and guidelines were considered source data.
Results. We reported updated information regarding the treatment of axSpA and PsA with nonsteroidal anti-inflammatory drugs, intra-articular glucocorticoids, conventional synthetic disease-modifying antirheumatic drugs (DMARDs), biologic DMARDs, and targeted synthetic DMARDs during the preconception period, pregnancy, and breastfeeding, as well as data related to paternal exposure. We highlighted any medications that should be discontinued and/or not used in the reproductive age group and also treatments that may be continued, avoiding the withdrawal of drugs that can be used in the different phases, thus preventing the risk of increasing disease activity and flares before, during, and after pregnancy in SpA patients.
Conclusions. The best management of pregnancy in patients with SpA is based on knowledge of updated drug recommendations, a careful and wise evaluation of the risks/benefits of starting or continuing treatment from the SpA diagnosis in a woman of childbearing age through pregnancy and lactation, and sharing therapeutic choices with other healthcare providers (in particular, gynecologists/obstetricians) and the patient.
Jethwa H, Lam S, Smith C, Giles I. Does rheumatoid arthritis really improve during pregnancy? A systematic review and metaanalysis. J Rheumatol 2019; 46: 245-50.
DOI: https://doi.org/10.3899/jrheum.180226
Maguire S, O’Dwyer T, Mockler D, O’Shea F, Wilson F. Pregnancy in axial spondyloarthropathy: a systematic review & meta-analysis. Semin Arthritis Rheum 2020; 50: 1269-79.
DOI: https://doi.org/10.1016/j.semarthrit.2020.08.011
Lui NL, Haroon N, Carty A, Shen H, Cook RJ, Shanmugarajah S, et al. Effect of pregnancy on ankylosing spondylitis: a case-control study. J Rheumatol 2011; 38: 2442-4.
DOI: https://doi.org/10.3899/jrheum.101174
van den Brandt S, Zbinden A, Baeten D, Villiger PM, Østensen M, Förger F. Risk factors for flare and treatment of disease flares during pregnancy in rheumatoid arthritis and axial spondyloarthritis patients. Arthritis Res Ther 2017; 19: 64.
DOI: https://doi.org/10.1186/s13075-017-1269-1
Rusman T, van Vollenhoven RF, van der Horst-Bruinsma IE. Gender Differences in axial spondyloarthritis: women are not so lucky. Curr Rheumatol Rep 2018; 20: 35.
DOI: https://doi.org/10.1007/s11926-018-0744-2
Meissner Y, Strangfeld A, Molto A, Forger F, Wallenius M, Costedoat-Chalumeau N, et al. Pregnancy and neonatal outcomes in women with axial spondyloarthritis: pooled data analysis from the European Network of Pregnancy Registries in Rheumatology (EuNeP). Ann Rheum Dis 2022; 81: 1524-33.
DOI: https://doi.org/10.1136/ard-2022-222641
Smith CJF, Förger F, Bandoli G, Chambers CD. Factors associated with preterm delivery among women with rheumatoid arthritis and women with juvenile idiopathic arthritis. Arthritis Care Res (Hoboken) 2019; 71: 1019-27.
DOI: https://doi.org/10.1002/acr.23730
Götestam Skorpen C, Hoeltzenbein M, Tincani A, Fischer-Betz R, Elefant E, Chambers C, et al. The EULAR points to consider for use of antirheumatic drugs before pregnancy, and during pregnancy and lactation. Ann Rheum Dis 2016; 75: 795-810.
DOI: https://doi.org/10.1136/annrheumdis-2015-208840
Ramiro S, Nikiphorou E, Sepriano A, Ortolan A, Webers C, Baraliakos X, et al. ASAS-EULAR recommendations for the management of axial spondyloarthritis: 2022 update. Ann Rheum Dis 2023; 82: 19-34.
DOI: https://doi.org/10.1136/ard-2022-223296
Russell MD, Dey M, Flint J, Davie P, Allen A, Crossley A, et al. British Society for Rheumatology guideline on prescribing drugs in pregnancy and breastfeeding: immunomodulatory anti-rheumatic drugs and corticosteroids. Rheumatology (Oxford) 2023; 62: e48-88.
