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Louchet M, Tisseyre M, Kaguelidou F, Treluyer JM, Préta LH, Chouchana L. Drug-induced fetal and offspring disorders, beyond birth defects. Therapie 2024; 79:205-219. [PMID: 38008599 DOI: 10.1016/j.therap.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 11/09/2023] [Indexed: 11/28/2023]
Abstract
Studies on drug utilization in western countries disclosed that about nine over ten women use at least one or more drugs during pregnancy. Determining whether a drug is safe or not in pregnant women is a challenge of all times. As a developing organism, the fetus is particularly vulnerable to effects of drugs used by the mother. Historically, research has predominantly focused on birth defects, which represent the most studied adverse pregnancy outcomes. However, drugs can also alter the ongoing process of pregnancy and impede the general growth of the fetus. Finally, adverse drug reactions can theoretically damage all developing systems, organs or tissues, such as the central nervous system or the immune system. This extensive review focuses on different aspects of drug-induced damages affecting the fetus or the newborn/infant, beyond birth defects, which are not addressed here.
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Affiliation(s)
- Margaux Louchet
- URP 7323 "Pharmacologie et évaluation des thérapeutiques chez l'enfant et la femme enceinte", Université Paris Cité, 75000 Paris, France; Service de gynécologie-obstétrique, Fédération hospitalo-universitaire PREMA, hôpital Louis-Mourier, AP-HP Nord - Université Paris Cité, 75000 Paris, France
| | - Mylène Tisseyre
- URP 7323 "Pharmacologie et évaluation des thérapeutiques chez l'enfant et la femme enceinte", Université Paris Cité, 75000 Paris, France; Centre régional de pharmacovigilance, service de pharmacologie périnatale, pédiatrique et adulte, hôpitaux Cochin-Necker, AP-HP Centre - Université Paris Cité, 75000 Paris, France
| | - Florentia Kaguelidou
- URP 7323 "Pharmacologie et évaluation des thérapeutiques chez l'enfant et la femme enceinte", Université Paris Cité, 75000 Paris, France; Centre d'investigation clinique pédiatrique, Inserm CIC 1426, hôpital Robert-Debré, AP-HP Nord - Université Paris Cité, 75000 Paris, France
| | - Jean-Marc Treluyer
- URP 7323 "Pharmacologie et évaluation des thérapeutiques chez l'enfant et la femme enceinte", Université Paris Cité, 75000 Paris, France; Centre régional de pharmacovigilance, service de pharmacologie périnatale, pédiatrique et adulte, hôpitaux Cochin-Necker, AP-HP Centre - Université Paris Cité, 75000 Paris, France
| | - Laure-Hélène Préta
- URP 7323 "Pharmacologie et évaluation des thérapeutiques chez l'enfant et la femme enceinte", Université Paris Cité, 75000 Paris, France
| | - Laurent Chouchana
- URP 7323 "Pharmacologie et évaluation des thérapeutiques chez l'enfant et la femme enceinte", Université Paris Cité, 75000 Paris, France; Centre régional de pharmacovigilance, service de pharmacologie périnatale, pédiatrique et adulte, hôpitaux Cochin-Necker, AP-HP Centre - Université Paris Cité, 75000 Paris, France.
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Mettler C, Beeker N, Collier M, Le Guern V, Terrier B, Chouchana L. Risk of Hypertensive Disorders and Preterm Birth in Pregnant Women With Systemic Vasculitides: A Nationwide Population-Based Cohort Study. Arthritis Rheumatol 2024; 76:429-437. [PMID: 37936542 DOI: 10.1002/art.42747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 09/29/2023] [Accepted: 10/23/2023] [Indexed: 11/09/2023]
Abstract
OBJECTIVE Even though systemic vasculitides (SVs) affect primarily patients over 50 years of age, they can occur among women of childbearing age. Preterm birth (PTB) and hypertensive disorders are frequent complications of pregnancy in SVs. This study aims to evaluate the risk of hypertensive disorders and PTB among pregnant women with SVs, and to identify associated risk factors. METHOD Using the French health insurance data warehouse, we conducted a nationwide cohort study including all pregnancies between 2013 and 2018 in women with SVs. Theses pregnancies were matched to pregnancies among women without SVs. We estimated risk of hypertensive disorders and PTB risk during pregnancy among women with SVs and investigated associated risk factors using a nested case-control design. RESULTS Among 3,155,723 pregnancies, we identified 646 pregnancies in women with SVs, matched to 3,230 controls. SVs were significantly associated with hypertensive disorders (odds ratio [OR] 1.7, 95% confidence interval [95% CI] 1.3-2.2) and PTB (OR 1.8, 95% CI 1.4-2.3). Chronic renal failure before pregnancy, history of or treated arterial hypertension, the occurrence of vasculitides flare during pregnancy, and the subgroup of SVs were independently associated with the occurrence of hypertensive disorders. Maternal age at delivery, chronic renal failure before conception, and the occurrence of vasculitides flare during pregnancy were independently associated with the occurrence of PTB. CONCLUSION About one of seven pregnancies in women with SVs is associated with hypertensive disorders or preterm birth. The occurrence of vasculitides flare was associated with these complications. Our findings support the importance of prepregnancy counseling to ensure disease stability.
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Affiliation(s)
- Camille Mettler
- Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Nathanael Beeker
- Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Mathis Collier
- Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France
| | | | - Benjamin Terrier
- Hôpital Cochin, Assistance Publique-Hôpitaux de Paris and Université Paris Cité, Paris, France
| | - Laurent Chouchana
- Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France
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3
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Sun Y, Cui L, Lu Y, Tan J, Dong X, Ni T, Yan J, Guan Y, Hao G, Liu JY, Zhang B, Wei D, Hong Y, He Y, Qi J, Xu B, Lu J, Zhang Q, Zhao S, Ji X, Du X, Zhang J, Liu J, Wang J, Huang Y, Huang D, Du Y, Vankelecom H, Zhang H, Chen ZJ. Prednisone vs Placebo and Live Birth in Patients With Recurrent Implantation Failure Undergoing In Vitro Fertilization: A Randomized Clinical Trial. JAMA 2023; 329:1460-1468. [PMID: 37129654 PMCID: PMC10155063 DOI: 10.1001/jama.2023.5302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 03/18/2023] [Indexed: 05/03/2023]
Abstract
Importance Implantation failure remains a critical barrier to in vitro fertilization. Prednisone, as an immune-regulatory agent, is widely used to improve the probability of implantation and pregnancy, although the evidence for efficacy is inadequate. Objective To determine the efficacy of 10 mg of prednisone compared with placebo on live birth among women with recurrent implantation failure. Design, Setting, and Participants A double-blind, placebo-controlled, randomized clinical trial conducted at 8 fertility centers in China. Eligible women who had a history of 2 or more unsuccessful embryo transfer cycles, were younger than 38 years when oocytes were retrieved, and were planning to undergo frozen-thawed embryo transfer with the availability of good-quality embryos were enrolled from November 2018 to August 2020 (final follow-up August 2021). Interventions Participants were randomized (1:1) to receive oral pills containing either 10 mg of prednisone (n = 357) or matching placebo (n = 358) once daily, from the day at which they started endometrial preparation for frozen-thawed embryo transfer through early pregnancy. Main Outcomes and Measures The primary outcome was live birth, defined as the delivery of any number of neonates born at 28 or more weeks' gestation with signs of life. Results Among 715 women randomized (mean age, 32 years), 714 (99.9%) had data available on live birth outcomes and were included in the primary analysis. Live birth occurred among 37.8% of women (135 of 357) in the prednisone group vs 38.8% of women (139 of 358) in the placebo group (absolute difference, -1.0% [95% CI, -8.1% to 6.1%]; relative ratio [RR], 0.97 [95% CI, 0.81 to 1.17]; P = .78). The rates of biochemical pregnancy loss were 17.3% in the prednisone group and 9.9% in the placebo group (absolute difference, 7.5% [95% CI, 0.6% to 14.3%]; RR, 1.75 [95% CI, 1.03 to 2.99]; P = .04). Of those in the prednisone group, preterm delivery occurred among 11.8% and of those in the placebo group, 5.5% of pregnancies (absolute difference, 6.3% [95% CI, 0.2% to 12.4%]; RR, 2.14 [95% CI, 1.00 to 4.58]; P = .04). There were no statistically significant between-group differences in the rates of biochemical pregnancy, clinical pregnancy, implantation, neonatal complications, congenital anomalies, other adverse events, or mean birthweights. Conclusions and Relevance Among patients with recurrent implantation failure, treatment with prednisone did not improve live birth rate compared with placebo. Data suggested that the use of prednisone may increase the risk of preterm delivery and biochemical pregnancy loss. Our results challenge the value of prednisone use in clinical practice for the treatment of recurrent implantation failure. Trial Registration Chinese Clinical Trial Registry Identifier: ChiCTR1800018783.
