For pregnant women with psoriatic arthritis (PsA), continuing biologic medication during pregnancy was correlated with low disease activity and low flare probability during gestation, whereas discontinuing biologic therapy before or shortly after becoming pregnant was correlated with higher risk of disease flares during and following pregnancy, according to findings published in The Journal of Rheumatology.
Despite reports of PsA symptom improvement during pregnancy, there is little research supporting this assertion. Investigators sought to explore the impact of pregnancy on PsA disease activity, as well as the effect that continuing vs stopping biologic therapy – which hadn’t been studied previously – had on disease activity during and following pregnancy.
The researchers conducted a retrospective review of Israeli women with PsA between the ages of 18 and 49 who had ≥1 pregnancy during the study period in addition to 1 PsA clinic visit during pregnancy or the immediate postpartum period (within 1 year of giving birth). The researchers defined initial PsA activity as none, mild, or moderate to severe; the same activity during and after pregnancy was rated as stable, improved, or worsened. Odds ratios (OR) were calculated to assess pregnancy-related risks.
The primary outcome of interest was the effect of pregnancy on PsA disease activity. The secondary outcome was the effect that continuing or stopping biologic therapy would have on disease activity while pregnant and during the first year postpartum.
A total of 25 patients (mean age at pregnancy, 32.5 years) representing 35 pregnancies were enrolled in the study, with 33 resulting in healthy babies that were further considered for analysis. The entire group did not experience any significant disease activity changes during pregnancy. However, 16 (48%) pregnancies saw the mothers report worse PsA symptoms during the first year postpartum, with a significant aggravation seen in terms of activity between the third trimester and the postpartum period (P =.01).
Out of 21 pregnancies in which the mother was previously taking biologics, 15 saw this treatment discontinued just prior to or just after conception. From these 15 cases, there were 5 in which PsA activity was rated as mild to severe before pregnancy; during the first and second trimesters and the postpartum period, this number rose to 8, 9, and 14, respectively. Compared to the third trimester, those who had stopped taking biologics saw significant worsening of their symptoms during the postpartum phase (P =.03). In contrast, the 6 cases in which biologic therapy was continued through pregnancy remained stable throughout gestation and the first year postpartum, without significant changes in disease activity.
Among all patients not treated with biologic therapy, there were notable improvements in PsA activity during the course of pregnancy, followed by marked declines symptomatically during the postpartum period. Those patients who discontinued biologic therapy prior to pregnancy had significantly worse disease activity in the postpartum period when compared to preconception levels (P =.0001). The OR for development of any type of disease activity following discontinuation of biologic therapy was 7.0 (95% CI, 0.5-98.6). Corticosteroids were used to treat active disease during pregnancy in only 6 cases, all of which involved early discontinuation of biologics.
Study limitations included a retrospective design, small sample size, and possible bias caused by inclusion of only live, healthy births.
Regarding clinical implications and treatment options, the authors advised, “It seems that regarding PsA disease activity, it may be recommended to continue treatment with [tumor necrosis factor]-alpha blockers during conception and up to the second trimester of pregnancy.”
Berman M, Zisman D, Wollman J, et al. The effect of pregnancy on disease activity in patients with psoriatic arthritis [published online September 15, 2018]. J Rheumatol. doi:10.3899/jrheum.171218