Background/Purpose: Optimal treatment of women with Rheumatoid Arthritis (RA) during pregnancy remains a challenge, mainly due to safety concerns. TNF inhibitors (TNFi) are now routinely used in young patients with pregnancy wish. Nevertheless it is recommended to discontinue treatment as soon as pregnancy is recognized because of lacking data concerning the long-term follow up of children exposed in utero. However, this approach may increase the risk of flares during pregnancy. We sought to explore the frequency of flare in pregnancies of women with RA who discontinue TNFi at conception. Methods: Pregnancies from a prospective pregnancy registry were evaluated before conception and during each trimester. Clinical characteristics, disease activity (DAS28-CRP), medication use, and pregnancy outcome were analyzed. A flare was defined as increase in clinical activity leading to intensifying treatment (new treatment with prednisolone or increase in dosage ≥5 mg/day and/or treatment with intraarticular glucocorticoids and/or (re-)treatment with DMARDS/TNFi). We applied a multivariate logistic regression model to assess the association between the use of TNFi at conception and the occurrence of flares during pregnancy. Adjustment for potential confounders was performed using logistic regression. Results: 42 pregnancies in women with RA were enrolled (median age 33 yrs, 71 % RF/ACPA positive). Eighteen (41%) pregnancies occurred in women with TNFi at conception. Twenty-four pregnancies in women without TNFi at conception served as controls. At conception, in 71 % disease activity was mild or in remission (DAS ≤ 3.2). We observed at least one flare in 16 pregnancies. Discontinuation of TNFi at conception was significantly associated with the occurrence of flares (OR 10.0, 95% CI 2.3-42.8, p=0.002). The strength of association was nearly constant after adjusting for age, RF, CCP, previous joint surgery, DAS28-CRP at conception, use and dosage of prednisolone during pregnancy. Twelve pregnancies had poor outcomes [10 (24%) with preterm delivery, 2 (4.7%) with preeclampsia]. The risk of preterm birth increased with every cumulative milligramme of Prednisolone [OR 1.08 (95% CI 1.02-1.15, p < 0.01)]. Conclusion: Women with RA who discontinue TNFi at conception face a high risk for flares during pregnancy, independently of known risk factors like sero-positivity. Flares are usually treated with Prednisolone. We found a dose-dependent significant increased risk for preterm birth associated with Prednisolone. In this era of treat-to-target management of RA, our paradigm for RA pregnancy management may need adjusting. By controlling RA activity with medications considered relatively safe in pregnancy, we may be able to improve both the pregnancy experience and pregnancy outcomes.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/high-risk-of-flares-during-pregnancy-in-women-with-rheumatoid-arthritis-who-discontinue-treatment-with-tnf-inhibitors-at-conception/