Risk factors for flare and treatment of disease flares during pregnancy in rheumatoid arthritis and axial spondyloarthritis patients.
During pregnancy, patients with rheumatoid arthritis (RA) and axial spondyloarthritis (axSpA) can experience active disease, which might be influenced by adjustment of treatment around conception. The aim of this study was to identify possible risk factors of disease flares during pregnancy and to evaluate the effect of treatment in pregnant patients experiencing a flare.



Pregnant patients with RA and axSpA were prospectively followed before, during, and after pregnancy. Disease activity and flares of disease activity were analyzed in regard to medication.



Among 136 pregnant patients, disease flares during pregnancy occurred in 29% of patients with RA and in 25% of patients with axSpA. In both diseases, active disease and tumor necrosis factor inhibitor (TNFi) discontinuation in early pregnancy were identified as risk factors for disease flares during pregnancy. Of 75 patients with RA, 15 patients were on TNFi and discontinued the treatment at the time of the positive pregnancy test. After stopping TNFi, disease activity increased, which was reflected by peaking C-reactive protein levels at the first trimester. The relative risk of flare in patients with RA stopping TNFi was 3.33 (95% CI 1.8-6.1). Initiation of TNFi or glucocorticosteroid (GC) treatment in 60% of these patients resulted in disease improvement at the second and third trimesters. In comparison, patients with RA without TNFi in the preconception period, most of whom had used pregnancy-compatible antirheumatic drugs, showed mild and stable disease activity before and during pregnancy. Of 61 patients with axSpA, 24 patients were on TNFi and discontinued the treatment at the time of the positive pregnancy test. In patients with axSpA stopping TNFi, a disease aggravation at the second trimester could be observed. The relative risk of flare in this group was 3.08 (95% CI 1.2-7.9). In spite of initiated TNFi or GC treatment in 62.5% of these patients, disease activity remained elevated throughout pregnancy. Patients with axSpA without TNFi in the preconception period showed persistent high disease activity from prepregnancy until the postpartum period.



On the basis of a risk-benefit analysis, to stabilize disease activity and to prevent a flare during pregnancy in patients with RA and axSpA, tailored medication including TNF inhibitors should be considered beyond conception.
Department of Rheumatology, Immunology and Allergology, University Hospital, University of Bern, Freiburgstrasse 8, 3010, Bern, Switzerland.|Clinical Immunology and Rheumatology, Academic Medical Center/University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands.
Stephanie
0000-0002-8241-4869
S
van den Brandt
Department of Rheumatology, Immunology and Allergology, University Hospital, University of Bern, Freiburgstrasse 8, 3010, Bern, Switzerland.
Astrid
A
Zbinden
Clinical Immunology and Rheumatology, Academic Medical Center/University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands.
Dominique
D
Baeten
Department of Rheumatology, Immunology and Allergology, University Hospital, University of Bern, Freiburgstrasse 8, 3010, Bern, Switzerland.
Peter M
PM
Villiger
Department of Rheumatology, Immunology and Allergology, University Hospital, University of Bern, Freiburgstrasse 8, 3010, Bern, Switzerland.
Monika
M
Østensen
Department of Rheumatology, Immunology and Allergology, University Hospital, University of Bern, Freiburgstrasse 8, 3010, Bern, Switzerland. frauke.foerger@insel.ch.
Frauke
F
Förger
D000293:Adolescent; D000328:Adult; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000627:therapeutic use; D018501:Antirheumatic Agents / Q000627:therapeutic use*; D001172:Arthritis, Rheumatoid / Q000150:complications / Q000188:drug therapy*; D018450:Disease Progression; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D011247:Pregnancy; D011248:Pregnancy Complications / Q000188:drug therapy*; D011446:Prospective Studies; D018570:Risk Assessment / Q000379:methods / Q000706:statistics & numerical data; D012307:Risk Factors; D012720:Severity of Illness Index; D013167:Spondylitis, Ankylosing / Q000150:complications / Q000188:drug therapy*; D014409:Tumor Necrosis Factor-alpha / Q000037:antagonists & inhibitors; D055815:Young Adult
D000894:Anti-Inflammatory Agents, Non-Steroidal; D018501:Antirheumatic Agents; D014409:Tumor Necrosis Factor-alpha
Axial spondyloarthritis; Pregnancy; Rheumatoid arthritis; Treatment; Tumor necrosis factor inhibitors