Editorial Open Access
Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Rheumatol. Jul 12, 2015; 5(2): 50-58
Published online Jul 12, 2015. doi: 10.5499/wjr.v5.i2.50
Use of biologic agents for rheumatic diseases in pregnancy
Yesim Garip
Yesim Garip, Department of Physical Medicine and Rehabilitation, 06934 Sincan, Ankara, Turkey
Yesim Garip, Department of Physical Medicine and Rehabilitation, Pinar Physical Therapy and Rehabilitation Center, 06010 Kecioren, Ankara, Turkey
Author contributions: Garip Y solely contributed to this manuscript.
Conflict-of-interest statement: Yesim Garip declares that she has no conflict of interest.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Yesim Garip, MD, Specialist, Department of Physical Medicine and Rehabilitation, Pinar Physical Therapy and Rehabilitation Center, Baglarbasi Mah Bursa Cad no 20, 06010 Kecioren, Ankara, Turkey. dryesimgarip@gmail.com
Telephone: +90-536-5844332 Fax: +90-312-2691718
Received: January 22, 2015
Peer-review started: January 24, 2015
First decision: February 7, 2015
Revised: April 29, 2015
Accepted: May 5, 2015
Article in press: May 6, 2015
Published online: July 12, 2015

Abstract

Biologic agents have ushered a new era in the treatment of inflammatory rheumatic diseases. In recent years, several biologic agents have been approved by food and drug administration and have significantly improved outcomes for patients with immune mediated inflammatory disorders including rheumatic and inflammatory bowel diseases. The most common used biologic therapeutic agents are tumor necrosis factor inhibitors (etanercept, infliximab, adalimumab, certolizumab pegol, and golimumab), an interleukin (IL)-6 inhibitor (tocilizumab), an IL-1 receptor antagonist (anakinra), an anti-CD-20 antibody (rituximab), and a T cell co-stimulation modulator (abatacept). Their use during pregnancy has been controversial because of absence of controlled studies which have enrolled pregnant women. This brief overview provides published data on use of biologic agents for the treatment of rheumatic diseases in pregnancy.

Key Words: Ankylosing spondylitis, Rheumatoid arthritis, Pregnancy, Disease-modifying antirheumatic drugs

Core tip: Biologic agents are increasingly being used in the treatment of rheumatic diseases. This article presents published data on use of biologic agents in pregnant women with rheumatic diseases.



INTRODUCTION

Most of the women with rheumatic diseases experience clinical remission during pregnancy, however in some cases, it is needed to continue the treatment throughout pregnancy[1,2]. Few studies have suggested that high disease activity in rheumatic diseases throughout pregnancy may lead to increased risks for preeclampsia[3], cesarean delivery[4], prematurity[5], low birth weight[6,7], and intrauterine growth restriction[4]. Owing to the fact that important antirheumatic agents such as methotrexate and leflunomide have teratogenic effects, the treatment options are limited, and biological agents may be therapeutic alternative in pregnant women with high disease activity.

Since cytokines play a crucial role in host defense against infections, cytokine blockade is associated with increased risk of opportunistic infections. Previous studies have suggested an increased risk of bacterial, viral and fungal infections due to mycobacterium[8], salmonella, listeria[9], hepatitis B and C, herpes[10], histoplasma, cryptococcus, coccidioides, candida, aspergillus and pneumocystis[11]. Pregnancy is a period of relative immunosuppression, thus use of biologic agents during pregnancy may further increase the risk of infections[12].

Since no drug trials have been performed in pregnant women to assess the risk of administration of biologic agents, safety of these agents during pregnancy is still a matter of debate. However, cumulative data suggest that frequency of birth defects after prenatal exposure to biologic agents does not seem to be higher than that occurs in the general population[13].

