Parity in patients with chronic inflammatory arthritides childless at time of diagnosis

Male patients with inflammatory joint diseases are less likely than controls to be childless: results from a Norwegian population-based cohort study of 10 865 patients

OBJECTIVES

To investigate the number of children per man and the proportion of childless men as a proxy of fertility in a national cohort of men with inflammatory joint diseases (IJDs), compared with matched controls from the general population.

METHODS

This is a nationwide, population-based retrospective cohort study. Male patients with IJDs (n = 10 865) in the Norwegian Arthritis Registry were individually matched 1:5 on birth year and county of residence with men without IJDs obtained from the National Population Register (n = 54 325). Birth data were obtained from the Medical Birth Registry of Norway. We compared the mean number of children per man and the proportion of childless men and analysed the impact of age and year of diagnosis.

RESULTS

The mean number of children per man in the patient group was 1.80 versus 1.69 in the comparison group (p <0.001), and 21% of the patients in the patient group were childless versus 27% in the comparison group (p <0.001). The finding of less childlessness and higher number of children per man remained consistent across age at diagnosis, except for those diagnosed at age 0-19 years. The difference in childlessness was most pronounced for men diagnosed after year 2000, especially when diagnosed at 30-39 years of age (22% vs 32%, p<0.001).

CONCLUSION

In this large cohort study we found that patients with IJD have a higher number of children and are less likely to be childless compared with controls. Factors associated with developing or having an IJD might influence fertility and this requires further investigation.

Number of children and disability pension due to mental and musculoskeletal disorders: A longitudinal register-based study in Norway

Earlier research has documented a relationship between parity and all-cause mortality, as well as parity and cause-specific mortality (e.g. cancer and cardiovascular disease mortality). Less is known about the relationship between parity and two very common (but less deadly) types of disorder: mental and musculoskeletal. We examine the association between parity and risk of disability pensioning from all causes and due to mental or musculoskeletal disorders, using Norwegian register data. In addition to controlling for adult socio-demographic characteristics, we control for unobserved confounding from family background by estimating sibling fixed-effects models. We find a higher risk of disability pensioning among the childless and those with one child than for parents with two children, both for all causes combined and for mental disorders. Childless men and fathers with one child also experience excess risk of being pensioned due to musculoskeletal disorders. For mental disorders, we find a positive association with high parity, particularly for men.

Immunology of pregnancy and reproductive health in autoimmune rheumatic diseases. Update from the 11th International Conference on Reproduction, Pregnancy and Rheumatic Diseases

Autoimmune rheumatic diseases (ARD) can affect women and men during fertile age, therefore reproductive health is a priority issue in rheumatology. Many topics need to be considered during preconception counselling: fertility, the impact of disease-related factors on pregnancy outcomes, the influence of pregnancy on disease activity, the compatibility of medications with pregnancy and breastfeeding. Risk stratification and individualized treatment approach elaborated by a multidisciplinary team minimize the risk of adverse pregnancy outcomes (APO). Research has been focused on identifying biomarkers that can be predictive of APO. Specifically, preeclampsia and hypertensive disorders of pregnancy tend to develop more frequently in women with ARD. Placental insufficiency can lead to intrauterine growth restriction and small-for-gestational age newborns. Such APO have been shown to be associated with maternal disease activity in different ARD. Therefore, a key message to be addressed to the woman wishing for a pregnancy and to her family is that treatment with compatible drugs is the best way to ensure maternal and fetal wellbeing. An increasing number of medications have entered the management of ARD, but data about their use in pregnancy and lactation are scarce. More information is needed for most biologic drugs and their biosimilars, and for the so-called small molecules, while there is sufficient evidence to recommend the use of TNF inhibitors if needed for keeping maternal disease under control. Other issues related to the reproductive journey have emerged as "unmet needs", such as sexual dysfunction, contraception, medically assisted reproduction techniques, long-term outcome of children, and they will be addressed in this review paper. Collaborative research has been instrumental to reach current knowledge and the future will bring novel insights thanks to pregnancy registries and prospective studies that have been established in several Countries and to their joint efforts in merging data.