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Affiliation(s)
- Yun Sun
- Center for Reproductive Medicine, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory for Assisted Reproduction and Reproductive Genetics, Shanghai, China
| | - Linlin Cui
- Center for Reproductive Medicine, Shandong University, Jinan, China
- Key Laboratory of Reproductive Endocrinology of Ministry of Education, Shandong University, Jinan, China
- Shandong Key Laboratory of Reproductive Medicine, Jinan, China
- Shandong Provincial Clinical Research Center for Reproductive Health, Jinan, China
- Shandong Technology Innovation Center for Reproductive Health, Jinan, China
- National Research Center for Assisted Reproductive Technology and Reproductive Genetics, Shandong University, Jinan, China
| | - Yao Lu
- Center for Reproductive Medicine, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory for Assisted Reproduction and Reproductive Genetics, Shanghai, China
| | - Jichun Tan
- Center of Reproductive Medicine, Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China
- Key Laboratory of Reproductive Dysfunction Diseases and Fertility Remodeling of Liaoning Province, Shenyang, China
| | - Xi Dong
- Reproductive Medicine Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Tianxiang Ni
- Center for Reproductive Medicine, Shandong University, Jinan, China
- Key Laboratory of Reproductive Endocrinology of Ministry of Education, Shandong University, Jinan, China
- Shandong Key Laboratory of Reproductive Medicine, Jinan, China
- Shandong Provincial Clinical Research Center for Reproductive Health, Jinan, China
- Shandong Technology Innovation Center for Reproductive Health, Jinan, China
- National Research Center for Assisted Reproductive Technology and Reproductive Genetics, Shandong University, Jinan, China
| | - Junhao Yan
- Center for Reproductive Medicine, Shandong University, Jinan, China
- Key Laboratory of Reproductive Endocrinology of Ministry of Education, Shandong University, Jinan, China
- Shandong Key Laboratory of Reproductive Medicine, Jinan, China
- Shandong Provincial Clinical Research Center for Reproductive Health, Jinan, China
- Shandong Technology Innovation Center for Reproductive Health, Jinan, China
- National Research Center for Assisted Reproductive Technology and Reproductive Genetics, Shandong University, Jinan, China
| | - Yichun Guan
- Reproductive Medicine Center, the Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Guimin Hao
- Department of Reproductive Medicine, the Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Jia-Yin Liu
- Department of Reproductive Medicine, the First Affiliated Hospital of Nanjing Medical University/Jiangsu Province Hospital, Nanjing, China
| | - Bo Zhang
- Center for Reproductive Medicine, Maternal and Child Health Hospital/Obstetrics and Gynecology Hospital of Guangxi Zhuang Autonomous Region, Guangxi, China
| | - Daimin Wei
- Center for Reproductive Medicine, Shandong University, Jinan, China
- Key Laboratory of Reproductive Endocrinology of Ministry of Education, Shandong University, Jinan, China
- Shandong Key Laboratory of Reproductive Medicine, Jinan, China
- Shandong Provincial Clinical Research Center for Reproductive Health, Jinan, China
- Shandong Technology Innovation Center for Reproductive Health, Jinan, China
- National Research Center for Assisted Reproductive Technology and Reproductive Genetics, Shandong University, Jinan, China
| | - Yan Hong
- Center for Reproductive Medicine, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory for Assisted Reproduction and Reproductive Genetics, Shanghai, China
| | - Yaqiong He
- Center for Reproductive Medicine, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory for Assisted Reproduction and Reproductive Genetics, Shanghai, China
| | - Jia Qi
- Center for Reproductive Medicine, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory for Assisted Reproduction and Reproductive Genetics, Shanghai, China
| | - Bing Xu
- Center for Reproductive Medicine, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory for Assisted Reproduction and Reproductive Genetics, Shanghai, China
| | - Juanjuan Lu
- Center for Reproductive Medicine, Shandong University, Jinan, China
- Key Laboratory of Reproductive Endocrinology of Ministry of Education, Shandong University, Jinan, China
- Shandong Key Laboratory of Reproductive Medicine, Jinan, China
- Shandong Provincial Clinical Research Center for Reproductive Health, Jinan, China
- Shandong Technology Innovation Center for Reproductive Health, Jinan, China
- National Research Center for Assisted Reproductive Technology and Reproductive Genetics, Shandong University, Jinan, China
| | - Qian Zhang
- Center for Reproductive Medicine, Shandong University, Jinan, China
- Key Laboratory of Reproductive Endocrinology of Ministry of Education, Shandong University, Jinan, China
- Shandong Key Laboratory of Reproductive Medicine, Jinan, China
- Shandong Provincial Clinical Research Center for Reproductive Health, Jinan, China
- Shandong Technology Innovation Center for Reproductive Health, Jinan, China
- National Research Center for Assisted Reproductive Technology and Reproductive Genetics, Shandong University, Jinan, China
| | - Shanshan Zhao
- Center of Reproductive Medicine, Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China
- Key Laboratory of Reproductive Dysfunction Diseases and Fertility Remodeling of Liaoning Province, Shenyang, China
| | - Xiaowei Ji
- Reproductive Medicine Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiaofang Du
- Reproductive Medicine Center, the Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jie Zhang
- Department of Reproductive Medicine, the Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Jinyong Liu
- Department of Reproductive Medicine, the First Affiliated Hospital of Nanjing Medical University/Jiangsu Province Hospital, Nanjing, China
| | - Jing Wang
- Department of Reproductive Medicine, the First Affiliated Hospital of Nanjing Medical University/Jiangsu Province Hospital, Nanjing, China
| | - Yingqin Huang
- Center for Reproductive Medicine, Maternal and Child Health Hospital/Obstetrics and Gynecology Hospital of Guangxi Zhuang Autonomous Region, Guangxi, China
| | - Dongmei Huang
- Center for Reproductive Medicine, Maternal and Child Health Hospital/Obstetrics and Gynecology Hospital of Guangxi Zhuang Autonomous Region, Guangxi, China
| | - Yanzhi Du
- Center for Reproductive Medicine, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory for Assisted Reproduction and Reproductive Genetics, Shanghai, China
| | - Hugo Vankelecom
- Laboratory of Tissue Plasticity in Health and Disease, Cluster of Stem Cell and Developmental Biology, Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Heping Zhang
- Department of Biostatistics, Yale University School of Public Health, New Haven, Connecticut
| | - Zi-jiang Chen
- Center for Reproductive Medicine, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory for Assisted Reproduction and Reproductive Genetics, Shanghai, China
- Center for Reproductive Medicine, Shandong University, Jinan, China
- Key Laboratory of Reproductive Endocrinology of Ministry of Education, Shandong University, Jinan, China
- Shandong Key Laboratory of Reproductive Medicine, Jinan, China
- Shandong Provincial Clinical Research Center for Reproductive Health, Jinan, China
- Shandong Technology Innovation Center for Reproductive Health, Jinan, China
- National Research Center for Assisted Reproductive Technology and Reproductive Genetics, Shandong University, Jinan, China
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Kocatürk E, Al-Ahmad M, Krause K, Gimenez-Arnau AM, Thomsen SF, Conlon N, Marsland A, Savk E, Criado RF, Danilycheva I, Fomina D, Godse K, Khoshkhui M, Gelincik A, Degirmentepe EN, Demir S, Ensina LF, Kasperska-Zajac A, Rudenko M, Valle S, Medina I, Bauer A, Zhao Z, Staubach P, Bouillet L, Küçük ÖS, Baygül A, Maurer M. Treatment patterns and outcomes in patients with chronic urticaria during pregnancy: Results of PREG-CU, a UCARE study. J Eur Acad Dermatol Venereol 2023; 37:356-364. [PMID: 36066999 DOI: 10.1111/jdv.18574] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 08/17/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Although chronic urticaria (CU) is a common and primarily affects females, there is little data on how pregnancy interacts with the disease. OBJECTIVE To analyse the treatment use by CU patients before, during and after pregnancy as well as outcomes of pregnancy. METHODS PREG-CU is an international, multicentre study of the Urticaria Centers of Reference and Excellence network. Data were collected via a 47-item-questionnaire completed by CU patients who became pregnant during their disease course. RESULTS Questionnaires from 288 CU patients from 13 countries were analysed. During pregnancy, most patients (60%) used urticaria medication including standard-dose second generation H1-antihistamines (35.1%), first generation H1-antihistamines (7.6%), high-dose second-generation H1-antihistamines (5.6%) and omalizumab (5.6%). The preterm birth rate was 10.2%; rates were similar between patients who did and did not receive treatment during pregnancy (11.6% vs. 8.7%, respectively). Emergency referrals for CU and twin birth were risk factors for preterm birth. The caesarean delivery rate was 51.3%. More than 90% of new-borns were healthy at birth. There was no link between any patient or disease characteristics or treatments and medical problems at birth. CONCLUSION Most CU patients used treatment during pregnancy especially second-generation antihistamines which seem to be safe during pregnancy regardless of the trimester. The rates of preterm births and medical problems of new-borns in CU patients were similar to population norms and not linked to treatment used during pregnancy. Emergency referrals for CU increased the risk of preterm birth and emphasize the importance of sufficient treatment to keep urticaria under control during pregnancy.
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Affiliation(s)
- Emek Kocatürk
- Department of Dermatology, Urticaria Center of Reference, and Excellence (UCARE), Koç University School of Medicine, Istanbul, Turkey
- Institute of Allergology, Urticaria Center of Reference and Excellence (UCARE), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Allergology and Immunology, Fraunhofer Institute for Translational Medicine and Pharmacology (ITMP), Berlin, Germany
| | - Mona Al-Ahmad
- Microbiology Department, Faculty of Medicine, Urticaria Center of Reference, and Excellence (UCARE), Kuwait University, Safat, Kuwait
| | - Karoline Krause
- Institute of Allergology, Urticaria Center of Reference and Excellence (UCARE), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Allergology and Immunology, Fraunhofer Institute for Translational Medicine and Pharmacology (ITMP), Berlin, Germany
| | - Ana M Gimenez-Arnau
- Department of Dermatology, Urticaria Center of Reference, and Excellence (UCARE), Hospital del Mar, IMIM, Universitat Pompeu Fabra, Barcelona, Spain
| | - Simon Francis Thomsen
- Department of Dermatology, Urticaria Center of Reference, and Excellence (UCARE), Bispebjerg Hospital, Copenhagen, Denmark
| | - Niall Conlon
- Department of Immunology, Urticaria Center of Reference and Excellence (UCARE), St. James's Hospital, Dublin and Trinity College, Dublin, Ireland
| | - Alexander Marsland
- Department of Dermatology, Urticaria Center of Reference, and Excellence (UCARE), The Urticaria Clinic, Salford Royal Foundation Trust, University of Manchester, Manchester, UK
| | - Ekin Savk
- Aydın Adnan Menderes University, Aydın, Turkey
| | - Roberta F Criado
- Department of Dermatology, Urticaria Center of Reference and Excellence (UCARE), Faculdade de Medicina do ABC (FMABC), Santo André, Brazil
| | | | - Daria Fomina
- First Moscow State Medical University, Moscow, Russia
- Urticaria Center of Reference and Excellence (UCARE), Moscow Center of Allergy and Immunology, Clinical Hospital 52, Ministry of Moscow Healthcare, Moscow, Russia
| | - Kiran Godse
- Dr. D.Y. Patil Medical College & Hospital, Mumbai, India
| | - Maryam Khoshkhui
- Allergy Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Aslı Gelincik
- Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | | | - Semra Demir
- Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | | | - Alicja Kasperska-Zajac
- European Center for Diagnosis and Treatment of Urticaria (GA2LEN UCARE Network), Medical University of Silesia in Katowice, Katowice, Poland
| | | | - Solange Valle
- Federal University of Rio de Janeiro, Rio De Janeiro, Brazil
| | - Iris Medina
- The Centro Médico Vitae, Buenos Aires, Argentina
| | - Andrea Bauer
- Department of Dermatology, University Allergy Center, University Hospital Carl Gustav Carus, Technical University Dresden, Dresden, Germany
| | - Zuotao Zhao
- Department of Dermatology and Venerology, Beijing Key Laboratory of Molecular Diagnosis on Dermatoses and National Clinical Research Center for Skin and Immune Diseases, Peking University First Hospital, Beijing, China
| | - Petra Staubach
- Department of Dermatology, University Medical Center, Mainz, Germany
| | | | - Özlem Su Küçük
- Department of Dermatology and Venerology, Bezmialem Vakif University School of Medicine, Istanbul, Turkey
| | - Arzu Baygül
- Department of Biostatistics, Koç University School of Medicine, Istanbul, Turkey
| | - Marcus Maurer
- Institute of Allergology, Urticaria Center of Reference and Excellence (UCARE), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Allergology and Immunology, Fraunhofer Institute for Translational Medicine and Pharmacology (ITMP), Berlin, Germany
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Bobircă A, Simionescu AA, Mușetescu AE, Alexandru C, Bobircă F, Bojincă M, Bălănescu A, Micu M, Ancuța C, Sima R, Andreoli L, Ancuța I. Outcomes of Prospectively Followed Pregnancies in Rheumatoid Arthritis: A Multicenter Study from Romania. Life (Basel) 2023; 13:life13020359. [PMID: 36836715 PMCID: PMC9958673 DOI: 10.3390/life13020359] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 01/23/2023] [Accepted: 01/27/2023] [Indexed: 01/31/2023] Open
Abstract
Women with rheumatoid arthritis (RA) may carry an increased risk of adverse pregnancy outcomes (APO). The aims of this study were to compare pregnancy outcomes in RA patients as compared to the general obstetric population (GOP) and to identify a risk profile in RA. A case-control study was conducted on 82 prospectively followed pregnancies in RA and 299 pregnancies from the GOP. The mean age at conception was 31.50 ± 4.5 years, with a mean disease duration of 8.96 ± 6.3 years. The frequency of APO in RA patients was 41.5%, 18.3% experienced spontaneous abortions, 11.0% underwent preterm deliveries, 7.3% had small for gestational age infants, 4.9% experienced intrauterine growth restriction, 1.2% experienced stillbirth, and 1.2% suffered from eclampsia. The risk of APO was correlated with a maternal age higher than 35 years (p = 0.028, OR = 5.59). The rate of planned pregnancies was 76.8%, and the subfertility rate was 4.9%. Disease activity improved every trimester, and approximately 20% experienced an improvement in the second trimester. Planned pregnancies and corticosteroids use (≤10 mg daily) were protective factors for APO in RA pregnancies (p < 0.001, OR = 0.12, p = 0.016, OR = 0.19, respectively). There was no significant association between APO and disease activity or DMARDs used before and during pregnancy. Regarding the comparison between the RA group and the controls, RA mothers were significantly older (p = 0.001), had shorter pregnancies (p < 0.001), and had neonates with a lower birth weight (p < 0.001).
