Regarding the concurrent increase in the use of biologic agents, Dr. Desai added, “With the number of different options available to practicing rheumatologists today compared with 10 years ago, it makes complete sense that it would show an increasing trend.”
Implications
According to Dr. Desai and his team, their results—a decreased use of steroids and nonbiologic agents other than hydroxychloroquine and an increase in the use of biologic agents during pregnancy—may reflect similar trends in the general population.10 The findings may also suggest that with more research showing the absence of a major fetal adverse event after use of biologic agents in pregnancy, physicians seem to be becoming more comfortable with patients continuing treatment with these agents during pregnancy.11
The sharp rise seen in the use of biologic agents during pregnancy highlights the need for continuing research evaluating the safety of biologic agents in terms of their effects on various maternal and fetal outcomes. Because many women discontinue immunomodulatory treatments during pregnancy, future research should also evaluate the impact of untreated active disease on fetal or maternal health.
“It’s definitely challenging to decide to continue or stop [taking medication during pregnancy], especially since there are no definitive data for fetal safety on most of these agents. This is because the conditions themselves are relatively infrequent in women of reproductive age and treatments are used by even fewer patients during pregnancy, so it’s difficult to design an adequately powered study to draw definitive conclusions regarding safety of these agents,” Dr. Desai says. “It’s a fine balance to keep disease activity in control and [minimize] fetal risk if you keep taking the medication. But at least there should be some clinical discussion around this issue rather than completely stopping out of fear because actually not taking the medication can put the baby into harm’s way even more than to keep taking it.”
To further the conversation about management of pregnant and lactating women with autoimmune disease, the ACR held a Reproductive Health Summit in 2014. The ACR also has an information page on its website regarding pregnancy and rheumatic disease, recommending that women ensure their disease is controlled for three to six months before attempting pregnancy.
Increasing the communication about medications and pregnancy is important, Dr. Desai says. “There was an interesting UK study that showed only about 65% of practicing rheumatologists reported always offering counseling regarding DMARD use during pregnancy,” he says.12 “This is suboptimal, obviously. Every patient who comes in with these conditions and who is on treatment, they have to be counseled on the risks [of discontinuing treatment] to make sure the decision has a clinical rationale and is not completely driven by fear.”
