THU0136 TNF INHIBITORS IN PREGNANCY: STOP, REDUCE OR CONTINUE? – OBSERVATIONS FROM A PREGNANCY OUTPATIENT CLINIC
Authors: Isabell Haase, Susanna Spaethling-Mestekemper, Matthias Schneider, Rebecca Fischer-Betz
Journal: Annals of the Rheumatic Diseases (2019)

<h3>Background</h3> Women with active Rheumatoid Arthritis (RA) are more prone to relapses and complications during pregnancy. The potential risks of disease activation and treatment during gestation should be weighed in a shared decision prior to conception. An increasing number of women who wish to conceive are being treated with TNF inhibitors (TNFi). Some wish to discontinue or at least reduce therapy while pregnant and require information on opportunities and risks. <h3>Objectives</h3> To study the outcome of pregnancies in women with RA who either discontinued, reduced or maintained their TNFi treatment after conception. <h3>Methods</h3> Pregnancies from an outpatient pregnancy clinic were evaluated before conception, during each trimester and postpartum. Clinical characteristics, disease activity (DAS28-CRP), medication use and pregnancy outcome were analysed. A flare was defined as increase in clinical activity leading to intensified treatment (new treatment with prednisolone or increase in dosage ≥5 mg/day and/or treatment with intraarticular glucocorticoids and/or (re-)treatment with DMARDs/TNFi). All women received extensive counselling before pregnancy based on current knowledge and subsequently decided to continue or stop TNFi at conception. If they stayed on TNFi and were in remission, women received the suggestion to stretch the therapy intervals in a disease activity guided manner. <h3>Results</h3> After exclusion of one miscarriage, 56 completed pregnancies were enrolled and grouped according to their decision to stop (group 1) or continue (group 2) TNFi therapy during pregnancy. The latter were subdivided into those who could stretch the therapy intervals (group 2a) and those who could not (group 2b). Group 1 also contained seven women who received Tocilizumab or Rituximab until conception. Despite low disease activity (DAS ≤ 3.2) at conception in all groups, a higher flare rate during pregnancy and postpartum was observed after discontinuation of TNFi. In addition, a higher dose of oral prednisolone and more frequent intraarticular therapy was reported in group 1 (table 1). Postpartum, 38.9% restarted TNFi therapy. About half of the women who chose to stay on therapy during gestation were able to stretch the injection interval of their TNFi, which was either Adalimumab (every 3.0 weeks), Certolizumab (median every 4.0 [min 4.0, max 5.0] weeks) or Etanercept (median every 3.0 [min 2.0, max 6.0] weeks) (Table 2). Relapse rate as well as prednisolone consumption was comparable between group 2a and group 2b. <h3>Conclusion</h3> Women with RA who discontinue TNFi at conception face a higher risk of flares during pregnancy and often have an increased demand for steroids to control disease activity. When in remission under ongoing TNFi therapy during pregnancy, it seems possible and safe for women to reduce the frequency of injections in a disease activity guided manner. These real-world data will help to provide women with comprehensive advice on treatment options and risks regarding TNFi therapy at pregnancy counselling. <h3>Disclosure of Interests</h3> Isabell Haase: None declared, Susanna Spaethling-Mestekemper: None declared, Matthias Schneider Grant/research support from: GlaxoSmithKline and UCB Pharma for performing the LuLa-study., Speakers bureau: Chugai, Rebecca Fischer-Betz Grant/research support from: GlaxoSmithKline and UCB Pharma for performing the LuLa-study.