Search strategy

A PubMed literature search (2000-2015) was performed to identify studies with human data on pregnancy outcomes after exposure to biologic agents during pregnancy. Search strategy was restricted to the articles published in English and Turkish and included the following search terms “tumor necrosis factor (TNF) inhibitors”, “etanercept”, “infliximab”, “adalimumab”, “certolizumab”, “golimumab”, “tocilizumab”, “anakinra”, “rituximab”, “abatacept”, and “pregnancy”. First, titles and abstracts of all 931 references were screened; articles which have insufficient data or do not address the topic of the interest were excluded. Inclusion criteria were data on pregnancy outcomes in patients who were exposed to biologic agents before conception and throughout pregnancy. Additionally a hand-search was made looking for the reference lists of the applicable publications. Adequate documentation was found in 10 reviews, 10 registries, 17 case series and 18 case reports. Published data on reports of biologic therapies are summarized in Table 1.

Table 1 An overview of published data from case reports, case series and registries on biologic agents.
Ref.Study designNo. of pregnanciesDiagnosisBiologic agentTime of exposureReported outcomes
Bortlik et al[16]Case series4127 CD 14 UKINF ETANR5 spontaneous abortion 2 elective termination 1 congenital malformation (mild hip dysplasia)
Burt et al[19]Case report1CDINFT1Healthy infant at 36 wk of gestation
Sinha and Patient[20]Case report1RAETAC + T1 + T2 + T3Healthy term delivery
Takayama et al[21]Case report1BDINFT2 + T3 (discontinued at 32 wk of gestation)Healthy term delivery
Coburn et al[22]Case report1CDADAT2 + T3Healthy term delivery
Akinci et al[23]Case report1ASINFT2 + T3Healthy term delivery
Kraemer et al[24]Case report1Takayasu arteritisADAC + T1 + T2 + T3Healthy term delivery
Hou et al[25]Case report1CDINFT1 + T2 + T3 (discontinued at 33 wk of gestation)Healthy term delivery
Umeda et al[26]Case report1RAETAT2 + T3Healthy term delivery
Puig et al[27]Case report1PsoriasisINFT1 + T2 + T3 (last infusion at 29 wk of gestation)Healthy term delivery
Jang et al[28]Case report1CDINFC + T1Healthy term delivery
Vesga et al[29]Case report1CDADAC + T1 + T2 + T3Healthy term delivery
Mahadevan et al[30]Case series10CDINFNR10 live birth 3 premature delivery 0 spontaneous abortion 0 elective termination 0 congenital malformation
Berthelot et al[31]Case series15SpA, RA, JIA, PsA3 INF 2 ADA 10 ETANR2 spontaneous abortion (ETA) 1 elective termination (ETA)
Rump et al[33]Case series8 pregnancies in 5 women4 RA 1 ASETANR1 spontaneous abortion 1 megacolon congenitum
Arguelles-Arias et al[34]Case series128 CD 4 UKINF1 C 2 T1 3 T1 + T2 6 T1 + T2 + T31 premature delivery No congenital malformation, IUGR, SGA
Diav-Citrin et al[35]Registry83CD, RA, UK, UndA, PsA, AS, BD35 INF 25 ETA 23 ADA81 T1 2 T2 or T367 live birth 9 spontaneous abortion 5 elective termination 0 congenital malformation
Chakravarty et al[36]Registry17RA15 ETA 2 INFNR1 spontaneous abortion (ETA) 1 elective termination (ETA) No congenital malformation, IUGR, SGA
Hyrich et al[37]Registry23RA17 ETA 3 INF 3 ADANR14 live births 6 spontaneous abortion (4 ETA, 1 INF, 1 ADA) 3 elective termination (all in patients receiving ETA, 2 also receiving MTX)
Carter et al[38]Registry41Autoimmune diseases22 ETA 19 INFNR24 (59%) children had one or more congenital deformities such as vertebral deformities, anal atresia, cardiac anomalies, tracheoesophageal fistula, renal anomalies and limb defects, which were the features of VACTERL
Offiah et al[40]Case report1PsAINFC + T1 + T2 + T3Transient collodion membrane
Guiddir et al[41]Case series4UKINFT1 + T2 + T34 neonatal neutropenia