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Affiliation(s)
- Anca Bobircă
- Department of Internal Medicine and Rheumatology, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Department of Internal Medicine and Rheumatology, Dr. I. Cantacuzino Clinical Hospital, 011437 Bucharest, Romania
| | - Anca Angela Simionescu
- Department of Obstetrics and Gynecology, Filantropia Hospital, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Anca Emanuela Mușetescu
- Rheumatology Department, University of Medicine and Pharmacy of Craiova, 200638 Craiova, Romania
| | - Cristina Alexandru
- Department of Internal Medicine and Rheumatology, Dr. I. Cantacuzino Clinical Hospital, 011437 Bucharest, Romania
- Correspondence: (C.A.); (F.B.)
| | - Florin Bobircă
- Department of General Surgery, “Carol Davila” University of Medicine and Pharmacy, Dr. I. Cantacuzino Clinical Hospital, 011437 Bucharest, Romania
- Correspondence: (C.A.); (F.B.)
| | - Mihai Bojincă
- Department of Internal Medicine and Rheumatology, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Department of Internal Medicine and Rheumatology, Dr. I. Cantacuzino Clinical Hospital, 011437 Bucharest, Romania
| | - Andra Bălănescu
- Department of Internal Medicine and Rheumatology, “Sfanta Maria” Hospital, 011172 Bucharest, Romania
| | - Mihaela Micu
- Rheumatology Division, 2nd Rehabilitation Department, Rehabilitation Clinical Hospital, 400066 Cluj-Napoca, Romania
| | - Codrina Ancuța
- Rheumatology Department, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Romina Sima
- Department of Obstetrics and Gynaecology, The “Bucur” Maternity, “Saint John” Hospital, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Laura Andreoli
- Rheumatology and Clinical Immunology Unit, Spedali Civili, Department of Clinical and Experimental Sciences, University of Brescia, 25121 Brescia, Italy
| | - Ioan Ancuța
- Department of Internal Medicine and Rheumatology, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Department of Internal Medicine and Rheumatology, Dr. I. Cantacuzino Clinical Hospital, 011437 Bucharest, Romania
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6
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Fetal and Neonatal Adverse Drug Reactions Associated with Biologics Taken During Pregnancy by Women with Autoimmune Diseases: Insights from an Analysis of the World Health Organization Pharmacovigilance Database (VigiBase ®). BioDrugs 2023; 37:73-87. [PMID: 36401769 PMCID: PMC9676840 DOI: 10.1007/s40259-022-00564-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/25/2022] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Published data on the safety of biologics other than tumor necrosis factor (TNF) inhibitors during pregnancy are limited. OBJECTIVE The aim was to detect pharmacovigilance signals for fetal and neonatal adverse drug reactions (ADRs) to biologics taken by pregnant women with autoimmune diseases. METHODS We performed a disproportionality analysis of the World Health Organization's VigiBase® pharmacovigilance database from 1968 to June 1, 2021. Data were collected in June 2021. By using terms for different hierarchical levels of the Medical Dictionary for Regulatory Activities, we selected the following fetal or neonatal ADRs: stillbirth, premature birth, low birth weight, small for gestational age, and congenital malformations. The frequency of all identified ADRs for biologics of interest (adalimumab, infliximab, golimumab, certolizumab, etanercept, anakinra, canakinumab, tocilizumab, sarilumab, ustekinumab, guselkumab, secukinumab, ixekizumab, belimumab, abatacept, and rituximab) was compared with that of all other reports for all other drugs and quoted as the reporting odds ratio (ROR) [95% confidence interval]. Reports with known concomitant use of teratogenic drugs were excluded from the main analysis. Other analyses included ROR stratifications by therapeutic indication in the periods 1968-2021 and 2001-2021, and an analysis after excluding reports with steroids. RESULTS In the main analysis, the RORs were particularly high for musculoskeletal malformations with anakinra (7.18 [3.50-14.73]), canakinumab (19.54 [12.82-29.79]), and abatacept (5.09 [2.77-9.33]), and for immune system disorders with canakinumab (347.88 [217.9-555.50]) and rituximab (9.27 [2.95-29.15]). After the exclusion of reports with steroids, the ROR was significant for neonatal infections with belimumab (28.49 [5.75-141.25]). CONCLUSION We identified possible associations with some adverse fetal and neonatal outcomes, suggesting that vigilance is required when prescribing certain biologics during pregnancy.
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7
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Bergstra SA, Sepriano A, Kerschbaumer A, van der Heijde D, Caporali R, Edwards CJ, Verschueren P, de Souza S, Pope JE, Takeuchi T, Hyrich KL, Winthrop KL, Aletaha D, Stamm TA, Schoones JW, Smolen JS, Landewé RBM. Efficacy, duration of use and safety of glucocorticoids: a systematic literature review informing the 2022 update of the EULAR recommendations for the management of rheumatoid arthritis. Ann Rheum Dis 2023; 82:81-94. [PMID: 36410794 DOI: 10.1136/ard-2022-223358] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 10/25/2022] [Indexed: 11/22/2022]
Abstract
This systematic literature review (SLR) regarding the efficacy, duration of use and safety of glucocorticoids (GCs), was performed to inform the 2022 update of the EULAR recommendations for the management of rheumatoid arthritis (RA). Studies on GC efficacy were identified from a separate search on the efficacy of disease-modifying antirheumatic drugs (DMARDs). A combined search was performed for the duration of use and safety of GCs in RA patients. Dose-defined and time-defined GC treatment of any dose and duration (excluding intra-articular GCs) prescribed in combination with other DMARDs were considered. Results are presented descriptively. Two included studies confirmed the efficacy of GC bridging as initial therapy, with equal efficacy after 2 years of initial doses of 30 mg/day compared with 60 mg/day prednisone. Based on a recently performed SLR, in clinical trials most patients starting initial GC bridging are able to stop GCs within 12 (22% patients continued on GCs) to 24 months (10% patients continued on GCs). The safety search included 12 RCTs and 21 observational studies. Well-known safety risks of GC use were confirmed, including an increased risk of osteoporotic fractures, serious infections, diabetes and mortality. Data on cardiovascular outcomes were Inconsistent. Overall, safety risks increased with increasing dose and/or duration, but evidence on which dose is safe was conflicting. In conclusion, this SLR has confirmed the efficacy of GCs in the treatment of RA. In clinical trials, most patients have shown to be able to stop GCs within 12-24 months. Well-known safety risks of GC use have been confirmed, but with heterogeneity between studies.
