Treat to Target: Rheumatoid Arthritis in Pregnant Patients

Both chronic HTN and DM have provided an excellent framework for the treat-to-target principle in nonpregnant individuals who may suffer fewer irreversible complications from undertreated disease as a result of achieving a low-disease state. This paradigm has been nicely translated to RA, with goals of low disease state/remission becoming increasingly possible with a growing arsenal of targeted drug therapy. With the adoption of treat to target, we can expect to see slowing or halting of RA-related damage accrual, including joint destruction, accelerated cardiovascular disease, and malignancy. In HTN and DM, however, treat-to-target goals extend into pregnancy, as it has been widely recognized that tight disease control during pregnancy improves both maternal and fetal outcomes. It is recognized that some therapeutic agents are “safer” than others during pregnancy, so that the medication regimen may need to be adjusted prior to conception, but the benefits of tight disease control far outweigh the risks of antenatal exposure to “safer” medications. Just as the rheumatology community has adopted the treat-to-target paradigm in the nonpregnant state, we should perhaps strongly consider similarly including these concepts during the peripregnancy period in female RA patients. Within the past few years, adverse pregnancy outcomes have been associated with RA, with some suggestion that these are directly related to increased disease activity. At the same time, effective medications that may be considered “safer” have become part of routine RA management. Because RA has been shown to improve during pregnancy, many women can hope to achieve good disease control without medical intervention. However, for the unlucky subset of women with moderate to severe disease during pregnancy, medical intervention may be warranted. The development of specific guidelines for RA control during pregnancy may aid in more widespread acceptance of medication use by both physicians and patients.

Disclosure

Dr. Chakravarty is a consultant for UCB and Genentech

Dr. Chakravarty is an associate member in Arthritis and Clinical Immunology at Oklahoma Medical Research Foundation in Oklahoma City.

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