Risk of pre-eclampsia and impact of disease activity and antirheumatic treatment in women with rheumatoid arthritis, axial spondylarthritis and psoriatic arthritis: a collaborative matched cohort study from Sweden and Denmark

Objective

To explore the risk of pre-eclampsia in rheumatoid arthritis (RA), axial spondyloarthritis (AxSpA) and psoriatic arthritis (PsA), focusing on the impact of treatment and disease activity.

Methods

We identified RA, AxSpA and PsA singleton pregnancies (2006–2018) by linking medical birth registers to Swedish (SRQ) and Danish (DANBIO) rheumatology registers. Control pregnancies from the medical birth registers were matched 1:10 on maternal age, parity and birth year.

We obtained information on antirheumatic treatment before and during pregnancy and disease activity during pregnancy. Risks of pre-eclampsia in RA, AxSpA and PsA pregnancies, compared with control pregnancies, were estimated overall and by antirheumatic treatment (conventional synthetic disease-modifying antirheumatic drug (DMARD)/biological DMARD/corticosteroids, as monotherapy or combination therapy) and disease load (Health Assessment Questionnaire≥1/C-reactive protein≥10/Disease Activity Score in 28 joints≥3.2) through logistic regression (adjusted ORs (aORs) with 95% CI).

Results

We observed 69, 34, and 26 pre-eclampsia events among RA (n=1739), AxSpA (n=819) and PsA (n=489), resulting in a risk of pre-eclampsia of, respectively, aOR 1.27 (95% CI 0.96 to 1.67), 1.17 (0.76 to 1.78) and 1.85 (1.10 to 3.12), compared with controls.

For RA, maternal combination therapy before and during pregnancy was associated with increased risk (1.59; 1.07 to 2.37 and 1.53; 0.97 to 2.39, respectively). For PsA, maternal monotherapy before pregnancy was associated with pre-eclampsia (2.72; 1.4 to 5.13). In RA pregnancies with available information (43%), high disease load was associated with doubled risk of pre-eclampsia (aOR 1.96; 1.26 to 3.04).

Conclusion

PsA pregnancies, but not AxSpA pregnancies, were at increased risk of pre-eclampsia. For RA, combination therapy (potentially a surrogate for high disease activity both before and during pregnancy) and high disease load during pregnancy might be a risk factor for pre-eclampsia.

The Impact of Pediatric Rheumatic Diseases on Sexual Health, Family Planning, and Pregnancy

A comprehensive review of reproductive health subtopics, including sexual intercourse, romantic relationships, contraception, sexually transmitted infections, pregnancy, and infertility, as they pertain to patients with pediatric rheumatic diseases and those who care for them.

[Insights into pregnancy and breastfeeding in inflammatory rheumatic diseases through observational data]

Information on pregnancy and breastfeeding in women with chronic inflammatory rheumatic diseases is relevant for a successful pregnancy and also for maternal and child health. In general, pregnant and breastfeeding women are excluded from randomized clinical trials and therefore evidence for clinical care and counselling has to be generated from observational studies. In the past decades, various data collections have been established for this purpose in addition to the existing spontaneous reporting systems initiated by drug authorities, with the aim of monitoring the teratogenic risk of a drug. Health insurance claims data, electronic health records and Scandinavian registers are also increasingly being used for research on pregnancy-associated events; however, all these data sources lack the inclusion of the maternal disease, especially with respect to its inflammatory component. Established cohort studies, biologics and disease registries record disease activity but are not designed for pregnancy-specific questions. Pregnancy registries and studies in rheumatology close this gap. In order to be able to make a better assessment of the possibilities and limitations of existing data sources on pregnancy and lactation, they are presented in detail in the following review including their respective advantages and disadvantages and examples from rheumatology are given. In addition, existing collaborations as well as studies for investigating the influence of paternal rheumatic disease are highlighted.