Grosen et al[44]Case report1UKINFT3Ten days after INF infusion serum sickness-like reaction in the mother (at 35 wk of gestation) Preterm infant without any congenital anomaly
Ergaz et al[45]Case report1RAETA (also receiving prednisone and hydroxychloroquineC + T1 + T2 + T3Congenital fulminant kaposiform hemangioendothelioma
Hultzsch et al[46]Case series2619 RA 6 AS 1 PsAETAT119 live birth 5 premature delivery 5 spontaneous abortion 2 elective termination 1 congenital renal agenesis 1 hypoplastic left heart syndrome + hypospadias 1 Wolff Parkinson White syndrome
Weber-Schoendorfer et al[47]Case series53Autoimmune diseases28 ADA 25 INFT146 live birth (24 ADA, 22 INF) 8 premature delivery (4 ADA, 4 INF) 4 spontaneous abortion (2 ADA, 2 INF) 3 elective termination (2 ADA, 1 INF) 1 autosomal disease inherited from his father (ADA) 1 ventricular septal defect (INF)
Johnson et al[48]Case series34RAADAT129 live birth 5 spontaneous abortion 1 undescended testicle 1 microcephaly
Katz et al[49]Registry6482 CD 8 RA 2 JRA 1 UKINF53 within 3 mo of C 25 within 3 mo prior to C 28 within 3 mo prior to C + T1 30 T1 7 > 3 mo prior to C 6 unknown64 live birth 14 spontaneous abortion 18 therapeutic termination 0 congenital malformation
Cheent et al[50]Case report1CDINFC + T1 + T2 + T3No congenital malformation, IUGR BCG vaccination at age of 3 mo Died from disseminated BCG disease at age of 4.5 mo
Mahadevan et al[51]Registry190124 CD 56 other diseasesCZPNR132 live birth 36 spontaneous abortion 22 elective termination vesicoureteral reflux, congenital morbus, congenital megacolon, congenital talipes equinovarus, aortic arch anomaly, and unilateral hydronephrosis in four infants
Lau et al[56]Case series4024 RA 1 PsA 5 AS 10 UKGLMNR19 live birth 13 spontaneous abortion 7 induced abortion 1 ectopic pregnancy 1 unspecific congenital malformation leading to intrauterine death and induced abortion
Berger et al[57]Case report1AOSDAnakinraC + T1 + T2 + T3Term delivery complicated with placental retention
Chang et al[59]Case series9CAPSAnakinraC + T1 + T2 + T3No preterm birth or serious complication Fetal loss of a twin due to renal agenesis. DNA testing revealed the same NLRP3 c.785T > C, p.V262A mutation as the mother
Rubbert-Roth et al[60]Registry33RATCZNR7 spontaneous abortion 13 elective termination 11 term delivery (1 infant died from ARDS 3 d after emergency cesarean section for intrapartum fetomaternal hemorrhage due to placenta previa)
Ojeda-Uribe et al[61]Case series3Autoimmune diseases2 RTX 1 abataceptT13 healthy term delivery
Chakravarty et al[64]Registry153Autoimmune diseasesRTXNR90 live birth 33 spontaneous abortion 28 elective termination 22 premature delivery 1 maternal death from autoimmune thrombocytopenia 1 perinatal death 11 perinatal hematologic anomalies 4 perinatal infections 1 congenital talipes equinovarus 1 cardiac malformation
Sangle et al[65]Case series65 SLE 1 WGRTX8-22 mo prior to C4 healthy term delivery (3 SLE, 1 WG) 1 preterm low birth weight (SLE) 1 esophageal atresia (SLE)
Pendergraft et al[66]Case report1Autoimmune vasculitisRTX7.5 mo prior to CSpontaneous abortion (Beckwith-Wiedemann Syndrome)
USE OF ANTI-CYTOKINES DURING PREGNANCY
Tumor necrosis factor inhibitors

Efficacy of TNF inhibitors has been demonstrated in reducing disease activity and joint damage and improving health-related quality of life in the patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA), juvenile idiopathic arthritis (JIA), and ankylosing spondylitis[14]. Most frequently used TNF inhibitors include etanercept, a soluble p75 TNF-receptor and IgG1 Fc fusion protein; infliximab, a human-murine IgG1 anti-TNF monoclonal antibody; adalimumab, a human IgG1 anti-TNF monoclonal antibody; certolizumab pegol, a pegylated Fab fragment of humanized anti-TNF monoclonal antibody; and golimumab, fully humanized TNF-alpha monoclonal antibody[15].