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Affiliation(s)
- Sytske Anne Bergstra
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Alexandre Sepriano
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands.,NOVA Medical School, Universidade Nova de Lisboa, Lisboa, Portugal
| | - Andreas Kerschbaumer
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Wien, Austria
| | | | - Roberto Caporali
- University of Milan, Milan and Department of Rheumatology, ASST PINI-CTO, Milano, Italy
| | - Christopher John Edwards
- NIHR Southampton Clinical Research Facility, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Patrick Verschueren
- Department of rheumatology, KU Leuven University Hospitals Leuven, Leuven, Belgium
| | - Savia de Souza
- EULAR Patient Research Partner Network, Zurich, Switzerland
| | - Janet E Pope
- University of Western Ontario, Schulich School of Medicine, London, Ontario, Canada
| | - Tsutomu Takeuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine Graduate School of Medicine, Shinjuku-ku, Japan.,Saitama Medical University, Iruma-gun, Saitama, Japan
| | - Kimme L Hyrich
- Centre for Epidemiology Versus Arthritis, The University of Manchester, Manchester, UK.,NIHR Manchester Biomedical Research Centre, Manchester University NHS Trust, UK
| | | | - Daniel Aletaha
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Wien, Austria
| | - Tanja A Stamm
- Section for Outcomes Research, Centre for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Wien, Austria.,Ludwig Boltzmann Institute for Arthritis and Rehabilitation, Vienna, Austria
| | - Jan W Schoones
- Walaeus Library, Leiden University Medical Center, Leiden, The Netherlands
| | - Josef S Smolen
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Wien, Austria.,2nd Department of Medicine, Hietzing Hospital, Wien, Austria
| | - Robert B M Landewé
- Amsterdam Rheumatology Center, Amsterdam University Medical Centres, Amsterdam, The Netherlands.,Rheumatology, Zuyderland Medical Centre Heerlen, Heerlen, The Netherlands
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Russell MD, Dey M, Flint J, Davie P, Allen A, Crossley A, Frishman M, Gayed M, Hodson K, Khamashta M, Moore L, Panchal S, Piper M, Reid C, Saxby K, Schreiber K, Senvar N, Tosounidou S, van de Venne M, Warburton L, Williams D, Yee CS, Gordon C, Giles I, Roddy E, Armon K, Astell L, Cotton C, Davidson A, Fordham S, Jones C, Joyce C, Kuttikat A, McLaren Z, Merrison K, Mewar D, Mootoo A, Williams E. British Society for Rheumatology guideline on prescribing drugs in pregnancy and breastfeeding: immunomodulatory anti-rheumatic drugs and corticosteroids. Rheumatology (Oxford) 2022; 62:e48-e88. [PMID: 36318966 PMCID: PMC10070073 DOI: 10.1093/rheumatology/keac551] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 09/15/2022] [Indexed: 11/07/2022] Open
Affiliation(s)
- Mark D Russell
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Mrinalini Dey
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Julia Flint
- Department of Rheumatology, Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Shropshire, UK
| | - Philippa Davie
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Alexander Allen
- Clinical Affairs, British Society for Rheumatology, London, UK
| | | | - Margreta Frishman
- Rheumatology, North Middlesex University Hospital NHS Trust, London, UK
| | - Mary Gayed
- Rheumatology, Sandwell and West Birmingham Hospitals, Birmingham, UK
| | | | - Munther Khamashta
- Lupus Research Unit, Division of Women's Health, King's College London, London, UK
| | - Louise Moore
- Rheumatic and Musculoskeletal Disease Unit, Our Lady's Hospice and Care Service, Dublin, Ireland
| | - Sonia Panchal
- Department of Rheumatology, South Warwickshire NHS Foundation Trust, Warwickshire, UK
| | - Madeleine Piper
- Royal National Hospital for Rheumatic Diseases, Royal United Hospital, Bath, UK
| | | | - Katherine Saxby
- Pharmacy, University College London Hospitals NHS Foundation Trust, London, UK
| | - Karen Schreiber
- Thrombosis and Haemostasis, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Department of Rheumatology, Danish Hospital for Rheumatic Diseases, Sonderborg, Denmark.,Department of Regional Health Research (IRS), University of Southern Denmark, Odense, Denmark
| | - Naz Senvar
- Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Sofia Tosounidou
- Lupus UK Centre of Excellence, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | | | | | - David Williams
- Obstetrics, University College London Hospitals NHS Foundation Trust, London, UK
| | - Chee-Seng Yee
- Department of Rheumatology, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, Doncaster, UK
| | - Caroline Gordon
- Rheumatology Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Ian Giles
- Centre for Rheumatology, Division of Medicine, University College London, London, UK
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9
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Nakai T, Fukui S, Ikeda Y, Suda M, Tamaki H, Okada M. Glucocorticoid discontinuation in patients with SLE with prior severe organ involvement: a single-center retrospective analysis. Lupus Sci Med 2022; 9:9/1/e000682. [PMID: 35654482 PMCID: PMC9163542 DOI: 10.1136/lupus-2022-000682] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 05/19/2022] [Indexed: 12/13/2022]
Abstract
Objective Long-term glucocorticoid use in SLE may have significant side effects; however, glucocorticoid discontinuation is occasionally associated with disease flare-ups. Therefore, we evaluated the risk factors for disease flares and the flare rate on glucocorticoid tapering in patients with prior severe organ involvement. Methods Data of patients with SLE with glucocorticoid tapering at our institution were retrospectively analysed. We divided the patients by the presence of prior severe organ involvement and compared flare rates after glucocorticoid discontinuation. Furthermore, we determined risk factors for flares after glucocorticoid discontinuation. Results In total, 309 patients with SLE were screened, 73 of whom met the inclusion criteria; 49 were classified as SLE with prior severe organ involvement. No significant differences were noted in the 52-week flare rate after glucocorticoid discontinuation between patients with and without prior severe organ involvement (16.7% vs 18.2%, p=1.0). Hypocomplementaemia, elevated anti-dsDNA antibody titres more than twice the upper limit of the laboratory reference range, positive anti-Smith/anti-ribonucleoprotein antibody, and use of any immunosuppressant on the day of glucocorticoid discontinuation were negatively associated with flare-free remission. Conclusions Glucocorticoid discontinuation after gradual tapering can often be achieved in patients with SLE, even with prior severe organ involvement, especially when the disease is clinically and serologically stable.
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Affiliation(s)
- Takehiro Nakai
- Immuno-Rheumatology Center, St Luke's International Hospital, Chuo-ku, Japan
| | - Sho Fukui
- Immuno-Rheumatology Center, St Luke's International Hospital, Chuo-ku, Japan.,Center for Clinical Epidemiology, St Luke's International University, Chuo-ku, Japan
| | - Yukihiko Ikeda
- Immuno-Rheumatology Center, St Luke's International Hospital, Chuo-ku, Japan
| | - Masei Suda
- Immuno-Rheumatology Center, St Luke's International Hospital, Chuo-ku, Japan.,Department of Rheumatology, Suwa Central Hospital, Nagano, Japan
| | - Hiromichi Tamaki
- Immuno-Rheumatology Center, St Luke's International Hospital, Chuo-ku, Japan
| | - Masato Okada
- Immuno-Rheumatology Center, St Luke's International Hospital, Chuo-ku, Japan
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10
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Ramoni VL, Häfeli C, Costedoat-Chalumeau N, Chambers C, Dolhain RJEM, Govoni M, Levy RA, Götestam Skorpen C, Tincani A, Förger F. Changes to expert opinion in the use of antirheumatic drugs before and during pregnancy five years after EULAR: points to consider. Rheumatology (Oxford) 2022; 61:e331-e333. [PMID: 35587743 DOI: 10.1093/rheumatology/keac262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 04/08/2022] [Accepted: 04/09/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Céline Häfeli
- Department of Rheumatology and Immunology, Inselspital, University Hospital and University of Berne, Freiburgstrasse, 3010, Bern, Switzerland
| | - Nathalie Costedoat-Chalumeau
- Service de médecine interne, Centre de référence maladies autoimmunes et systémiques rares Île de France, APHP, Hôpital Cochin, F-75014, Paris, France.,Université de Paris, Centre de recherche épidémiologie et biostatistiques de Sorbonne Paris Cité, F-75004, Paris, France
| | - Christina Chambers
- University of California San Diego, Department of Pediatrics, 9500, Gilman Drive, La Jolla, USA
| | - Radboud J E M Dolhain
- Department of Rheumatology, Erasmus University Medical Center; Rotterdam, The Netherlands
| | - Marcello Govoni
- Azienda Ospedaliero Universitaria S. Anna, Ferrara, Italy.,Department of Medical Sciences, University of Ferrara, Italy
| | | | - Carina Götestam Skorpen
- Department of Rheumatology, Ålesund Hospital, Ålesund, Norway.,Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Angela Tincani
- Rheumatology and Clinical Immunology Unit, ASST-Spedali Civili and University of Brescia-Italy
| | - Frauke Förger
- Department of Rheumatology and Immunology, Inselspital, University Hospital and University of Berne, Freiburgstrasse, 3010, Bern, Switzerland
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11
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Clowse M, Fischer-Betz R, Nelson-Piercy C, Scheuerle AE, Stephan B, Dubinsky M, Kumke T, Kasliwal R, Lauwerys B, Förger F. Pharmacovigilance pregnancy data in a large population of patients with chronic inflammatory disease exposed to certolizumab pegol. Ther Adv Musculoskelet Dis 2022; 14:1759720X221087650. [PMID: 35464812 PMCID: PMC9023886 DOI: 10.1177/1759720x221087650] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 02/15/2022] [Indexed: 12/29/2022] Open
Abstract
Introduction: Chronic inflammatory diseases (CIDs), including rheumatic diseases and other inflammatory conditions, often affect women of reproductive age. Tumor necrosis factor inhibitors (TNFi) are widely used to treat CID, but there is limited information on outcomes of TNFi-exposed pregnancies. We evaluated pregnancy outcomes from 1392 prospectively reported pregnancies exposed to certolizumab pegol (CZP), a PEGylated, Fc-free TNFi with no to minimal placental transfer. Methods: CZP-exposed pregnancies in patients with CID from the UCB Pharmacovigilance global safety database were reviewed from the start of CZP clinical development (July 2001) to 1 November 2020. To limit bias, the analysis focused on prospectively reported cases with known pregnancy outcomes. Results: In total, 1392 prospective pregnancies with maternal CZP exposure and known pregnancy outcomes (n = 1425) were reported; 1021 had at least first-trimester CZP exposure. Live birth was reported in 1259/1425 (88.4%) of all prospective outcomes. There were 150/1425 (10.5%) pregnancy losses before 20 weeks (miscarriage/induced abortion), 11/1425 (0.8%) stillbirths, and 5/1392 (0.4%) ectopic pregnancies. Congenital malformations were present in 30/1259 (2.4%) live-born infants, of which 26 (2.1%) were considered major according to the Metropolitan Atlanta Congenital Defects Program criteria. There was no pattern of congenital malformations. Discussion and conclusion: No signal for adverse pregnancy outcomes or congenital malformations was observed in CZP-exposed pregnancies. Although the limitations of data collected through this methodology (including underreporting, missing information, and absence of a comparator group) should be considered, these data provide reassurance for women with CID who require CZP treatment during pregnancy, and their treating physicians.
