Treating and Preventing Arthritic Flares During Pregnancy

March 27, 2017

Tailored medication should be considered beyond conception to stabilize low disease activity and prevent flares during pregnancy, study reports.

Approximately 29% of rheumatoid arthritis patients and 25% of axial spondyloarthritis patients experience flares during pregnancy, a new study finds. Discontinuation of tumor necrosis factor inhibitors was associated with increased flares in these patients.

The study appears in the March 20 issue of Arthritis Research & Therapy.

“Elevated disease activity and TNFi discontinuation in early pregnancy may cause a relapse of disease activity in patients with rheumatoid arthritis and axial spondyloarthritis (axSpA). Restart of medication controls disease activity in pregnant patients with RA but shows insufficient effect in pregnant patients with axSpA,” wrote Stephanie van den Brandt, M.D., from the University of Bern in Switzerland and colleagues.

This was a prospective study of 136 pregnant patients in Switzerland with rheumatoid arthritis and axial spondyloarthritis who were followed between 2000 and 2015. Patients with rheumatoid arthritis had to fulfill the revised 1987 American College of Rheumatology classification criteria, while patients with spondyloarthritis had to met the European Spondylarthropathy Study Group criteria for spondyloarthritis.

Patients in the study were examined within 6 months before conception, at each trimester, and 6-8 weeks postpartum. Flares were evaluated at each visit during pregnancy as well as postpartum. When needed, glucocorticosteroids or tumor necrosis factor inhibitors were started during pregnancy based on shared decision making and a risk-benefit analysis.

Led by van den Brandt, the objective of this study was to identify risk factors for flares during pregnancy and to evaluate the effects of treatment used in pregnant patients who experience flares.

Prior to pregnancy, approximately 61 rheumatoid arthritis patients had low disease activity and 8.6% had active disease. However, during pregnancy, approximately 29% of rheumatoid arthritis experienced a flare of active disease activity. Most flares occurred in the first trimester. Moreover, the discontinuation of tumor necrosis factor inhibitor in early pregnancy correlated with the risk of flares (P = 0.001). Flares during pregnancy for rheumatoid arthritis patients were also associated with elevated disease activity (P=0.038) and C-reactive protein levels in early pregnancy (P=0.008). The initiation of tumor necrosis factor inhibitor or glucocorticosteroid demonstrated disease improvement at the second and third trimesters for approximately 60% of these patients.

In patients with axial spondyloarthritis, 25% showed active disease flares, with most occurring in the second half of pregnancy. Discontinuation of tumor necrosis factor inhibitor at a positive pregnancy test (P=0.017), elevated C-reactive protein levels (P=0.006), and active disease at early pregnancy were all associated with flares for this group. In particular, pregnant women with axial spondyloarthritis experienced high disease activity throughout pregnancy, with C-reactive protein levels peaking at the second trimester. Even with tumor necrosis factor inhibitor or glucocorticosteroid treatment in roughly 62.5% of these patients, disease activity stayed elevated throughout their pregnancy.

Rheumatoid arthritis and axial spondyloarthritis are two conditions that affect many women of childbearing age. During pregnancy, active disease can be seen in approximately 35% to 52% of women with rheumatoid arthritis, and in 60 % to 80% of women with axial spondyloarthritis.

Active disease and flares during pregnancy have the potential to harm both the mother and the fetus; however, it remains unclear how to best treat these patients. In particular, more research is needed to determine if changing treatment prior to pregnancy or early in pregnancy will influence the course of these diseases throughout pregnancy.

“Our study shows that, in the subgroup of patients with RA and axSpA treated with TNFi for at least 5 months before conception, the discontinuation of TNFi early in pregnancy could be a risk factor for disease flares during pregnancy,” wrote van den Brandt and colleagues. “The data indicate that tailored medication should be considered beyond conception to stabilize low disease activity and to prevent a flare during pregnancy.”

 

References:

Stephanie van den Brandt, Astrid Zbinden, Dominique Baeten, et al. “Risk factors for flare and treatment of disease flares during pregnancy in rheumatoid arthritis and axial spondyloarthritis patients,” Arthritis Research & Therapy. Published March 20, 2017. DOI: 10.1186/s13075-017-1269-1.