Clinicians must 'quiet' rheumatic disease activity before pregnancy for optimal outcomes
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It is essential that rheumatologists aim for “low” or “quiescent” disease activity several months before conception in their patients who desire to become pregnant, according to a presenter at the 2020 Congress of Clinical Rheumatology-East.
“My goal today is to talk about how to assess pregnancy risk for patients with rheumatic diseases,” Lisa R. Sammaritano, MD, a rheumatologist at the Hospital for Special Surgery, and of the department of rheumatology at Weill Cornell Medical College, said in her presentation.
She also sought to offer clinicians strategies to manage complications that may arise in patients who do become pregnant, and to provide insight into medication use before, during and after pregnancy.
Thanks to a wider array of therapies and increased understanding of disease pathogenesis, rheumatology patients have far more options for safe conception and pregnancy than ever before. But this may be for naught if rheumatologists fail to talk openly with their patients about those options. “Talk to them about pregnancy,” Sammaritano said. “Talk to them about safe and effective conception.”
While patients with rheumatic diseases tend to have more complications in pregnancy than the general population, the degree of maternal and fetal risk varies greatly depending on the individual patient, their disease and their treatment regimen.
That said, Sammaritano offered one overarching goal for rheumatologists to consider. “The best outcomes in our patients are in those who have quiet or low disease activity 6 months before pregnancy, and those who are on drugs that are OK with pregnancy,” she said.
The first step is to look at disease severity, which Sammaritano suggested translates to organ damage associated with disease. “Some scenarios where disease-related damage is a contraindication for pregnancy includes renal disease or insufficiency, valvular disease or pulmonary hypertension,” she said. “In terms of disease activity, active disease at conception will impact both mother and child.”
Disease-specific considerations
Drilling down to specific disease states, Sammaritano said systemic lupus and antiphospholipid syndrome (APS) are the diagnoses that raise the most concern when considering pregnancy. “However, there have been improvements in recent years,” she said.
For patients with lupus, renal disease, nephritis and proteinuria should be on every clinician’s radar. “Lupus nephritis and pregnancy is a worrisome combination,” Sammaritano said.
“When we think of APS, we think of two large sets of complications,” she added. “We think of thrombosis and obstetric complications.”
Sjogren’s syndrome is associated with a high prevalence of anti-Ro and La antibodies, which can be problematic in pregnancy, according to Sammaritano. In addition, fetal survival can decrease in patients who develop polymyositis or dermatomyositis during pregnancy. “But if these diseases are well managed before pregnancy, fetal survival is pretty good,” she said.
Patients with rheumatoid arthritis often experience an improvement in disease activity, if not remission, during pregnancy. However, postpartum relapses are common. “You should have a plan for postpartum flare,” Sammaritano said. “It is almost inevitable.”
Pre-pregnancy pharmacotherapy
Turning to medications, if there is one over-arching consideration for pharmacotherapy in the rheumatology patient who wishes to become pregnant, it is that timing of exposure is important, according to Sammaritano.
Cyclophosphamide, thalidomide, methotrexate, leflunomide and mycophenolate are all contraindicated for pregnancy. “They should be discontinued 6 to 8 weeks before conception,” Sammaritano said.
Tacrolimus, TNF inhibitors, rituximab (Rituxan, Genentech) and other non-TNF biologics may be considered up to the time of conception. “But we currently recommend stopping [biologics] at that point due to lack of data,” Sammaritano said.
Looking at specific disease/drug combinations, Sammaritano suggested that in lupus patients, mycophenolate should be changed to azathioprine. In addition, while NSAIDs may impact fertility, they are safe for breastfeeding mothers.
In conclusion, Sammaritano underscored the message of planning and communication. “Unplanned pregnancy is not a good thing for our patients,” she said. “Timing is critical. Try to help them achieve quiescent disease before conception.”
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Sammaritano LR. Pregnancy in Patients with Rheumatic Diseases. Presented at: Congress of Clinical Rheumatology-East annual symposium; September 10-13, 2020 (virtual meeting).
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