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Affiliation(s)
- Megan Clowse
- Division of Rheumatology, Duke University Medical Center, 3535, Durham, NC 27710, USA
| | - Rebecca Fischer-Betz
- Department for Rheumatology and Hiller Research Institute, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | | | - Angela E. Scheuerle
- Department of Pediatrics, Division of Genetics and Metabolism, UT Southwestern Medical Center, Dallas, TX, USA
| | - Brigitte Stephan
- Institute for Health Services Research in Dermatology and Nursing (IVDP), University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Marla Dubinsky
- The Susan and Leonard Feinstein IBD Center, Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
| | | | | | | | - Frauke Förger
- Department of Rheumatology and Immunology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
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12
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Alijotas-Reig J, Esteve-Valverde E, Anunciación-Llunell A, Marques-Soares J, Pardos-Gea J, Miró-Mur F. Pathogenesis, Diagnosis and Management of Obstetric Antiphospholipid Syndrome: A Comprehensive Review. J Clin Med 2022; 11:jcm11030675. [PMID: 35160128 PMCID: PMC8836886 DOI: 10.3390/jcm11030675] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 01/18/2022] [Accepted: 01/25/2022] [Indexed: 02/04/2023] Open
Abstract
Antiphospholipid syndrome is an autoimmune disorder characterized by vascular thrombosis and/or pregnancy morbidity associated with persistent antiphospholipid antibody positivity. Cases fulfilling the Sydney criteria for obstetric morbidity with no previous thrombosis are known as obstetric antiphospholipid syndrome (OAPS). OAPS is the most identified cause of recurrent pregnancy loss and late-pregnancy morbidity related to placental injury. Cases with incomplete clinical or laboratory data are classified as obstetric morbidity APS (OMAPS) and non-criteria OAPS (NC-OAPS), respectively. Inflammatory and thrombotic mechanisms are involved in the pathophysiology of OAPS. Trophoblasts, endothelium, platelets and innate immune cells are key cellular players. Complement activation plays a crucial pathogenic role. Secondary placental thrombosis appears by clot formation in response to tissue factor activation. New risk assessment tools could improve the prediction of obstetric complication recurrences or thromboses. The standard-of-care treatment consists of low-dose aspirin and prophylactic low molecular weight heparin. In refractory cases, the addition of hydroxychloroquine, low-dose prednisone or IVIG improve pregnancy outcomes. Statins and eculizumab are currently being tested for treating selected OAPS women. Finally, we revisited recent insights and concerns about the pathophysiology, diagnosis and management of OAPS.
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Affiliation(s)
- Jaume Alijotas-Reig
- Systemic Autoimmune Diseases Research Unit, Vall d’Hebron Hospital Campus, Vall d’Hebron Institut de Recerca (VHIR), Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (A.A.-L.); (J.M.-S.); (J.P.-G.)
- Systemic Autoimmune Diseases Unit, Department of Internal Medicine, Vall d’Hebron Hospital Campus, Hospital Universitari Vall d’Hebron (HUVH), Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain
- Department of Medicine, Faculty of Medicine, Universitat Autònoma de Barcelona (UAB), 08193 Barcelona, Spain
- Correspondence: (J.A.-R.); (F.M.-M.); Tel.: +34-93-489-4194 (J.A.-R.); +34-93-489-4047 (F.M.-M.); Fax: +34-93-489-4047 (J.A.-R.)
| | - Enrique Esteve-Valverde
- Department of Internal Medicine, Althaia Xarxa Assistencial, Carrer Dr Joan Soler 1-3, 08243 Manresa, Spain;
| | - Ariadna Anunciación-Llunell
- Systemic Autoimmune Diseases Research Unit, Vall d’Hebron Hospital Campus, Vall d’Hebron Institut de Recerca (VHIR), Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (A.A.-L.); (J.M.-S.); (J.P.-G.)
| | - Joana Marques-Soares
- Systemic Autoimmune Diseases Research Unit, Vall d’Hebron Hospital Campus, Vall d’Hebron Institut de Recerca (VHIR), Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (A.A.-L.); (J.M.-S.); (J.P.-G.)
- Systemic Autoimmune Diseases Unit, Department of Internal Medicine, Vall d’Hebron Hospital Campus, Hospital Universitari Vall d’Hebron (HUVH), Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain
| | - Josep Pardos-Gea
- Systemic Autoimmune Diseases Research Unit, Vall d’Hebron Hospital Campus, Vall d’Hebron Institut de Recerca (VHIR), Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (A.A.-L.); (J.M.-S.); (J.P.-G.)
- Systemic Autoimmune Diseases Unit, Department of Internal Medicine, Vall d’Hebron Hospital Campus, Hospital Universitari Vall d’Hebron (HUVH), Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain
| | - Francesc Miró-Mur
- Systemic Autoimmune Diseases Research Unit, Vall d’Hebron Hospital Campus, Vall d’Hebron Institut de Recerca (VHIR), Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (A.A.-L.); (J.M.-S.); (J.P.-G.)
- Correspondence: (J.A.-R.); (F.M.-M.); Tel.: +34-93-489-4194 (J.A.-R.); +34-93-489-4047 (F.M.-M.); Fax: +34-93-489-4047 (J.A.-R.)
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13
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Palmsten K, Bandoli G, Vazquez-Benitez G, Chambers CD. Differences in the association between oral corticosteroids and risk of preterm birth by data source: Reconciling the results. Arthritis Care Res (Hoboken) 2022; 74:1332-1341. [PMID: 35089649 PMCID: PMC9438740 DOI: 10.1002/acr.24865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 01/19/2022] [Accepted: 01/25/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To investigate causes of discrepancies in the association between early pregnancy oral corticosteroid (OCS) use and preterm birth (PTB) risk among women with rheumatoid arthritis (RA) in health care utilization [California Medicaid (Medi-Cal)] and prospective cohort (MotherToBaby Pregnancy Studies) data. METHODS Separately, we estimated risk ratios (RR) between OCS exposure before gestational day 140 and PTB risk in Medi-Cal (2007-2013; n=844) and MotherToBaby (2003-2014; n=528) data. We explored differences in socio-economic status, OCS dose distribution, exposure misclassification, and confounding by RA severity across the data sources. RESULTS PTB risk in women without OCS's was 17.3% in Medi-Cal and was 9.7% in MotherToBaby. There was no association between OCS and PTB in Medi-Cal (adjusted (a)RR: 1.00 (95% CI: 0.71, 1.42)), and a 1.85-fold (95% CI: 1.20, 2.84) increased PTB risk in MotherToBaby. When restricting each sample to women with a high school degree or less, PTB risk following no OCS exposure was 15.9% in Medi-Cal and 16.7% in MotherToBaby; aRR's were 1.16 (95% CI: 0.74, 1.80) in Medi-Cal and 0.81 (95% CI: 0.25, 2.64) in MotherToBaby. Cumulative OCS dose was higher in MotherToBaby (median: 684 mg) than Medi-Cal (median: 300 mg). OCS dose ≤300 mg was not associated with increased PTB risk. Exposure misclassification and confounding by RA severity were unlikely explanations of differences. DISCUSSION Higher baseline PTB risk and lower OCS dose distribution in Medi-Cal may explain the discrepancies. Studies are needed to understand the effects of autoimmune disease severity and under-treatment on PTB risk in low-income populations.
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Affiliation(s)
- Kristin Palmsten
- HealthPartners Institute, Minneapolis, MN.,Department of Pediatrics, University of California, San Diego, La Jolla, CA
| | - Gretchen Bandoli
- Department of Pediatrics, University of California, San Diego, La Jolla, CA.,Department of Family Medicine and Public Health, University of California, San Diego, La Jolla, CA
| | | | - Christina D Chambers
- Department of Pediatrics, University of California, San Diego, La Jolla, CA.,Department of Family Medicine and Public Health, University of California, San Diego, La Jolla, CA
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14
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Wood ME, Lupattelli A, Palmsten K, Bandoli G, Hurault-Delarue C, Damase-Michel C, Chambers CD, Nordeng HME, van Gelder MMHJ. Longitudinal Methods for Modeling Exposures in Pharmacoepidemiologic Studies in Pregnancy. Epidemiol Rev 2022; 43:130-146. [PMID: 34100086 PMCID: PMC8763114 DOI: 10.1093/epirev/mxab002] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 06/02/2021] [Accepted: 06/04/2021] [Indexed: 12/17/2022] Open
Abstract
In many perinatal pharmacoepidemiologic studies, exposure to a medication is classified as "ever exposed" versus "never exposed" within each trimester or even over the entire pregnancy. This approach is often far from real-world exposure patterns, may lead to exposure misclassification, and does not to incorporate important aspects such as dosage, timing of exposure, and treatment duration. Alternative exposure modeling methods can better summarize complex, individual-level medication use trajectories or time-varying exposures from information on medication dosage, gestational timing of use, and frequency of use. We provide an overview of commonly used methods for more refined definitions of real-world exposure to medication use during pregnancy, focusing on the major strengths and limitations of the techniques, including the potential for method-specific biases. Unsupervised clustering methods, including k-means clustering, group-based trajectory models, and hierarchical cluster analysis, are of interest because they enable visual examination of medication use trajectories over time in pregnancy and complex individual-level exposures, as well as providing insight into comedication and drug-switching patterns. Analytical techniques for time-varying exposure methods, such as extended Cox models and Robins' generalized methods, are useful tools when medication exposure is not static during pregnancy. We propose that where appropriate, combining unsupervised clustering techniques with causal modeling approaches may be a powerful approach to understanding medication safety in pregnancy, and this framework can also be applied in other areas of epidemiology.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Marleen M H J van Gelder
- Correspondence to Dr. Marleen van Gelder, Department for Health Evidence, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, the Netherlands (e-mail: )
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15
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Hellgren K, Secher AE, Glintborg B, Rom AL, Gudbjornsson B, Michelsen B, Granath F, Hetland ML. Pregnancy outcomes in relation to disease activity and anti-rheumatic treatment strategies in women with rheumatoid arthritis. Rheumatology (Oxford) 2021; 61:3711-3722. [PMID: 34864891 DOI: 10.1093/rheumatology/keab894] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 11/23/2021] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES To explore the association of maternal rheumatoid arthritis (RA) to pregnancy outcomes, especially preterm birth (PTB) and small for gestational age (SGA), in relation to disease activity and anti-rheumatic treatment before and during pregnancy. METHODS By linking prospective clinical rheumatology registers (CRR) in Sweden (SRQ) and Denmark (DANBIO) with medical birth registers, we identified 1,739 RA-pregnancies and 17 390 control-pregnancies (matched 1:10 on maternal age, birth year, parity) with delivery 2006-2018. Disease activity (DAS28, CRP, HAQ-score) and anti-rheumatic treatment nine months before and during pregnancy were identified through CRR and prescribed drug registers. Using logistic regression, we estimated adjusted odds ratios (aOR) with 95% confidence intervals (CI) for PTB and SGA overall and stratified by disease activity and anti-rheumatic treatment before and during pregnancy, adjusting for maternal characteristics. RESULTS We found increased aOR of PTB (1.92, 1.56-2.35) and SGA (1.93, 1.45-2.57) in RA-pregnancies vs control-pregnancies. For RA-pregnancies with DAS28-CRP ≥ 4.1 vs < 3.2 during pregnancy, aOR was 3.38 (1.52-7.55) for PTB and 3.90 (1.46-10.4) for SGA. Use of oral corticosteroids (yes/no) during pregnancy resulted in an aOR of 2.11 (0.94-4.74) for PTB. Corresponding figure for biologics was 1.38 (0.66-2.89). Combination therapy, including biologics before pregnancy, was a marker of increased risk of both PTB and SGA. CONCLUSION During pregnancy, disease activity rather than treatment seems to be the most important risk factor for PTB and SGA in RA. Women with RA should be carefully monitored during pregnancy, especially if they have moderate to high disease activity or/and are treated with extensive anti-rheumatic treatment.
