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vol. 53

Motherhood and fatherhood of patients with inflammatory rheumatic diseases in the era of biologics. Where are we after 20 years of anti-TNFs’ use?

Robert J. Moots
Anna Felis-Giemza

Reumatologia 2015; 53, 5: 233–235
Online publish date: 2015/12/08
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Biologic therapies have revolutionised the treatment of inflammatory rheumatic diseases such as rheumatoid arthritis (RA), spondyloarthropathies (SpA) and psoriatic arthritis (PsA), enhancing not only outcomes but also patients’ expectations. The most frequently used biologics in rheumatology currently are the anti-tumour necrosis factor agents (anti-TNFs), which have been used in routine care for nearly 20 years. The development of these drugs, alongside a treat-to-target strategy, now allows both physicians and patients to work together with the goal of inducing remission and raising quality of life to that of healthy people. Patients can now expect to work productively and enjoy their life in a manner hitherto unimaginable. We are concerned, however, that these huge advances have not yet been fully translated into effective management of fertility and pregnancy.
Current manufacturers’ guidelines recommend that anti-TNFs should be discontinued prior to conception for periods ranging from 3 weeks for etanercept to 6 months for infliximab and golimumab [1]. In Poland, recommendations provided by the “Drug Program” are even more restrictive [2] and, we believe, in need of revision to deliver optimal evidence-based care.
The key goals are to maximise the opportunity for conception and produce the best outcomes for mother and baby. However, there is clearly an important balance to be made. Whilst optimising care pre-conception will minimise inflammatory disease (enhancing conception and helping maintain pregnancy), it is essential to avoid exposure of both mother and developing foetus to harm. In inflammatory arthritis, the most critical period in a planned pregnancy is the preconception period. Withdrawal of drugs, whether biologics or disease-modifying anti-rheumatic drugs (DMARDs), during this time is highly likely to result in a flare, which in turn may reduce the chance of conception and risk an adverse pregnancy outcome. In the case of drugs with teratogenic properties, such as methotrexate (MTX) or leflunomide (LEF), ceasing therapy pre-conception is clearly essential. However, few other synthetic or biologic DMARDs appear to provide a real life risk. According to the US Food and Drug Administration (FDA), anti-TNFs, together with sulphasalazine (SSZ) and hydroxychloroquine, are only considered as category B (Table I).
During their 20 years of use in rheumatic diseases, a large body of evidence has emerged to suggest that continuation...

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