Modern Treatment Tied to Low Disease Activity in Pregnant Patients With Rheumatoid Arthritis

By Lisa Rapaport

February 25, 2021

(Reuters Health) - Many pregnant women with rheumatoid arthritis may achieve low disease activity in the third trimester with a modern treatment regimen that includes anti-tumor necrosis factor (TNF) medications, a recent study suggests.

Researchers examined data on 309 patients with rheumatoid arthritis (RA) who were pregnant or trying to conceive and who were treated with modern treat-to-target medication regimen that included anti-TNF medications as well as low-dose prednisone and disease-modifying antirheumatic agents (DMARDs). They compared outcomes for this group of women to results from a historic reference cohort of women treated from 2002 to 2010.

In the modern treatment study cohort, 75.4% of women were in remission or had low disease activity before pregnancy, and this rose to 90.4% during pregnancy. By contrast, 33.2% of women in the historic reference cohort were in remission or had low disease activity before pregnancy, and this rose to 47.3% during pregnancy.

"I think the take-home message should be that clinicians should apply a treat-to-target approach before and during pregnancy," said lead study author Dr. Hieronymus T.W. Smeele of Erasmus University Medical Center in Rotterdam, The Netherlands.

"This will lead to 80%-90% of patients in low disease activity during pregnancy," Dr. Smeele said by email. "Hopefully our future research will show that low disease activity has a beneficial effect on the offspring as well."

In the historic cohort, women were treated by their own rheumatologist according to the standards of that time for pregnancy, mainly using sulfasalazine, prednisone or no medication, the study team notes in Annals of the Rheumatic Diseases.

In the modern cohort, 87 patients (47.3%) used an anti-TNF agent at some point during pregnancy, and 56 women used these medications during the third trimester. A total of 188 children were born to women in the modern cohort.

After delivery, none of the women who received modern treatment had a severe increase in rheumatoid arthritis disease activity postpartum. But 5.7% of those in the historical reference cohort had a severe increase in disease activity postpartum.

In addition, 12.2% of the women who received modern treatment had a moderate increase in disease activity postpartum, compared with 21.0% of the historical reference cohort.

One limitation of the study is that researchers were unable to show whether the treat-to-target therapy approach, newer targeted therapies such as anti-TNF agents, combination therapy, or all of these things combined might have contributed to disease outcomes. In addition, because researchers only examined data on women who were able to conceive, it's possible that selection bias influenced the results.

Conception, contraception and family planning should be an important point in discussion when patients in the reproductive age group are started on DMARDs or biologics because it may influence the choice of medication, said Dr. Ashima Makol, chair of the connective tissue disease subspecialty group and director of the Scleroderma/Raynauds/Nailfold Videocapillaroscopy Clinic at the Mayo Clinic in Rochester, Minnesota.

"This study confirms that in pregnant women with RA or those wishing to conceive, achieving low disease activity and remission can be feasible goals with treat-to-target strategies," Dr. Makol, who wasn't involved in the study, said by email. "There are thankfully many more options to choose from now than used to be in the past, to optimize maternal health, while still keeping the safety of the fetus a prime priority."

SOURCE: Annals of the Rheumatic Diseases, online February 10, 2021.