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Affiliation(s)
- Karin Hellgren
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Insititutet, Stockholm, Sweden.,Rheumatology, Theme Inflammation & Infection, Karolinska University Hospital, Stockholm, Sweden
| | - Anne Emilie Secher
- DANBIO and Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, Copenhagen University Hospital Rigshospitalet, Glostrup, Denmark
| | - Bente Glintborg
- DANBIO and Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, Copenhagen University Hospital Rigshospitalet, Glostrup, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Ane Lilleøre Rom
- Department of Obstetrics, The Juliane Marie Centre, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark.,The Research Unit for Women's and Children's Health, The Juliane Marie Centre, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark.,Research Unit of Gynecology and Obstetrics, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Bjorn Gudbjornsson
- Centre for Rheumatology Research, Landspitali University Hospital, and Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Brigitte Michelsen
- Department of Rheumatology, Diakonhjemmet Hospital, Norway.,Division of Rheumatology, Department of Medicine, Hospital of Southern Norway Trust, Norway
| | - Fredrik Granath
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Insititutet, Stockholm, Sweden
| | - Merete Lund Hetland
- DANBIO and Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, Copenhagen University Hospital Rigshospitalet, Glostrup, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
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16
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Häfeli C, Förger F. [Current aspects of antirheumatic therapy in pregnancy planning, during pregnancy and breastfeeding]. Z Rheumatol 2021; 80:716-725. [PMID: 34581874 PMCID: PMC8477645 DOI: 10.1007/s00393-021-01095-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/01/2021] [Indexed: 11/25/2022]
Abstract
Active rheumatic disease is a known factor for increased fetomaternal risks during pregnancy. Remission or inactive disease should therefore be targeted to reduce these risks by using pregnancy-compatible antirheumatic drugs as recommended by international guidelines. Teratogenic antirheumatic drugs, such as mycophenolate, methotrexate, cyclophosphamide and thalidomide should be stopped about 3 months prior to conception. Leflunomide is a weak human teratogen that should be stopped and eliminated with cholestyramine prior to conception. Furthermore, drugs with limited data, such as apremilast and JAK inhibitors as well as new biologics should be avoided during gestation. Pregnancy-compatible drugs are the antirheumatic drugs hydroxychloroquine, sulfasalazine, azathioprine, cyclosporine, tacrolimus, colchicine, non-selective NSAIDs, low-dose prednisone/prednisolone and TNF inhibitors. These drugs as well as other biologics, such as rituximab can be used during lactation. In a preconception counselling visit, the benefits and the international recommendations of pregnancy-compatible antirheumatic drugs should be discussed with the patient and be weighed against the possible fetomaternal risks of an active disease to enable a shared decision-making.
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Affiliation(s)
- Celine Häfeli
- Universitätsklinik für Rheumatologie und Immunologie, Inselspital Bern, Freiburgstraße 18, 3010, Bern, Schweiz
| | - Frauke Förger
- Universitätsklinik für Rheumatologie und Immunologie, Inselspital Bern, Freiburgstraße 18, 3010, Bern, Schweiz.
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17
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Bérard A, Strom S, Zhao JP, Kori S, Albrecht D. Dihydroergotamine and triptan use to treat migraine during pregnancy and the risk of adverse pregnancy outcomes. Sci Rep 2021; 11:19302. [PMID: 34588467 PMCID: PMC8481540 DOI: 10.1038/s41598-021-97092-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 08/06/2021] [Indexed: 11/20/2022] Open
Abstract
Migraine is prevalent during pregnancy. Antimigraine medications such as dihydroergotamine (DHE) and triptans have been associated with adverse pregnancy outcomes in individual studies but lack of consensus remains. We compared the risk of prematurity, low birth weight (LBW), major congenital malformations (MCM), and spontaneous abortions (SA) associated with gestational use of DHE or triptans. Three cohort and one nested-case–control analyses were conducted within the Quebec Pregnancy Cohort to assess the risk of prematurity, LBW, MCM, and SA. Exposure was defined dichotomously as use of DHE or triptan during pregnancy. Generalized estimation equations were built to quantify the associations, adjusting for potential confounders. 233,900 eligible pregnancies were included in the analyses on prematurity, LBW, and MCM; 29,104 cases of SA were identified. Seventy-eight subjects (0.03%) were exposed to DHE and 526 (0.22%) to triptans. Adjusting for potential confounders, DHE and triptans were associated with increased risks of prematurity, LBW, MCM, and SA but not all estimates were statistically significant. DHE was associated with the risk of prematurity (aRR: 4.12, 95% CI 1.21–13.99); triptans were associated with the risk of SA (aOR: 1.63, 95% CI 1.34–1.98). After considering maternal migraine, all antimigraine specific medications increased the risk of some adverse pregnancy outcomes, but estimates were unstable.
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Affiliation(s)
- Anick Bérard
- Faculty of Pharmacy, University of Montreal, Montreal, QC, H3T 1J4, Canada. .,Research Center, CHU Sainte-Justine, Montreal, QC, H3T 1C5, Canada. .,Faculty of Medicine, Université Claude Bernard, Lyon 1, 69622, Lyon, France.
| | - Shannon Strom
- Satsuma Pharmaceuticals, Inc, San Francisco, CA, 94080, USA
| | - Jin-Ping Zhao
- Research Center, CHU Sainte-Justine, Montreal, QC, H3T 1C5, Canada
| | - Shashi Kori
- Satsuma Pharmaceuticals, Inc, San Francisco, CA, 94080, USA
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18
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Bérard A, Sheehy O, Zhao JP, Vinet E, Quach C, Kassai B, Bernatsky S. Available medications used as potential therapeutics for COVID-19: What are the known safety profiles in pregnancy. PLoS One 2021; 16:e0251746. [PMID: 34010282 PMCID: PMC8133446 DOI: 10.1371/journal.pone.0251746] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 04/30/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Medications already available to treat other conditions are presently being studied in clinical trials as potential treatments for COVID-19. Given that pregnant women are excluded from these trials, we aimed to investigate their safety when used during pregnancy within a unique population source. METHODS Using the population-based Quebec Pregnancy Cohort, we identified women who delivered a singleton liveborn (1998-2015). Taking potential confounders into account including indications for use, the risk of prematurity, low birth weight (LBW), small for gestational age (SGA), and major congenital malformation (MCM) associated with COVID-19 repurposed drug use during pregnancy were quantified using generalized estimation equations. RESULTS Of the 231,075 eligible pregnancies, 107 were exposed to dexamethasone (0.05%), 31 to interferons (0.01%), 1,398 to heparins (0.60%), 24 to angiotensin-receptor blockers (ARB) (0.01%), 182 to chloroquine (0.08%), 103 to hydroxychloroquine (0.05%), 6,206 to azithromycin (2.70%), 230 to oseltamivir (0.10%), and 114 to HIV medications (0.05%). Adjusting for potential confounders, we observed an increased risk of prematurity related to dexamethasone (aOR 1.92, 95%CI 1.11-3.33; 15 exposed cases), anti-thrombotics (aOR 1.58, 95%CI 1.31-1.91; 177 exposed cases), and HIV medications (aOR 2.04, 95%CI 1.01-4.11; 20 exposed cases) use. An increased risk for LBW associated with anti-thrombotics (aOR 1.72, 95%CI 1.41-2.11; 152 exposed cases), and HIV medications (aOR 2.48, 95%CI 1.25-4.90; 21 exposed cases) use were also found. Gestational exposure to anti-thrombotics (aOR 1.20, 95%CI 1.00-1.44; 176 exposed cases), and HIV medications (aOR 2.61, 95%CI 1.51-4.51; 30 exposed cases) were associated with SGA. First-trimester dexamethasone (aOR 1.66, 95%CI 1.02-2.69; 20 exposed cases) and azithromycin (aOR 1.10, 95%CI 1.02-1.19; 747 exposed cases) exposures were associated with MCM. CONCLUSIONS Many available medications considered as treatments for COVID-19 are associated with adverse pregnancy outcomes. Caution is warranted when considering these medications during the gestational period.
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Affiliation(s)
- Anick Bérard
- Research Center, CHU Sainte-Justine, Montreal, Quebec, Canada
- Faculty of Pharmacy, University of Montreal, Montreal, Quebec, Canada
- Faculty of Medicine, Université Claude Bernard, Lyon, France
| | - Odile Sheehy
- Research Center, CHU Sainte-Justine, Montreal, Quebec, Canada
| | - Jin-Ping Zhao
- Research Center, CHU Sainte-Justine, Montreal, Quebec, Canada
| | - Evelyne Vinet
- Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Caroline Quach
- Research Center, CHU Sainte-Justine, Montreal, Quebec, Canada
- Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Behrouz Kassai
- Faculty of Medicine, Université Claude Bernard, Lyon, France
| | - Sasha Bernatsky
- Faculty of Medicine, McGill University, Montreal, Quebec, Canada
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19
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Palmsten K, Bredesen D, JaKa MM, Kumar PC, Ziegenfuss JY, Kharbanda EO. "I know my body better than you:" patient focus groups to inform a decision aid on oral corticosteroid use during pregnancy. Pharmacoepidemiol Drug Saf 2021; 30:451-461. [PMID: 33314542 PMCID: PMC8686489 DOI: 10.1002/pds.5183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 12/07/2020] [Indexed: 01/03/2023]
Abstract
PURPOSE There is unmet need for decision support regarding medication use during pregnancy. We aimed to inform the development of a decision aid on oral corticosteroid (OCS) use during pregnancy through focus groups. METHODS We invited patients from one health system who had a recent live birth and a condition for which OCSs may be prescribed (ie, asthma or other autoimmune disease) to participate in focus groups. We conducted conventional qualitative content analysis of verbatim transcripts of the focus groups using inductive coding. RESULTS There were 30 participants across five focus groups from May to June 2019. Women endorsed the need for patient-provider discussions about OCS use during pregnancy in which the provider shares risks and benefits and the patient makes her decision. Furthermore, women generally expressed support for patient-centered handouts about OCS use during pregnancy that the provider discusses with the patient. When considering whether to take OCSs in pregnancy, women had concerns about: the medication's impact on their baby (eg, miscarriage, birth defects, long-term effects), themselves (eg, effects on mood, sleep, weight gain), pregnancy complications (eg, preterm birth, increased blood pressure), and lactation. Women wanted information on OCSs (eg, indications, length of treatment, and cost), alternative treatments, and risks of not taking OCSs. CONCLUSIONS We established patient need for a decision aid on OCS use during pregnancy that providers can discuss with patients. To address patient concerns, the aid should at a minimum describe the medication's impact on baby, including long-term effects, maternal health, pregnancy complications, and lactation.
