TNFi for RA during pregnancy – to stop or not to stop?

Discontinuing TNF inhibitors (TNFi) when conceiving bares the risk of flares and higher need for steroids during pregnancy. If the mothers choose to maintain TNFi therapy, it may be safe to expand injection intervals when in remission [1].

Although there is a chance of amelioration of rheumatoid arthritis (RA) during pregnancy, many women face disease activation and flares when childbearing [2]. Disease management decisions during this time not only have to take potential harm of therapy into account but also potential risks of flares and disease activation [1]. Already prior to conception, a growing rate of future mothers are treated with TNFi.

Dr Isabell Haase (Heinrich-Heine University Düsseldorf, Germany) and her fellow researchers conducted a prospective observational study to investigate the effects of continuing, stopping, or reducing TNFi therapy during pregnancy. Data was collected for clinical findings, Disease Activity Score 28/C-reactive protein (DAS28-CRP) as a measure of disease activity, and pregnancy outcome. First assessment was done prior to conception when the women were also counselled on the currently known pros and cons of treatment cessation at conception. Further evaluations were performed at each trimester and after birth. Participating women were free to choose if they wanted to continue TNFi after conception or not. When in remission, those who opted to continue TNFi also received guidance on the possibilities to reduce dosage by expanding treatment intervals. Data from 70 completed pregnancies was entered into a multivariate logistic regression model adjusted for possible confounders like age, disease duration, and previous treatment with methotrexate. In the final analysis, 2 cases of miscarriage were excluded.

The partaking women were assigned to 2 groups: group 1 had chosen to stop and group 2 to continue TNFi (i.e. adalimumab/certolizumab/etanercept). Group 2 consisted of 2 subgroups depending on those who were in a position to stretch the dosing intervals (around 59%; group 2a) and those who were not (2b). Continuance of TNFi led to a significantly lower rate of flares during pregnancy with an odds ratio for exacerbation of 0.06 (2a) and 0.12 (2b) (see Table). For the postpartum phase, both groups with continued TNFi also showed a lower flare rate, but statistical significance was found only in those who were able to reduce the dosage (OR 0.27). Participants not taking TNFi while pregnant needed more oral prednisolone. This data could help give recommendations and guide women planning their TNFi therapy during pregnancy.

Table: Flares during pregnancy and pregnancy outcomes with and without TNFi exposure until birth [1]

1. 
   
   1. Haase I, et al. Abstract 2279. ACR 2019. 8-13 November, Atlanta (GA/USA).
   2. Gerosa M et al. Expert Opin Pharmacother. 2016;17:1539-47.

Posted on 4 February 202016 February 2024