Changes in Rheumatoid Arthritis Pharmacotherapy During Pregnancy

Clinicians should consider supplementation with calcium 1.25 g/day and vitamin D or a combined formula for bone protection for all pregnant women taking steroids.1 A 2011 study by Dr Kuriya and associates found that glucocorticoids, received by >30% of women, comprised the largest number of RA therapies dispensed during the gestational period, and that they were used more frequently during pregnancy than before.15

“Since many DMARDs are contraindicated during pregnancy, and we have seen that some NSAIDs may be harmful, steroids at low to moderate doses are often preferred to treat flares of RA during pregnancy,” Dr Kuriya stated.

More research is needed on the effect of RA on disease activity and the effects of RA medications on the fetus, especially as the RA treatment armamentarium expands. The benefits of maintaining good disease control and avoiding progression must be balanced with potential medication risks.  

“I believe rheumatologists are increasingly becoming better at counseling women about the risks and benefits of RA therapies but also of the impact of the disease itself.  Tools such as national guidelines about the safety of drugs during pregnancy and lactation help physicians in their counseling, but greater education and outreach are still needed to keep up with all of the emerging new therapies we have for RA,” noted Dr Kuriya.

References

1.     Soh MC, Nelson-Piercy C. Update of the management of rheumatoid arthritis in pregnancy. Expert Rev Obstet Gynecol. 2012;7(1):77-96.

2.     Van vollenhoven RF. Sex differences in rheumatoid arthritis: more than meets the eye. BMC Med. 2009;7:12. doi: 10.1186/1741-7015-7-12

3.     Carmona L, Cross M, Williams B, Lassere M, March L. Rheumatoid arthritis. Best Pract Res Clin Rheumatol. 2010;24(6):733-745.

4.     Cush JJ, Kavanaugh A. Editorial: pregnancy and rheumatoid arthritis – do not let the perfect become the enemy of the good. Curr Opin Rheumatol. 2014;26(3):299-301.

5.     de Man YA, Dolhain RJEM, van de Geijn FE, Willemsen SP, Hazes JMW. Disease activity of rheumatoid arthritis during pregnancy: results from a nationwide prospective study. Arthritis Care Res. 2008;59(9):1241-1248.

6.     Nelson JL. Maternal-fetal immunology and autoimmune disease: is some autoimmune disease auto-alloimmune or allo-autoimmune? Arthritis Rheum. 1996;39(2):191-194.

7.     Barrett JH, Brennan P, Fiddler M, Silman AJ. Does rheumatoid arthritis remit during pregnancy and relapse postpartum? Results from a nationwide study in the United Kingdom performed prospectively from late pregnancy. Arthritis Rheum. 1999;42(6):1219-1227.

8.     Chakravarty EF. Rheumatoid arthritis and pregnancy: beyond smaller and preterm babies. Arthritis Rheum. 2011;63(6):1469-1471.

9.     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(10):1836-1841. doi:10.1136/annrheumdis-2014-205383.

10.  Provost M, Eaton JL, Clowse ME. Fertility and infertility in rheumatoid arthritis.  Curr Opin Rheumatol. 2014;26(3):308-314.

11.  Jawaheer D, Zhu JL, Nohr EA, Olsen J. Time to pregnancy among women with rheumatoid arthritis. Arthritis Rheum. 2011;63(6):1517-1521.

12.  Ince-Askan H, Dolhain RJEM. Pregnancy and rheumatoid arthritis. Best Pract Res Clin Rheumatol. 2015;29(4-5):580-596.

13.  Carter JD, Ladhani A, Ricca LR, Valeriano J, Vasey FB. A safety assessment of tumor necrosis factor antagonists during pregnancy: a review of the Food and Drug Administration database. J Rheumatol. 2009;36(3):635-641.

14.  Williams M, Chakravarty EF. Rheumatoid arthritis and pregnancy: impediments to optimal management of both biologic use before, during and after pregnancy. Curr Opin Rheumatol. 2014;26(3):341-346.

15.  Kuriya B, Hernández-díaz S, Liu J, Bermas BL, Daniel G, Solomon DH. Patterns of medication use during pregnancy in rheumatoid arthritis. Arthritis Care Res (Hoboken). 2011;63(5):721-728.