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20
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Chambers CD, Krishnan JA, Alba L, Albano JD, Bryant AS, Carver M, Cohen LS, Gorodetsky E, Hernandez-Diaz S, Honein MA, Jones BL, Murray RK, Namazy JA, Sahin L, Spong CY, Vasisht KP, Watt K, Wurst KE, Yao L, Schatz M. The safety of asthma medications during pregnancy and lactation: Clinical management and research priorities. J Allergy Clin Immunol 2021; 147:2009-2020. [PMID: 33713765 DOI: 10.1016/j.jaci.2021.02.037] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 02/19/2021] [Indexed: 12/26/2022]
Abstract
Asthma is one of the most common underlying diseases in women of reproductive age that can lead to potentially serious medical problems during pregnancy and lactation. A group of key stakeholders across multiple relevant disciplines was invited to take part in an effort to prioritize, strategize, and mobilize action steps to fill important gaps in knowledge regarding asthma medication safety in pregnancy and lactation. The stakeholders identified substantial gaps in the literature on the safety of asthma medications used during pregnancy and lactation and prioritized strategies to fill those gaps. Short-term action steps included linking data from existing complementary study designs (US and international claims data, single drug pregnancy registries, case-control studies, and coordinated systematic data systems). Long-term action steps included creating an asthma disease registry, incorporating the disease registry into electronic health record systems, and coordinating care across disciplines. The stakeholders also prioritized establishing new infrastructures/collaborations to perform research in pregnant and lactating women and to include patient perspectives throughout the process. To address the evidence gaps, and aid in populating product labels with data that inform clinical decision making, the consortium developed a plan to systematically obtain necessary data in the most efficient and timely manner.
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Affiliation(s)
| | | | - Lorene Alba
- Asthma and Allergy Foundation of America, Arlington, Va
| | | | | | | | - Lee S Cohen
- Massachusetts General Hospital, Boston, Mass
| | | | | | | | - Bridgette L Jones
- Children's Mercy Kansas City, Kansas City, Mo; University of Missouri Kansas City School of Medicine, Children's Mercy Kansas City, Kansas City, Mo
| | | | | | - Leyla Sahin
- US Food and Drug Administration, Silver Spring, Md
| | - Catherine Y Spong
- the Department of Obstetrics and Gynecology, UT Southwestern Medical Center, Dallas, Tex
| | - Kaveeta P Vasisht
- US Food and Drug Administration, Office of Women's Health, Silver Spring, Md
| | - Kevin Watt
- University of Utah School of Medicine, Salt Lake City, Utah
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21
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Decidual cell FKBP51-progesterone receptor binding mediates maternal stress-induced preterm birth. Proc Natl Acad Sci U S A 2021; 118:2010282118. [PMID: 33836562 PMCID: PMC7980401 DOI: 10.1073/pnas.2010282118] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Depression and posttraumatic stress disorder increase the risk of idiopathic preterm birth (iPTB); however, the exact molecular mechanism is unknown. Depression and stress-related disorders are linked to increased FK506-binding protein 51 (FKBP51) expression levels in the brain and/or FKBP5 gene polymorphisms. Fkbp5-deficient (Fkbp5 -/-) mice resist stress-induced depressive and anxiety-like behaviors. FKBP51 binding to progesterone (P4) receptors (PRs) inhibits PR function. Moreover, reduced PR activity and/or expression stimulates human labor. We report enhanced in situ FKBP51 expression and increased nuclear FKBP51-PR binding in decidual cells of women with iPTB versus gestational age-matched controls. In Fkbp5 +/+ mice, maternal restraint stress did not accelerate systemic P4 withdrawal but increased Fkbp5, decreased PR, and elevated AKR1C18 expression in uteri at E17.25 followed by reduced P4 levels and increased oxytocin receptor (Oxtr) expression at 18.25 in uteri resulting in PTB. These changes correlate with inhibition of uterine PR function by maternal stress-induced FKBP51. In contrast, Fkbp5 -/- mice exhibit prolonged gestation and are completely resistant to maternal stress-induced PTB and labor-inducing uterine changes detected in stressed Fkbp5 +/+ mice. Collectively, these results uncover a functional P4 withdrawal mechanism mediated by maternal stress-induced enhanced uterine FKBP51 expression and FKPB51-PR binding, resulting in iPTB.
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22
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Vomstein K, Feil K, Strobel L, Aulitzky A, Hofer-Tollinger S, Kuon RJ, Toth B. Immunological Risk Factors in Recurrent Pregnancy Loss: Guidelines Versus Current State of the Art. J Clin Med 2021; 10:869. [PMID: 33672505 PMCID: PMC7923780 DOI: 10.3390/jcm10040869] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 02/13/2021] [Accepted: 02/15/2021] [Indexed: 02/06/2023] Open
Abstract
Around 1-5% of all couples experience recurrent pregnancy loss (RPL). Established risk factors include anatomical, genetic, endocrine, and hemostatic alterations. With around 50% of idiopathic cases, immunological risk factors are getting into the scientific focus, however international guidelines hardly take them into account. Within this review, the current state of immunological risk factors in RPL in international guidelines of the European Society of Reproduction and Embryology (ESHRE), American Society of Reproductive Medicine (ASRM), German/Austrian/Swiss Society of Obstetrics and Gynecology (DGGG/OEGGG/SGGG) and the Royal College of Obstetricians and Gynecologists (RCOG) are evaluated. Special attention was drawn to recommendations in the guidelines regarding diagnostic factors such as autoantibodies, natural killer cells, regulatory T cells, dendritic cells, plasma cells, and human leukocyte antigen system (HLA)-sharing as well as treatment options such as corticosteroids, intralipids, intravenous immunoglobulins, aspirin and heparin in RPL. Finally, the current state of the art focusing on both diagnostic and therapeutic options was summarized.
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Affiliation(s)
- Kilian Vomstein
- Department of Gynecological Endocrinology and Reproductive Medicine, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria; (K.F.); (L.S.); (A.A.); (S.H.-T.); (B.T.)
| | - Katharina Feil
- Department of Gynecological Endocrinology and Reproductive Medicine, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria; (K.F.); (L.S.); (A.A.); (S.H.-T.); (B.T.)
| | - Laura Strobel
- Department of Gynecological Endocrinology and Reproductive Medicine, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria; (K.F.); (L.S.); (A.A.); (S.H.-T.); (B.T.)
| | - Anna Aulitzky
- Department of Gynecological Endocrinology and Reproductive Medicine, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria; (K.F.); (L.S.); (A.A.); (S.H.-T.); (B.T.)
| | - Susanne Hofer-Tollinger
- Department of Gynecological Endocrinology and Reproductive Medicine, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria; (K.F.); (L.S.); (A.A.); (S.H.-T.); (B.T.)
| | - Ruben-Jeremias Kuon
- Department of Gynecological Endocrinology and Fertility Disorders, Ruprecht-Karls University Heidelberg, Im Neuenheimer Feld 440, 69120 Heidelberg, Germany;
| | - Bettina Toth
- Department of Gynecological Endocrinology and Reproductive Medicine, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria; (K.F.); (L.S.); (A.A.); (S.H.-T.); (B.T.)
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23
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Smeele HT, Röder E, Wintjes HM, Kranenburg-van Koppen LJ, Hazes JM, Dolhain RJ. Modern treatment approach results in low disease activity in 90% of pregnant rheumatoid arthritis patients: the PreCARA study. Ann Rheum Dis 2021; 80:859-864. [PMID: 33568387 PMCID: PMC8237196 DOI: 10.1136/annrheumdis-2020-219547] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 01/28/2021] [Accepted: 02/04/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVES In patients with rheumatoid arthritis (RA), high disease activity impairs fertility outcomes and increases the risk of adverse pregnancy outcomes. The aim of this study was to determine the feasibility of a modern treatment approach, including treat-to-target (T2T) and the prescription of tumour necrosis factor (TNF) inhibitors, in patients with RA with a wish to conceive or who are pregnant. METHODS Patients were derived from the Preconception Counseling in Active RA (PreCARA) cohort. Patients with a wish to conceive or who are pregnant were treated according to a modified T2T approach, in which the obvious restrictions of pregnancy were taken into account. Results of the PreCARA study were compared with results of the Pregnancy-induced Amelioration of Rheumatoid Arthritis (PARA) study, a historic reference cohort on RA during pregnancy. Patients in the PARA cohort were treated according to the standards of that time (2002-2010). Differences in disease activity over time between the two cohorts were tested using a linear mixed model. RESULTS 309 patients with RA were included in the PreCARA study, 188 children were born. 47.3% of the patients used a TNF inhibitor at any time during pregnancy. Mean disease activity over time in the PreCARA cohort was lower than in the reference cohort (p<0.001). In the PreCARA cohort, 75.4% of the patients were in low disease activity (LDA) or remission before pregnancy increasing to 90.4% in the third trimester, whereas in the PARA cohort, these percentages were 33.2% and 47.3%, respectively. CONCLUSIONS This first study on a modern treatment approach in pregnant patients with RA shows that LDA and remission are an attainable goal during pregnancy, with 90.4% of patients achieving this in the third trimester.
