Fertility in women with rheumatoid arthritis: influence of disease activity and medication.
OBJECTIVE
Many female rheumatoid arthritis (RA) patients attempting to conceive have a time to pregnancy (TTP) of >12 months. During this period RA often cannot be treated optimally. We sought to identify clinical factors associated with prolonged TTP in female RA patients.


METHODS
In a nationwide prospective cohort study on pregnancy in RA patients (PARA study), women were included preconceptionally or during the first trimester. Cox regression analysis was used to study the association of disease characteristics and medication use with TTP.


RESULTS
TTP exceeded 12 months in 42% of 245 patients. Longer TTP was related to age, nulliparity, disease activity (DAS28), and preconception use of non-steroidal anti-inflammatory drugs (NSAIDs) and prednisone. These variables were independently associated with TTP, with HRs for occurrence of pregnancy of 0.96 (95% CI 0.92 to 1.00) per year of age, 0.52 (0.38 to 0.70) for nulliparity, 0.81 (0.71 to 0.93) per point increase in DAS28, 0.66 (0.46 to 0.94) for NSAIDs and 0.61 (0.45 to 0.83) for prednisone use. The impact of prednisone use was dose dependent, with significantly longer TTP when daily dose was >7.5 mg. Smoking, disease duration, rheumatoid factor, anti-citrullinated protein antibodies, past methotrexate use, and preconception sulfasalazine use did not prolong TTP.


CONCLUSIONS
TTP in RA is longer if patients are older or nulliparous, have higher disease activity, use NSAIDs or use prednisone >7.5 mg daily. Preconception treatment strategies should aim at maximum suppression of disease activity, taking account of possible negative effects of NSAIDs use and higher prednisone doses.
Department of Rheumatology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands Division of Reproductive Medicine, Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.
Jenny
J
Brouwer
Department of Rheumatology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.
Johanna M W
JM
Hazes
Division of Reproductive Medicine, Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.
Joop S E
JS
Laven
Department of Rheumatology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.
Radboud J E M
RJ
Dolhain
D000328:Adult; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000009:adverse effects / Q000494:pharmacology / Q000627:therapeutic use; D001172:Arthritis, Rheumatoid / Q000150:complications* / Q000188:drug therapy; D004305:Dose-Response Relationship, Drug; D005260:Female; D005938:Glucocorticoids / Q000009:adverse effects / Q000494:pharmacology / Q000627:therapeutic use; D006801:Humans; D007247:Infertility, Female / Q000209:etiology*; D010298:Parity; D011241:Prednisone / Q000009:adverse effects / Q000494:pharmacology / Q000627:therapeutic use; D011247:Pregnancy; D011446:Prospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D016019:Survival Analysis; D061685:Time-to-Pregnancy / Q000187:drug effects
D000894:Anti-Inflammatory Agents, Non-Steroidal; D005938:Glucocorticoids; D011241:Prednisone
DAS28; NSAIDs; Rheumatoid Arthritis