Can low disease activity be achieved with a modern treatment approach in pregnant women with rheumatoid arthritis?

This study evaluated whether a modern treatment approach is suitable in patients with rheumatoid arthritis (RA) that were pregnant or intended to become pregnant. The authors concluded that low disease activity (LDA) and remission are possible with a modern approach in these women.

RA is an inflammatory disease. It is associated with pain, decreased quality of life, and even reduced fertility and pregnancy outcomes. Modern approaches to RA treatments include the availability of new disease-modifying anti-rheumatic drugs (DMARDs), such as tumor necrosis factor (TNF) inhibitors and a treat-to-target (T2T) approach. T2T involves setting specific goals such as reduced disease activity or absence of signs and symptoms of RA. The patient is monitored closely and treatment is changed until the target is achieved.

Most TNF inhibitors are anti-inflammatory drugs that can be safely used during pregnancy. A problem with this treatment is that around 18 weeks of pregnancy TNF inhibitors can enter the blood of the baby. Therefore, it is recommended women stop treatment in the second trimester of pregnancy. However, the effect of stopping the use of RA treatments like TNF inhibitors during pregnancy or the strategy for doing so is unknown. 

This study included 184 women with RA that had babies. 47.3% of patients used a TNF inhibitor at any time during the study. The most commonly used TNF inhibitor was certolizumab pegol (Cimzia). 56 pregnant patients used a TNF inhibitor during the third trimester of pregnancy. 6% of patients did not use any DMARDs during pregnancy. Other commonly used DMARDs were sulfasalazine (Azulfidine), hydroxychloroquine (Plaquenil), and prednisone (Deltasone). 

The disease activity score was compared with another study that took place between 2002 and 2010 (control group). This study included 253 women with RA. Of these, 41.2% did not use any drugs during pregnancy. 85% of women who received medication had the same medication during pregnancy as before conceiving. Prednisone and sulfasalazine were the most common DMARDs used.

The average disease activity over time was significantly lower in the study involving TNF inhibitors (current study) compared to the control group. In the current study, 75.4% of patients were in remission or had low disease activity (LDA) before becoming pregnant. In their third trimester, 90.4% were in remission or had LDA. In the control group, 33.2% of the patients were in LDA or remission before pregnancy which increased to 47.3% in the third trimester.

In the current study, there was no difference in disease activity between patients who used TNF inhibitors during pregnancy and those who did not. No patient (0%) in the current study had a severe increase in disease activity after pregnancy compared to 5.7% of the control study. 12.2% of the women in the current study had a moderate increase in disease activity compared to 21% in the control study. However, this difference was not considered significant.

The study showed that LDA and remission are attainable goals during pregnancy for patients with RA using a modern treatment approach.

The patients were recruited differently in the 2 studies and may have had different characteristics. This may have influenced the results. Randomized studies are needed.