Mary A. De Vera
Although rheumatologists overwhelmingly agree on the use of conventional synthetic DMARDs and biologic drugs for inflammatory arthritis in patients with planned pregnancies, there appears to be little consensus on when to suspend drugs and how to handle unplanned pregnancies, according to survey data in BMC Rheumatology.
“Although, historically some [inflammatory arthritides (IA)] were recognized to improve during pregnancy, particularly RA , recent evidence suggests remission during pregnancy in less than 20% of women with RA,” Mary A. De Vera, PhD, of the University of British Columbia, and colleagues wrote. “Consequently, it is estimated that 40% to 50% of women with IA require treatment throughout the perinatal period. Managing IA pregnancy is an important clinical challenge. A 2013 U.K. survey of rheumatologists and obstetricians showed no uniform practice for using IA medications during pregnancy.”
To evaluate Canadian rheumatologists’ views on the management of inflammatory arthritis in patients who are pregnant, and to identify practice patterns and gaps in knowledge, De Vera and colleagues conducted a survey of members of the Canadian Rheumatology Association. The survey included 23 general and specific questions on the use of 12 specific conventional synthetic DMARDs, 12 biologics or small-molecule drugs and prednisone. In addition, questions gauged participants’ management of planned and unplanned pregnancies in patients.
There appears to be little consensus among rheumatologists on when to suspend drugs and how to handle unplanned pregnancies, according to survey data.
The researchers distributed the survey to 450 members of the Canadian Rheumatology Association, including rheumatologists and rheumatology trainees. In all, 96 recipients opened the survey and 90 consented to participate. Although just 68 participants completed at least 76% of the survey, all responses were included in the final analysis. Of the participants, 57% had been practicing rheumatology for more than 10 years.
According to the researchers, there was a broad consensus among rheumatologists on the discontinuation of four conventional synthetic DMARDs, specifically in planned pregnancies. Of these, 100% agreed on ceasing cyclophosphamide, 98% agreeing on leflunomide, 96% agreed on methotrexate and 89% agreed on mycophenolate mofetil.
However, responses were markedly more varied on when to discontinue treatment in the event of an unplanned pregnancy, and there was not much agreement on how to manage them in general. Still, participants agreed that three conventional synthetic DMARDs were safe to continue in planned and unplanned pregnancies. These were azathioprine, with 84% agreement; hydroxychloroquine, with 95% agreement; and sulfasalazine, with an agreement of 77%.
There was also agreement on the use of four biologics in planned pregnancies — adalimumab (Humira, AbbVie), certolizumab (Cimzia, UCB), etanercept (Enbrel, Amgen), and infliximab (Remicade, Janssen). However, there remained uncertainty on when they should be discontinued, as well as their use in unplanned pregnancies.
“This national survey shows consensus among rheumatologists on the safety of some [conventional synthetic] DMARDs and biologics/small molecules in IA patients planning pregnancy,” De Vera and colleagues wrote. “However, there was limited knowledge on when to discontinue these medications and what to do in unplanned pregnancies. Findings are timely as they establish baseline practice patterns and identify gaps that may be addressed by recently published points and guidelines.” – by Jason Laday
Disclosures: The researchers report no relevant financial disclosures.