TNF inhibitors have been rated as Food and Drug Administration (FDA) category B (No evidence of a risk to the fetus was found in animal toxicity studies; however there are no controlled studies which have enrolled pregnant women). TNF inhibitors do not actively cross the placenta during the first trimester and organogenesis, but they are transferred across the placenta during the late second and third trimester[12]. These can be found in newborn’s cord blood in levels that exceed those of the corresponding maternal serum[16,17]. Additionally, they are detectable in blood of the infant for more than six months after the birth, reducing the safety of vaccination[16]. Certolizumab does not contain Fc region, thus it does not actively cross the placenta[18].

Use of TNF inhibitors has been reported in almost 2000 pregnancies of the patients with rheumatic diseases, inflammatory bowel diseases and psoriasis. Based on the published data from case reports[19-29], case series[30-34] and registries on etanercept, infliximab, adalimumab, golimumab and certolizumab[35-37], it has been found that preconception exposure to biologic agents or use of them during pregnancy including first, second and third trimesters is not associated with increased risk of adverse pregnancy outcomes, malformations or birth defects compared with general population.

An FDA database review revealed 61 birth defects in 41 children born to mothers receiving TNF inhibitors[38]. Of these mothers, 22 received etanercept and 19 received infliximab. The most common congenital anomalies were heart defects, spinal deformities, imperforate anus, tracheoesophageal fistula, renal anomalies and limb defects, which were the features of vertebral defects, anal atresia, cardiac defects, tracheo-esophageal fistula, renal anomalies, and limb abnormalities association. These anomalies were found to be linked with use of TNF antagonists and it was suggested that these agents should not be administered during pregnancy.

British society for rheumatology biologics register (BSRBR) is a database which keeps information about RA patients taking TNF antagonists. Between 2005 and 2006, 11473 patients were registered with the BSRBR. Of these patients, 17 received etanercept, 3 received infliximab and 3 received adalimumab. No congenital malformation was observed[37]. After this report, another BSRBR report which assesses the outcomes of 118 pregnancies in patients who were exposed to TNF antagonists was published in 2008[39]. The rate of miscarriage was 27% in the patients who received anti-TNF at the time of conception (group 1), 17% in those with prior exposure to anti-TNF (group 2) and 10% in those who were never exposed to anti-TNF (group 3). The rate of premature delivery was 26% in group 1, 17% in group 2, and 20% in group 3. A perinatal death causing from hypoxia was reported in a patient who was exposed to etanercept at the time of conception. Additionally four cases of congenital anomalies were reported. In group 1, congenital hip dysplasia and pylorostenosis, and in group 2 Marcus Gunn syndrome and infantile hemangioma were observed. The authors suggested that treatment with TNF inhibitors might be linked with an increased risk of spontaneous abortion, however the effects of disease activity and other antirheumatic agents could not be eliminated.

Offiah et al[40] reported a transient collodion membrane in a 2-d-old infant born to mother receiving infliximab for severe psoriasis and PsA throughout pregnancy in United States. The skin turned to normal at age 1 year with mineral oil treatment.

Guiddir et al[41] reported four cases of severe neutropenia in newborn patients exposed to infliximab. High serum infliximab concentrations were detected several months after birth. It was suggested that the mononuclear phagocyte system of a newborn is inadequate to clear the antibody rapidly.

