TNF inhibitor use during pregnancy in RA reduces risk for low birth weight
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TNF inhibitor use in pregnant patients with well-controlled rheumatoid arthritis reduces the risk for children born small-for-gestational-age, according to data published in Annals of the Rheumatic Diseases.
However, it did not increase the risk for large-for-gestational age birth weights, the researchers added.
“Pregnancy outcomes, like small-for-gestational age (SGA) and hypertensive disorders, in women with RA are impaired compared with healthy women, especially in women with active disease during pregnancy,” Hieronymus T.W. Smeele, MD, of Erasmus Medical Center, in Rotterdam, the Netherlands, and colleagues wrote. “In recent years, more treatment options during pregnancy became available, including tumor necrosis factor (TNF)-inhibitors (TNFi), resulting in improved disease outcomes in women with RA during pregnancy.”
To examine pregnancy outcomes in patients with RA, the Smeele and colleagues conducted a prospective study including eligible patients from the Preconception Counseling in Active RA (PreCARA) study, a prospective cohort study of inflammatory rheumatic diseases prior to and during pregnancy. Established in 2011, the PreCARA study is ongoing.
Patients in the cohort are managed following a modified treat-to-target approach, with the goal of achieving minimal disease activity. Providers gave more intense treatment, if necessary, during follow-up visits. Following this protocol, treatment started with sulfasalazine and/or hydroxychloroquine. If necessary, prednisone and/or a TNF inhibitor were added.
The current analysis included patients who became pregnant during TNF inhibitor use, which was discontinued when gestational age was reached depending on the drug in use. Patients enrolled in the PreCARA study had clinical visits every 3 months before becoming pregnant. Subsequent visits were then planned for the first, second and third trimesters, and at 6, 12 and 26 weeks post-birth. Patients underwent joint examination, produced blood samples and responded to electronic surveys at each visit.
The PreCARA researchers collected data regarding pregnancy outcomes, including birth weight, gestational age at the time of delivery, sex of the baby and location and method of delivery. They also collected information regarding pregnancy complications, such as premature birth, low birth weight, high birth weight, hypertensive disorders, diabetes mellitus, and congenital malformations. In situations where patients gave birth outside of the investigating hospital, the attending physicians provided the pertinent information.
Among the 188 patients in the study, 92 received a TNF inhibitor during pregnancy. The DAS28 C-reactive protein was “low” at all time points throughout the pregnancies, the researchers wrote.
According to Smeele and colleagues, the use of TNF inhibitors was not linked to an increase in adverse outcomes, including low birth weight, emergency cesarean section, hypertensive disorders or congenital malformation.
In addition, TNF inhibitor use resulted in fewer children born small-for-gestational age (P = .05). However, it did not increase the risk for large-for-gestational age births (P = .73). Among patients who used a TNF inhibitor during pregnancy, the mean birth weight was 173 g higher than in those who did not — 3.344kg vs. 3.171kg (P = .03). In the multivariate analysis, maternal age (β = –0.023; 95% CI, –0.04 to –0.0065), TNF inhibitor use (β = 0.2; 95% CI, 0.066-0.34), diabetes mellitus (β = 0.37; 95% CI, 0.12-0.63) and gestational age (β = 0.18; 95% CI, 0.15-0.2) were statistically significantly associated with birth weight.
“Our study shows that the use TNFi during pregnancy is associated with increased birth weight of offspring of women with well-controlled RA,” Smeele and colleagues wrote. “Interestingly TNFi use during pregnancy results in less children born SGA, however, it does not increase the risk of born [large-for-gestational-age].
“Our results might pave the way towards new clinical indications for the use of TNFi during pregnancy such as intrauterine growth restriction,” they added.
References:
- Smeele HTW, et al. Ann Rheum Dis. 2021;doi: 10.1136/annrheumdis-2020-219547.
- Smeele HTW, et al. Semin Arthritis Rheum. 2019;doi: 10.1016/j.semarthrit.2019.09.010.
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