DOI: https://doi.org/10.1093/rheumatology/keac686
Flint J, Panchal S, Hurrell A, van de Venne M, Gayed M, Schreiber K, et al. BSR and BHPR guideline on prescribing drugs in pregnancy and breastfeeding-Part I: standard and biologic disease modifying anti-rheumatic drugs and corticosteroids. Rheumatology (Oxford) 2016; 55: 1693-7.
DOI: https://doi.org/10.1093/rheumatology/kev404
Flint J, Panchal S, Hurrell A, van de Venne M, Gayed M, Schreiber K, et al. BSR and BHPR guideline on prescribing drugs in pregnancy and breastfeeding-Part II: analgesics and other drugs used in rheumatology practice. Rheumatology (Oxford) 2016; 55: 1698-702.
DOI: https://doi.org/10.1093/rheumatology/kev405
ISS. La salute riproduttiva nei pazienti con malattie reumatologiche. Available from: https://www.iss.it/-/salute-riproduttiva-in-pazienti-con-malattie-reumatologiche. Accessed on: 7/01/2024.
Schünemann HJ, Wiercioch W, Brozek J, Etxeandia-Ikobaltzeta I, Mustafa RA, Manja V, et al. GRADE evidence to decision (EtD) frameworks for adoption, adaptation, and de novo development of trustworthy recommendations: GRADE-ADOLOPMENT. J Clin Epidemiol 2017; 81: 101-10.
DOI: https://doi.org/10.1016/j.jclinepi.2016.09.009
Sammaritano LR, Bermas BL, Chakravarty EE, Chambers C, Clowse MEB, Lockshin MD, et al. 2020 American College of Rheumatology guideline for the management of reproductive health in rheumatic and musculoskeletal diseases. Arthritis Rheumatol 2020; 72: 529-56.
DOI: https://doi.org/10.1002/art.41191
Wang R, Bathon JM, Ward MM. Nonsteroidal antiinflammatory drugs as potential disease-modifying medications in axial spondyloarthritis. Arthritis Rheumatol 2020; 72: 518-28.
DOI: https://doi.org/10.1002/art.41164
Stone S, Khamashta MA, Nelson-Piercy C. Nonsteroidal anti-inflammatory drugs and reversible female infertility: is there a link?. Drug Saf 2002; 25: 545-51.
DOI: https://doi.org/10.2165/00002018-200225080-00001
Pall M, Fridén BE, Brännström M. Induction of delayed follicular rupture in the human by the selective COX-2 inhibitor rofecoxib: a randomized double-blind study. Hum Reprod 2001; 16: 1323-8.
DOI: https://doi.org/10.1093/humrep/16.7.1323
Micu MC, Micu R, Ostensen M. Luteinized unruptured follicle syndrome increased by inactive disease and selective cyclooxygenase 2 inhibitors in women with inflammatory arthropathies. Arthritis Care Res (Hoboken) 2011; 63: 1334-8.
DOI: https://doi.org/10.1002/acr.20510
Brouwer J, Hazes JMW, Laven JSE, Dolhain RJEM. Fertility in women with rheumatoid arthritis: influence of disease activity and medication. Ann Rheum Dis 2015; 74: 1836-41.
DOI: https://doi.org/10.1136/annrheumdis-2014-205383
Maguire S, Molto A. Pregnancy & neonatal outcomes in spondyloarthritis. Best Pract Res Clin Rheumatol 2023; 37: 101868.
DOI: https://doi.org/10.1016/j.berh.2023.101868
Hamroun S, Couderc M, Flipo RM, Sellam J, Richez C, Dernis E, et al. Op0153 Preconceptional nsaid treatment is associated with longer time-to-conception in women with spondyloarthritis: analysis of the prospective Gr2 cohort. Ann Rheum Dis 2022; 81: 99.
