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From the perspective of domestic and foreign guidelines, the strategies of chronic rheumatic diseases in women of childbearing age were discussed

 Last Update: 2023-01-01
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Management of chronic rheumatic diseases in women of childbearing age: a comparison of domestic and international guidelines

Some rheumatic diseases occur more frequently in women than in men, and peak in childbearing age ^[1,2].
This feature brings great challenges
to the disease management and medication compliance of some women.
In women of childbearing age, women often discontinue medication on their own because they are concerned about the reproductive effects of disease medication ^[3].

Patients with rheumatic diseases are at risk of exacerbation or outbreak in the postpartum period of disease that cannot be ignored
.
Patients with rheumatoid arthritis, ankylosing spondylitis, and psoriatic arthritis have a 48 percent, 90 percent, and 40 percent risk of postpartum disease outbreaks, respectively ^[4,5].
Whether from the maternal or fetal outcome, the management of rheumatic diseases in women of childbearing age should be fully paid attention to to avoid irreparable harm
to maternal and infant outcomes caused by erroneous and outdated medication concepts.
In recent years, domestic and foreign guidelines have made important updates
to the medication of patients with rheumatism during pregnancy and lactation.
【2020 ACR Guidelines for Reproductive Management of Rheumatism】The
American College of Rheumatology published guidelines on reproductive health management of rheumatic and musculoskeletal disorders on February 23, 2020 ^[7], which cover contraception, assisted reproduction, The use of gonadotropins for fertility preservation, menopausal hormone replacement therapy, pregnancy assessment and management, and medication use are six areas
.

For women, the effects of
the drug should be considered before trying to conceive.
The guidelines recommend drugs to be used in women over three periods
.
TNF-α inhibitors are considered to be one of the very important drugs for the control of chronic rheumatic diseases and are widely used in the treatment
of rheumatoid arthritis and other diseases.
At present, the commonly used TNF-α inhibitors in China mainly include: infliximab, etanercept, adalimumab, peselizumab, golimumab, tocilizumab
.

Of all current TNF-α inhibitors, the American College of Rheumatology (ACR) is the only one that strongly recommends peselizumab for the entire course of disease management (pregnancy, pregnancy, and lactation)
in women of childbearing age.
For the use of infliximab, etanercept, adalimumab, etc.
in women of childbearing age, strict attention should be paid to the time of
discontinuation.
The degree of disease activity and the risk of disease outbreaks after stopping the drug need special attention
.

【2016 version of EULAR medication recommendations】The
European Union of Rheumatology (EULAR) gives relevant definitions for the use of anti-rheumatic drugs before pregnancy, pregnancy and lactation.
In the 2016 version of the guidelines, 4 general principles and 11 recommendations for the use of antirheumatic drugs in pregnancy and lactation ^{were developed [6].}

TNF-α antagonists in biologics are safe
for use in the first and second trimesters.
Enhanced patient education can help improve the treatment
of rheumatic diseases during pregnancy and lactation.
In its general senses, EULAR emphasizes the need to pay attention to pregnancy planning for patients with rheumatic diseases of childbearing age; The aim of treating rheumatology patients before, during and during breastfeeding is to reduce the activity of the mother; The risks of medication to the fetus and newborn should be weighed against the pros and cons, and the risks of untreated maternal disease are not only harmful to the patient itself, but also to the fetus and newborn; Medication decisions during pregnancy and lactation should be made by all physicians, patients and other relevant personnel
.

EULAR Expert Opinion and Consensus Statement on the Use of Biologics in Pregnancy/Lactating Patients (2016 Edition) EULAR
recommends that the highest priority during pregnancy and lactation is The TNF-α inhibitor that can be used in the course of treatment is also peselizumab, which is consistent
with ACR guidelines.
【Chinese Evidence-based Guidelines】The
above are the guideline recommendations for the management of rheumatic diseases in women of childbearing age widely used abroad, and the Rheumatology Society Branch of the Chinese Medical Association has updated the relevant guideline recommendations for rheumatology patients during pregnancy, pregnancy and lactation based on evidence-based medicine ^[8]
。 The update of this guideline is an important embodiment
of China's clinical strengthening of disease standard management for patients with rheumatic diseases of childbearing age.