Tetralogy of Fallot, intestinal malrotation, hypothyroidism, intracranial and intrapulmonary hemorrhage, unilateral renal agenesis, serum sickness-like reaction (with infliximab)[35,42-44], infantile kaposiform hemangioendothelioma, Kasabach-Merritt syndrome, renal agenesis, urethral defects, cardiac conduction system abnormalities, pylorostenosis, congenital megacolon (with etanercept)[32,39,45,46], and ventricular septal defect, congenital hip dysplasia, spina bifida with hydrocephalus, aortic valve disease, corpus callosum agenesis, and congenital hypothyroidism (with adalimumab)[47,48] have been reported in the babies born to mothers directly exposed to TNF inhibitors during pregnancy. However rates of these anomalies have been found to be similar to those expected for the general population[35,46,49].

Cheent et al[50] reported use of infliximab during pregnancy in a 28-year-old patient with Crohn’s disease. Newborn had no congenital malformation or intrauterine growth retardation. He was healthy until bacillus calmette-guerin (BCG) vaccine administered at the age of three months. One point five months later he died from disseminated BCG disease which was a rare life-threatening complication of BCG administration.

Certolizumab is different from other TNF inhibitors, it does not contain Fc region, thus it is not actively transported through the placenta[16]. It has only minimal transplacental transmission to newborn via passive diffusion during first, second and third trimesters[17].

The Union Chimique Belge Pharma global safety database revealed 69.5% live birth rate in 190 pregnant women exposed to certolizumab[51]. The rates of spontaneous abortions and elective terminations were 18.9% and 11.6%, respectively. Six birth defects were observed in four infants among all live births: vesicoureteral reflux, congenital morbus, congenital megacolon, congenital talipes equinovarus, aortic arch anomaly, and unilateral hydronephrosis. However these congenital anomalies were not thought to be associated with exposure to certolizumab. These pregnancy outcomes were comparable to those reported for united states general population (65% live births, 17% spontaneous abortions, and 18% elective abortions)[52]. In Pregnancy in Inflammatory Bowel Diseases and Neonatal Outcomes study[53] where women with inflammatory bowel disease exposed to certolizumab in the third trimester of pregnancy were compared with unexposed group, it was suggested that use of certolizumab in the third trimester was not associated with increase in infant infection rates.

Golimumab is a newer TNF inhibitor and there is limited data on its use during pregnancy[54]. In a study by Martin et al[55] performed in cynomolgus monkeys received 25-50 mg/kg golimumab twice weekly during pregnancy, no effect was observed on pregnancy outcomes or fetal immune system. Experience with use of golimumab during pregnancy has been limited to conference abstracts. Lau et al[56] reported pregnancy outcomes of 40 women exposed to golimumab at the American College of Rheumatology (ACR) Annual Meeting in 2013. Outcomes included one unspecific congenital anomaly, 19 live births, 13 spontaneous abortions and 7 induced abortions. Of 13 mothers with spontaneous abortion, 4 had concomitant methotrexate use.

Anakinra

Anakinra is a human IL-1 receptor antagonist certified by FDA for the therapy of RA patients with intermediate/high disease activity[14]. It has been rated as FDA pregnancy category B. It has a half-life of 4-6 h. Because of its short half-life, discontinuance of anakinra before conception is not necessary[18]. Experiences with use of anakinra during pregnancy are limited. Three pregnancies in patients received anakinra for the treatment of adult onset Still’s disease resulted in term live births[57,58]. Chang et al[59] described outcomes of fifteen pregnancies in nine women receiving anakinra for the treatment of cryopyrin-associated periodic syndrome. Outcomes included 14 healthy term infants and one intrauterine fetal demise resulting from renal agenesis.

Tocilizumab

Tocilizumab is a humanized IL-6 receptor inhibitor used in the therapy of moderate to severe RA and polyarticular and systemic JIA. It is categorized as FDA pregnancy category C. Tocilizumab should be discontinued three months before conception[18]. Experiences with use of tocilizumab during pregnancy were reported by Rubbert-Roth et al[60] at the ACR Annual Meeting in 2010. Of 33 pregnancies, 13 resulted in induced abortion, 7 resulted in spontaneous abortion and 11 resulted in live births. Of 7 mothers with spontaneous abortion, 5 had concomitant methotrexate use.