DOI: https://doi.org/10.1136/annrheumdis-2022-eular.2031
Koren G, Florescu A, Costei AM, Boskovic R, Moretti ME. Nonsteroidal antiinflammatory drugs during third trimester and the risk of premature closure of the ductus arteriosus: a meta-analysis. Ann Pharmacother 2006; 40: 824-9.
DOI: https://doi.org/10.1345/aph.1G428
Filippini C, Saran S, Chari B. Musculoskeletal steroid injections in pregnancy: a review. Skeletal Radiol 2023; 52: 1465-73.
DOI: https://doi.org/10.1007/s00256-023-04320-9
Chen J, Lin S, Liu C. Sulfasalazine for ankylosing spondylitis. Cochrane Database Syst Rev 2014; 11: CD004800.
DOI: https://doi.org/10.1002/14651858.CD004800.pub3
Khanna Sharma S, Kadiyala V, Naidu G, Dhir V. A randomized controlled trial to study the efficacy of sulfasalazine for axial disease in ankylosing spondylitis. Int J Rheum Dis 2018; 21: 308-14.
DOI: https://doi.org/10.1111/1756-185X.13124
Chen J, Veras MMS, Liu C, Lin J. Methotrexate for ankylosing spondylitis. Cochrane Database Syst Rev 2013; 2: CD004524.
DOI: https://doi.org/10.1002/14651858.CD004524.pub4
Tsao NW, Sayre EC, Hanley G, Sadatsafavi M, Lynd LD, Marra CA, et al. Risk of preterm delivery and small-for-gestational-age births in women with autoimmune disease using biologics before or during pregnancy: a population-based cohort study. Ann Rheum Dis 2018; 77: 869-74.
DOI: https://doi.org/10.1136/annrheumdis-2018-213023
Beltagy A, Aghamajidi A, Trespidi L, Ossola W, Meroni PL. Biologics during pregnancy and breastfeeding among women with rheumatic diseases: safety clinical evidence on the road. Front Pharmacol 2021; 12: 621247.
DOI: https://doi.org/10.3389/fphar.2021.621247
Puchner A, Gröchenig HP, Sautner J, Helmy-Bader Y, Juch H, Reinisch S, et al. Immunosuppressives and biologics during pregnancy and lactation : a consensus report issued by the Austrian Societies of Gastroenterology and Hepatology and Rheumatology and Rehabilitation. Wien Klin Wochenschr 2019; 131: 29-44.
DOI: https://doi.org/10.1007/s00508-019-1448-y
Allen KD, Kiefer MK, Butnariu M, Afzali A. Pregnant women with immune mediated inflammatory diseases who discontinue biologics have higher rates of disease flare. Arch Gynecol Obstet 2022; 306: 1929-37.
DOI: https://doi.org/10.1007/s00404-022-06463-x
Porter C, Armstrong-Fisher S, Kopotsha T, Smith B, Baker T, Kevorkian L, et al. Certolizumab pegol does not bind the neonatal Fc receptor (FcRn): consequences for FcRn-mediated in vitro transcytosis and ex vivo human placental transfer. J Reprod Immunol 2016; 116: 7-12.
DOI: https://doi.org/10.1016/j.jri.2016.04.284
Atzeni F, Carriero A, Boccassini L, D’Angelo S. Anti-IL-17 agents in the treatment of axial spondyloarthritis. Immunotargets Ther 2021; 10: 141-53.
DOI: https://doi.org/10.2147/ITT.S259126
Frieder J, Kivelevitch D, Menter A. Secukinumab: a review of the anti-IL-17A biologic for the treatment of psoriasis. Ther Adv Chronic Dis 2018; 9: 5-21.
DOI: https://doi.org/10.1177/2040622317738910
Blauvelt A. Ixekizumab: a new anti-IL-17A monoclonal antibody therapy for moderate-to severe plaque psoriasis. Expert Opin Biol Ther 2016; 16: 255-63.
DOI: https://doi.org/10.1517/14712598.2016.1132695
Warren RB, Reich K, Langley RG, Strober B, Gladman D, Deodhar A, et al. Secukinumab in pregnancy: outcomes in psoriasis, psoriatic arthritis and ankylosing spondylitis from the global safety database. Br J Dermatol 2018; 179: 1205-7.