The use of TNF-α inhibitors during pregnancy did not increase the incidence of adverse pregnancy events and neonatal defects, and did not increase the risk of serious infection in the newborn ^[8].
Conversely, discontinuation of TNF-α inhibitors during pregnancy may increase the risk of
relapse and exacerbation of perinatal or postpartum disease.

It is worth noting that consistent with the two authoritative guidelines abroad, China's drug use regulations also clearly point out that the preferred TNF-α inhibitor during pregnancy should be peselizumab, because it does not contain Fc segment, so it is rarely transported through the placenta, and the drug can be used throughout pregnancy without dose
adjustment.
Ten-Fc TNF-α inhibitors need to be discontinued in the third trimester of pregnancy to reduce the potential risk
to the fetus from entering the fetal circulation.

Drugs to avoid during pregnancy and discontinuation time in female rheumatology patients during pregnancy ^[8] [Summary]
Overall, Disease activity is strongly associated
with adverse pregnancy outcomes.
The focus of rheumatic disease treatment for women of childbearing age can be divided into before, during, and after
pregnancy.
This issue briefly describes the correct medication concept
for chronic rheumatic diseases in women of childbearing age from the perspective of updated guidelines in various countries.
During the pregnancy of rheumatology patients, attention should always be paid to their clinical normative management, control disease activity and prevent disease outbreaks
at all stages.

Some patients with rheumatic disease are at high risk of pregnancy, and increased management of chronic rheumatic disease in women of childbearing age can help control disease activity for optimal pregnancy outcomes
.
Selecting the most appropriate drug for rheumatic disease at each stage according to national guidelines is essential
for the clinical benefit of pregnant patients.

Expert profiles

Li Ling Deputy Chief Physician

M.
D
Director of Rheumatology Department, Guangdong Provincial People's Hospital, Master Supervisor
Graduated from Peking Union Medical College Hospital majoring in rheumatology and immunology
Visiting scholar at the Clinical Rheumatology Center of the Polytechnic University of Marche, Italy
Specialty: Musculoskeletal joint ultrasound technology is used in the early diagnosis and individualized treatment of various rheumatoid arthritis
Member of the Youth Committee of the 3rd Rheumatology Branch of the Chinese Medical Doctor Association
Member of the Psychosomatic Rheumatology Group of the Psychosomatic Medicine Branch of the Chinese Medical Association
Member of the Rheumatology and Immunological Rehabilitation Professional Committee of the Chinese Association of Rehabilitation Medicine
Member of the Rheumatology and Immunology Drug Research Committee of the China Association of Traditional Chinese Medicine
Vice Chairman of the Youth Committee of Internal Medicine Branch of Guangdong Medical Association
Vice Chairman of Rheumatology Branch of Guangdong Medical Industry Association
Deputy leader of the psychosomatic rheumatology group of the Psychosomatic Medicine Branch of Guangdong Clinical Medical Association
Vice Chairman of the Spine Health and Disease Prevention Committee of Guangdong Clinical Medical Association
Member of the Standing Committee of the Rheumatology Branch of Guangzhou Medical Association

References

[1] Rudan I, et al, J Glob Health.
2015 Jun; 5(1):010409.

[2] Li Rong, et al.
Chinese Journal of Rheumatology,2021,25(03):202-206.

[3] Tincani A, Taylor P, Fischer-Betz R, et al.
Annals of the Rheumatic Diseases 2018; 77:866

[4]de Man YA, et al.
Arthritis Rheum.
2008; 59(9):1241–1248.

[5] Jethwa H, et al.
J Rheumatol.
2019 Mar; 46(3):245-250.

[6] Götestam Skorpen C, et al.
Ann Rheum Dis.
2016 May; 75(5):795-810.

[7] Sammaritano LR, et al.
Arthritis Rheumatol.
2020 Apr; 72(4):529-556.

[8] Zhang Wen, et al.
Chinese Journal of Internal Medicine,2021,60(11):946-953.

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