ANTI-CELLULAR THERAPY DURING PREGNANCY
Rituximab

Rituximab is a chimeric monoclonal antibody against the B cell surface antigen CD20[61]. It is indicated for the treatment of severe refractory RA with inadequate response to TNF inhibitors, certain types of vasculitis, non-Hodgkin’s lymphoma and chronic lymphoid leukemia[42]. It is classified as FDA category C, meaning “it has not been studied on pregnant women, however animal developmental toxicity studies have shown an adverse effects on the fetus”. It has no active transplacental passage during the first trimester and organogenesis, but actively crosses the placenta during the late second and third trimester[62], and may affect fetal and neonatal B cell development, causing increased risk for infections[63]. Chakravarty et al[64] reported pregnancy outcomes in 153 patients exposed to rituximab. Of these pregnancies, 90 resulted in live births, 22 resulted in prematurity and one resulted in perinatal death. 11 infants had hematologic abnormalities at birth (peripheral B-cell depletion, neutropenia, lymphopenia, thrombocytopenia and anemia) and four had perinatal infections. Two infants had congenital defects (congenital talipes equinovarus and cardiac malformation). Sangle et al[65] reported pregnancy outcomes in 5 patients with systemic lupus erythematosus exposed to rituximab before conception. One of the infants was born with esophageal atresia, while the others were healthy. Pendergraft et al[66] reported a miscarriage at 15 wk in a mother exposed to rituximab 7.5 mo prior to conception. Histologic and genetic evaluation of fetus revealed Beckwith-Wiedemann Syndrome. Ojeda-Uribe et al[61] reported two successful outcomes in two women with autoimmune diseases received rituximab in the first trimester of pregnancy.

Preconception and first trimester exposure to rituximab seems not to indicate an excess risk of adverse fetal outcomes. Exposure during second and third trimesters causes decrease in B cells in the fetus[18]. Further studies, especially prospective registries are needed to explore immune response to vaccines and perinatal infections in infants born to mothers received rituximab during second and third trimesters.

Abatacept

Abatacept (CTLA4-Ig) is a recombinant fusion protein that modulates T cell costimulatory signal mediated through the CD28-CD80/86 pathway[67]. It has been approved for the treatment of refractory RA[4]. Abatacept therapy should be stopped three months before conception[18]. Ojeda-Uribe et al[61] reported a healthy infant born to a 33-year-old mother exposed to abatacept in the first trimester.

CONCLUSION

Since TNF inhibitors are classified in FDA category B, they are safer than synthetic Disease Modifying Anti Rheumatic Drugs such as methotrexate and leflunomide. Although sporadic cases of congenital malformations have been reported in newborns born to mothers exposed to biologics, these rates appear to be comparable with those expected in the general population. Maternal exposure to TNF inhibitors at conception seems not to be related to adverse pregnancy outcomes. TNF inhibitors do not pass through the placenta during the first trimester, but they cross the placenta during the late second and third trimester. They can be used in the first trimester if no therapeutic alternative is available. But use of these agents in late second and third trimester should be reconsidered more carefully because of high placental transfer. Collected experience does not suggest an increased risk of opportunistic infections in pregnant patients and fetus. However, in case of exposure to these agents in the late second and third trimester, live vaccines should not be administered in the first six months of life because of increased risk for infections.

Abatacept and tocilizumab are classified as FDA pregnancy category C, and they should be discontinued three months before conception. Experiences with use of anakinra and rituximab during pregnancy are limited, larger studies are needed to bring further clarity.

The decision to use biologic agents during pregnancy is difficult. The benefits of biologic agents must outweigh the risks to the fetus/embryo or the mother. Larger and further studies are needed to demonstrate the safety of these agents during pregnancy.

Footnotes

P- Reviewer: Chizzolini C, Martinez-Lostao L, Nas K, Rothschild BM, Song J S- Editor: Ji FF L- Editor: A E- Editor: Jiao XK

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