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Affiliation(s)
| | - Esther Röder
- Rheumatology, Erasmus MC, Rotterdam, The Netherlands
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24
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Ghalandari N, Dolhain RJEM, Hazes JMW, van Puijenbroek EP, Kapur M, Crijns HJMJ. Intrauterine Exposure to Biologics in Inflammatory Autoimmune Diseases: A Systematic Review. Drugs 2020; 80:1699-1722. [PMID: 32852745 PMCID: PMC7568712 DOI: 10.1007/s40265-020-01376-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Inflammatory autoimmune diseases are chronic diseases that often affect women of childbearing age. Therefore, detailed knowledge of the safety profile of medications used for management of inflammatory autoimmune diseases during pregnancy is important. However, in many cases the potential harmful effects of medications (especially biologics) during pregnancy (and lactation) on mother and child have not been fully identified. OBJECTIVE Our aim was to update the data on the occurrence of miscarriages and (major) congenital malformations when using biologics during pregnancy based on newly published articles. Additionally, we selected several different secondary outcomes that may be of interest for clinicians, especially information on adverse events in the use of a specific biologic during pregnancy. MATERIAL AND METHODS A search was conducted from 1 January 2015 until 4 July 2019 in Embase.com, Medline Ovid, Web of Science, Cochrane CENTRAL, and Google Scholar with specific search terms for each database. Selection of publications was based on title/abstract and followed by full text (double blinded, two researchers). An overview was made based on outcomes of interest. References of the included publications were reviewed to include and minimize the missing publications. RESULTS A total of 143 publications were included. The total number of cases ranged from nine for canakinumab to 4276 for infliximab. The rates of miscarriages and major congenital malformations did not show relevant differences from those rates in the general population. CONCLUSION Despite limitations to our study, no major safety issues were reported and no trend could be identified in the reported malformations.
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Affiliation(s)
- N Ghalandari
- Department of Rheumatology, Erasmus University Medical Center, Rotterdam, The Netherlands.
- Medicines Evaluation Board (MEB), Graadt van Roggenweg 500, 3531 AH, Utrecht, The Netherlands.
- Academic Center of Inflammunity, Erasmus University Medical Center, Rotterdam, The Netherlands.
| | - R J E M Dolhain
- Department of Rheumatology, Erasmus University Medical Center, Rotterdam, The Netherlands
- Academic Center of Inflammunity, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - J M W Hazes
- Department of Rheumatology, Erasmus University Medical Center, Rotterdam, The Netherlands
- Medicines Evaluation Board (MEB), Graadt van Roggenweg 500, 3531 AH, Utrecht, The Netherlands
- Academic Center of Inflammunity, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - E P van Puijenbroek
- Netherlands Pharmacovigilance Centre Lareb, 's Hertogenbosch, The Netherlands
| | - M Kapur
- Utrecht University of Medical Sciences, Utrecht, The Netherlands
| | - H J M J Crijns
- Medicines Evaluation Board (MEB), Graadt van Roggenweg 500, 3531 AH, Utrecht, The Netherlands
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25
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Nakamura E, Kotani T, Hiramatsu Y, Hata K, Yoshikawa A, Matsumura Y, Tokai N, Wada Y, Fujita D, Takeuchi T. Simplified disease activity index and clinical disease activity index before and during pregnancy correlate with those at postpartum in patients with rheumatoid arthritis. Mod Rheumatol 2020; 31:809-816. [PMID: 32990114 DOI: 10.1080/14397595.2020.1829342] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVES We explored rheumatoid arthritis (RA) disease activity before, during, and after pregnancy in patients treated with tight control and investigated the association between disease activity in the postpartum period and those before and during pregnancy. METHODS We retrospectively reviewed disease activity and medications of 27 patients before pregnancy, at every trimester, and in the postpartum period. RESULTS Prednisolone was administered to 33% of patients with a median dose of 0 (0-2.5) mg/day and biologic agents was 78% in the third trimester. The median remission rates during all periods were the Disease Activity Score-28-C-reactive Protein assessed with three variables (DAS28-CRP-3) 85%, Simplified Disease Activity Index (SDAI) 55%, and Clinical Disease Activity Index (CDAI) 54%. Although SDAI and CDAI decreased significantly from before pregnancy to the first trimester and increased from the third trimester to the postpartum period, DAS28-CRP-3 did not change during all periods. Although SDAI and CDAI before and during pregnancy were significantly correlated with those in the postpartum period, DAS28-CRP-3 was not. CONCLUSIONS Tight control before pregnancy suppressed RA disease activity during pregnancy and in the postpartum period. SDAI/CDAI before and during pregnancy were predictive for disease activity in the postpartum period.
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Affiliation(s)
- Eri Nakamura
- Division of Rheumatology, Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Takuya Kotani
- Division of Rheumatology, Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Yuri Hiramatsu
- Division of Rheumatology, Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Kenichiro Hata
- Division of Rheumatology, Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Ayaka Yoshikawa
- Division of Rheumatology, Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Yoko Matsumura
- Division of Rheumatology, Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Nao Tokai
- Division of Rheumatology, Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Yumiko Wada
- Division of Rheumatology, Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Daisuke Fujita
- Department of Obstetrics and Gynecology, Osaka Medical College, Osaka, Japan
| | - Tohru Takeuchi
- Division of Rheumatology, Department of Internal Medicine, Osaka Medical College, Osaka, Japan
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Palmsten K, Chambers CD, Wells A, Bandoli G. Patterns of prenatal antidepressant exposure and risk of preeclampsia and postpartum haemorrhage. Paediatr Perinat Epidemiol 2020; 34:597-606. [PMID: 32207549 PMCID: PMC7819597 DOI: 10.1111/ppe.12660] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 01/16/2020] [Accepted: 01/26/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Antidepressant use later in pregnancy has been associated with preeclampsia and postpartum haemorrhage (PPH) in some studies. OBJECTIVES To evaluate the association between patterns of prenatal antidepressant dose across gestationand risk of precclampsia and PPH. METHODS We utilised OptumLabs® Data Warehouse (2012-2016) administrative health care claims, identifying 226 932 singleton liveborn deliveries for this retrospective cohort study. Antidepressant dispensing doses were converted to fluoxetine equivalents. Using k-means longitudinal, we identified women with similar patterns of antidepressant exposure, that is, trajectory groups, during the first 20 and 35 gestational weeks. We estimated risk ratios (RR) and 95% confidence intervals (CI) for the association between trajectory groups and preeclampisa (20-week groups) and PPH (35-week groups), adjusting for demographics, co-morbidities, and other psychotropic medications. Linear trend tests assessing increasing risk of the outcomes across groups were performed. RESULTS Among 15 041 (6.6%) pregnancies exposed to an antidepressant, the following trajectory groups were identified: A-low exposure, starting pregnancy at ~10 mg/d, with 1st trimester reduction/discontinuation, B-low sustained exposure of ~20 mg/d, C-moderate exposure (~40 mg/d) with 1st trimester reduction/discontinuation, D-moderate sustained exposure of ~40 mg/d, and E-high sustained exposure of ~75 mg/d. In the low exposure with reduction/discontinuation trajectory, risks were 8.2% for preeclampsia and 2.7% for PPH. Compared with this group, low, moderate, and high sustained trajectories were associated with preeclampsia (adjusted RR 1.17, 95% CI 1.01, 1.34; RR 1.31, 95% CI 1.12, 1.54; and RR 1.41, 95% CI 1.05, 1.90, respectively) and PPH (RR 1.32, 95% CI 1.05, 1.66; RR 1.35, 95% CI 1.03, 1.78; RR 2.51, 95% CI 1.69, 3.71, respectively); P < .01 for linear trend tests for both outcomes. There was no increased risk for either outcome for moderate exposure with reduction/discontinuation (trajectory C). CONCLUSIONS Women with sustained antidepressant exposure, especially at higher doses, were at increased risk for preeclampsia and PPH, but underlying depression and anxiety may contribute to the increased risk.
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Affiliation(s)
- Kristin Palmsten
- Health Partners Institute, Minneapolis, MN, Department of Pediatrics, University of California San Diego, La Jolla, CA, OptumLabs Visiting Fellow, Cambridge, MA
| | - Christina D Chambers
- Department of Pediatrics, University of California San Diego, La Jolla, CA, OptumLabs Visiting Fellow, Cambridge, MA, Department of Family Medicine and Public Health, University of California San Diego, La Jolla, CA
| | - Alan Wells
- Department of Pediatrics, University of California San Diego, La Jolla, CA
| | - Gretchen Bandoli
- Department of Pediatrics, University of California San Diego, La Jolla, CA, OptumLabs Visiting Fellow, Cambridge, MA, Department of Family Medicine and Public Health, University of California San Diego, La Jolla, CA
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27
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Palmsten K, Bandoli G, Watkins J, Vazquez-Benitez G, Gilmer TP, Chambers CD. Oral Corticosteroids and Risk of Preterm Birth in the California Medicaid Program. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:375-384.e5. [PMID: 32791247 DOI: 10.1016/j.jaip.2020.07.047] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 07/03/2020] [Accepted: 07/27/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND There is limited information regarding the impact of dose and gestational timing of oral corticosteroid (OCS) use on preterm birth (PTB), especially among women with asthma. OBJECTIVES To evaluate OCS dose and timing on PTB for asthma and, as a comparison, systemic lupus erythematosus (SLE). METHODS We used health care data from California Medicaid enrollees linked to birth certificates (2007-2013), identifying women with asthma (n = 22,084) and SLE (n = 1174). We estimated risk ratios (RR) for OCS cumulative dose trajectories and other disease-related medications before gestational day 140 and hazard ratios (HR) for time-varying exposures after day 139. RESULTS For asthma, PTB risk was 14.0% for no OCS exposure and 14.3%, 16.8%, 20.5%, and 32.7% in low, medium, medium-high, and high cumulative dose trajectory groups, respectively, during the first 139 days. The high-dose group remained associated with PTB after adjustment (adjusted RR [aRR]: 1.46; 95% confidence interval [CI]: 1.00, 2.15). OCS dose after day 139 was not clearly associated with PTB, nor were controller medications. For SLE, PTB risk for no OCS exposure was 24.9%, and it was 39.1% in low- and 61.2% in high-dose trajectory groups. aRR were 1.80 (95% CI: 1.34, 2.40) for high and 1.24 (95% CI: 0.97, 1.58) for low groups. Only prednisone equivalent dose >20 mg/day after day 139 was associated with increased PTB (adjusted HR: 2.54; 95% CI: 1.60, 4.03). CONCLUSIONS For asthma, higher OCS doses early in pregnancy, but not later, were associated with increased PTB. For SLE, higher doses early and later in pregnancy were associated with PTB.
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Affiliation(s)
- Kristin Palmsten
- Research Division, HealthPartners Institute, Minneapolis, Minn; Department of Pediatrics, University of California, San Diego, Calif.
| | - Gretchen Bandoli
- Department of Pediatrics, University of California, San Diego, Calif; Department of Family Medicine and Public Health, University of California, San Diego, Calif
| | - Jim Watkins
- Research and Analytic Studies Division, California Department of Health Services, Sacramento, Calif
| | | | - Todd P Gilmer
- Department of Family Medicine and Public Health, University of California, San Diego, Calif
| | - Christina D Chambers
- Department of Pediatrics, University of California, San Diego, Calif; Department of Family Medicine and Public Health, University of California, San Diego, Calif
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