18 February 2021

Treat-to-target controls RA during pregnancy

Management Rheumatoid Arthritis Women

A modified treat-to-target approach sees most women with RA achieving low disease activity or remission during pregnancy and after birth, a Dutch study finds.

Comparing women’s disease activity before, during and after pregnancy between a prospective study and a historic cohort, the study found applying a modern treatment approach helped over 90 per cent of pregnant women with RA achieve good disease control in their third trimester.

It shows that it is possible to aim for and achieve tight control of RA using a modified treat-to-target approach during pregnancy, said Gene-Siew Ngian, a rheumatologist at the Royal Melbourne Hospital.

“Rheumatologists in the current treatment era no longer accept that flares of RA and possible progression of disease are unavoidable consequences of periods off treatment during the conception period and pregnancy,” Dr Ngian said.

Even though many women with RA see improvements in disease activity during pregnancy, one-fifth of women experience elevated disease activity while pregnant, and disease flares after childbirth are common.

In this study, nearly 185 pregnant women who had RA were drawn from a prospective cohort study currently underway at one hospital in Rotterdam, The Netherlands, and managed using a treat-to-target (T2T) approach aiming for remission yet accommodating medication restrictions of pregnancy.

Women continued on the TNF inhibitor they had been prescribed before pregnancy, but stopped or switched to another treatment before their third trimester, as recommended by EULAR. Treatments considered in late pregnancy included certolizumab pegol, low-dose prednisone and a combination of DMARDs.

Over 90 per cent of women managed using modern T2T strategies had low disease activity or remission in their third trimester of pregnancy. Only half of the women in the historic cohort, treated between 2002 and 2010 when treatment standards were more cautious, achieved the same result.

Not one patient in the prospective cohort experienced disease flares 6 months after childbirth, though roughly 12 per cent of women experienced a moderate increase in disease activity after giving birth, compared to one-fifth in the historic cohort.

Disease activity did not differ between women who used a TNF inhibitor during pregnancy, and those who did not, nor was there any difference between patients who switched or stopped their TNF inhibitor, and used prednisone or not.

“It was impossible to show that either T2T or new targeted therapies such as TNF inhibitors or combination therapy, or all were responsible for the improved disease outcomes during pregnancy,” the study authors noted in their paper.

Nevertheless, the study – featuring a sizable and prospective cohort – should give rheumatologists confidence that a T2T approach is feasible in pregnancy, said Dr Ngian, who has authored papers on managing women with RA during pregnancy.

“Other factors can make this difficult – for example, patient reluctance to escalate medications during pregnancy. But this highlights the importance of a good patient-clinician relationship and clear lines of communication,” Dr Ngian said.

Aiming for good disease control before conception also means women have a better chance of achieving low disease activity during pregnancy and a lower risk of postpartum flares.

Ann Rheum Dis 2021, 10 Feb