Chronic rheumatism management in women of childbearing age: what should we focus on?

*For medical professionals only

Discussion on medication safety of chronic rheumatism in women of childbearing age
.

In addition to affecting joints and surrounding tissues, rheumatism can also affect various organs and organs
throughout the body such as the heart, lungs, and kidneys.
Common rheumatoid diseases include rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), ankylosing spondylitis (AS), Sjogren's syndrome (SS) and systemic sclerosis (SSc
).

Most rheumatism occurs much more in women than in men, and is more likely to occur in women of childbearing age (15-49 years old).

With the continuous improvement of rheumatism in China's awareness and diagnosis and treatment level, in addition to the control of rheumatism itself, female patients are paying more and more
attention to fertility-related issues.
About 50% of patients with rheumatism in pregnancy fail to accurately diagnose rheumatism before pregnancy ^[1], which also poses new challenges
to the clinical management of the disease.
Patients with rheumatic immune diseases need to form a multidisciplinary disease management team composed of obstetrics, rheumatology and immunology, hematology, vascular surgery, neonatology, etc.
throughout pregnancy, pregnancy and lactation ^[2].

According to the individual situation of different patients, formulate a rational medication plan to reduce the adverse effects
on pregnant women or fetuses caused by uncomfortable drug discontinuation or inappropriate medication.

【What do patients of childbearing age need to pay attention to?】 】

Individualized, multidisciplinary medication regimen: very important
.

▌【Pre-pregnancy】Control of disease activity, contraception and drug treatment can not be ignored
.

It is important for women planning to become pregnant to control rheumatism
.
Approximately one-third of women diagnosed with RA before pregnancy have been found to have a prolonged duration of conception (> 12 months) ^[3].

Patients with high disease activity in RA had significantly more difficulty conceiving (COX regression risk ratio of 0.
81), and nearly 75% of patients with very high disease activity did not conceive
in the first year.

It can be seen that controlling disease activity is very important
for the successful conception of the patient.

For women with pregnancy plans, the drugs that can be used during pregnancy and pregnancy need to be planned
with the participation of doctors and pharmacists.
For clinically commonly used antirheumatic drugs to improve the condition, the following drugs need to be discontinued in a planned manner ^[4].

Contraception is necessary
during the use of these drugs.

TNF-α inhibitors are one of the important drugs to control the disease activity of
RA and AS.
Of all TNF-α inhibitors, peselizumab is the only Fc fragment-free, peg-modified TNF-α inhibitor with low immunogenicity, rapid onset of penetration, and non-binding to placental FcRn ^[5,6], so pecelizumab is highly recommended by the 2020 ACR guidelines for disease control in women of childbearing age trying to conceive ^[7]
。

▌【During pregnancy】Stop taking the drug after pregnancy? Absolutely not
.

The control and management of chronic rheumatism is a long-term process, and due to changes in hormone levels during pregnancy and childbirth, some rheumatism can transform from occult and atypical to overt, relapse or exacerbate; A few are relieved during pregnancy ^[1].

Therefore, different patients show different disease progression during pregnancy for the disease, and the medical team needs to make medication adjustments after evaluating the patient's condition, and should not stop the drug
without authorization.

TNF-α inhibitors are relatively safe biologics for pregnant women ^[4].

Discontinuation of TNF-α inhibitors during pregnancy may increase the risk of
recurrence or exacerbation of perinatal or postpartum disease.
If TNF-α inhibitors are being used in the preconception period, the risk of
disease exacerbation or recurrence after discontinuation should be alerted.

Neonatal exposure to TNF-α inhibitors in pregnancy

Neonates exposed to TNF-α inhibitors during pregnancy should avoid live attenuated vaccine for the first 6 months of life to avoid secondary infection
.

CRIB pharmacokinetic studies ^[8] showed that pecelizumab did not metastasize from the mother through the placenta to the baby, or the amount of placental metastasis was minimal, and the level of intrauterine fetal drug exposure that occurred later in pregnancy was extremely low
.
The 2021 Guidelines for the Use of Perigestational Drugs in Patients with Rheumatic Diseases clearly states that the preferred TNF-α inhibitor during pregnancy is peselizumab without dose
adjustment.

▌【Breastfeeding after pregnancy】

Lactation can be performed during the use of all TNF-α inhibitors ^[4,7].

It can be seen that active and scientific standardized management of chronic rheumatism can bring better disease control and good maternal and infant outcomes
to female patients who are trying to conceive, during and after pregnancy.
For female patients with family plans, they should work together with clinicians, pay attention to prenatal diagnosis and disease control, reasonably choose the timing of pregnancy, and scientifically select and standardize the use
of drugs used during pregnancy.