DOI: https://doi.org/10.1111/bjd.16901
Meroni M, Generali E, Guidelli GM, Parodi M, Cutolo M, Selmi C. THU0319 overall safety of 7-week secukinumab exposure during pregnancy in women with psoriatic arthritis. Ann Rheum Dis 2018; 77: 377-8.
DOI: https://doi.org/10.1136/annrheumdis-2018-eular.4760
Dowty ME, Lin J, Ryder TF, Wang W, Walker GS, Vaz A, et al. The pharmacokinetics, metabolism, and clearance mechanisms of tofacitinib, a janus kinase inhibitor, in humans. Drug Metab Dispos 2014; 42: 759-73.
DOI: https://doi.org/10.1124/dmd.113.054940
Coates LC, Soriano ER, Corp N, Bertheussen H, Callis Duffin K, Campanholo CB, et al. Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA): updated treatment recommendations for psoriatic arthritis 2021. Nat Rev Rheumatol 2022; 18: 465-79.
DOI: https://doi.org/10.1038/s41584-022-00798-0
Wilsdon TD, Whittle SL, Thynne TR, Mangoni AA. Methotrexate for psoriatic arthritis. Cochrane Database Syst Rev 2019; 1: CD012722.
DOI: https://doi.org/10.1002/14651858.CD012722.pub2
Mease PJ, Gladman DD, Collier DH, Ritchlin CT, Helliwell PS, Liu L, et al. Etanercept and methotrexate as monotherapy or in combination for psoriatic arthritis: primary results from a randomized, controlled phase III trial. Arthritis Rheumatol 2019; 71: 1112-24.
DOI: https://doi.org/10.1002/art.40851
Weber-Schoendorfer C, Diav-Citrin O. Methotrexate in pregnancy: still many unanswered questions. RMD Open 2023; 9: e002899.
DOI: https://doi.org/10.1136/rmdopen-2022-002899
Mahadevan U, Naureckas S, Tikhonov I, Wang Y, Lin CB, Geldhof A, et al. Pregnancy outcomes following periconceptional or gestational exposure to ustekinumab: review of cases reported to the manufacturers global safety database. Aliment Pharmacol Ther 2022; 56: 477-90.
DOI: https://doi.org/10.1111/apt.16960
Drugs and Lactation Database (LactMed®). Bethesda, MD, USA: National Institute of Child Health and Human Development; 2006.
Griswold MD. Spermatogenesis: the commitment to meiosis. Physiol Rev 2016; 96: 1-17.
DOI: https://doi.org/10.1152/physrev.00013.2015
Zarén P, Turesson C, Giwercman A. Methotrexate use among men—association with fertility and the perinatal health of their children: a Swedish nationwide register study. Fertil Steril 2023; 120: 661-9.
DOI: https://doi.org/10.1016/j.fertnstert.2023.05.005
Mahadevan U, Dubinsky MC, Su C, Lawendy N, Jones TV, Marren A, et al. Outcomes of pregnancies with maternal/paternal exposure in the tofacitinib safety databases for ulcerative colitis. Inflamm Bowel Dis 2018; 24: 2494-500.
DOI: https://doi.org/10.1093/ibd/izy160
Costanzo G, Firinu D, Losa F, Deidda M, Barca MP, Del Giacco S. Baricitinib exposure during pregnancy in rheumatoid arthritis. Ther Adv Musculoskelet Dis 2020; 12: 1759720X19899296.
DOI: https://doi.org/10.1177/1759720X19899296
How to Cite
Manara, M., Bruno, D., Ferrito, M., Perniola, S., Caporali, R., & Gremese, E. (2024). Treatment of spondyloarthritis with disease-modifying anti-rheumatic drugs during pregnancy and breastfeeding: comparing the recommendations and guidelines of the principal societies of rheumatology. Reumatismo, 76(3). https://doi.org/10.4081/reumatismo.2024.1781
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