Views of Mexican outpatients with rheumatoid arthritis on sexual and reproductive health: A cross-sectional study

BACKGROUND

Rheumatoid arthritis (RA) impacts sexual and reproductive health (SRH), which is a prominent component of a patient´s quality of life and highly influenced by the cultural background. The aim of the study was to explore the interest of Mexican outpatients with RA in SRH and to examine patient view on SRH.

METHODS

This cross-sectional study surveyed 303 consecutive outpatients with RA on their perceptions of SRH importance, SRH satisfaction, access to SRH information, preferences regarding SRH communication with healthcare professionals, and understanding of SRH (qualitative open-ended descriptions). Descriptive statistics and inferential analysis were used. Patient knowledge of each dimension of SRH was rated based on pre-specified criteria. Two assessors assigned ten major themes to each patient´s description of both dimensions of SRH.

RESULTS

Patients perceived their SRH as an important component of their general health and wished to address the topic, although few had access to such communication. Female patients assigned lesser importance to SRH, showed lesser degree of satisfaction with SRH, and expressed preference for a truthful physician. Age showed a linear association with individual survey responses, except for satisfaction with reproductive health dimension. There was a linear association between increased age and decreased years of formal education with a lower level of SRH knowledge. Ten major themes emerged for each of the two dimensions of the SRH construct, although most individual descriptions were assigned to one or two major themes.

CONCLUSIONS

Further education and assessment of SRH in Mexican patients with RA is warranted.

Regulating Gut Microbiome: Therapeutic Strategy for Rheumatoid Arthritis During Pregnancy and Lactation

Rheumatoid arthritis (RA) is an autoimmune disease characterized by synovial inflammation and bone destruction. Microbial infection is considered to be the most important inducement of RA. The pregnancy planning of women in childbearing age is seriously affected by the disease activity of RA. Gut microbiome, related to immunity and inflammatory response of the host. At present, emerging evidence suggested there are significant differences in the diversity and abundance of gut microbiome during pregnancy and lactation, which may be associated with the fluctuation of RA disease activity. Based on these research foundations, we pioneer the idea of regulating gut microbiome for the treatment of RA during pregnancy and lactation. In this review, we mainly introduce the potential treatment strategies for controlling the disease activity of RA based on gut microbiome during pregnancy and lactation. Besides, we also briefly generalize the effects of conventional anti-rheumatic drugs on gut microbiome, the effects of metabolic changes during pregnancy on gut microbiome, alteration of gut microbiome during pregnancy and lactation, and the effects of anti-rheumatic drugs commonly used during pregnancy and lactation on gut microbiome. These will provide a clear knowledge framework for researchers in immune-related diseases during pregnancy. Regulating gut microbiome may be a potential and effective treatment to control the disease activity of RA during pregnancy and lactation.

Fertility and infertility implications in rheumatoid arthritis; state of the art

BACKGROUND

A bulk of investigations imply that women with rheumatoid arthritis (RA) deliver fewer children in comparison to healthy women.

PURPOSE

This review article attempts to clarify the involvement of infertility-related issues in both RA men and women. Moreover, the effect of RA disease on the fertility quality and quantity will be discussed.

RESULTS

Declined fertility rate in RA women seems to stem from modified inflammatory settings, advanced maternal age, limited sexual activity, and adverse effects of drugs on ovarian function. Women with RA may have smaller families and seem to be slower to conceive relative to their peer women. The chance of gestation in RA women may drop due to suppressed sexual function through pain and fatigue. In addition, treatment of RA women with non-steroidal anti-inflammatory drugs (NSAIDs) may prevent ovulation and therefore hinder the conception.

CONCLUSIONS

A complex interaction between RA disease and fertility related issues is present. Despite an increase rate of infertility in RA females or males, the mechanisms involved in this outcome is still unknown. Plausible causes of the decreased fertility rate in RA patients might be due to inflammatory cytokines, suppressed sexual activity, drug treatments, mother age, personal choice, or a combination of these elements.

Factors Associated With Time to Pregnancy in Women With Axial Spondyloarthritis: A Registry-Based Multicenter Study

OBJECTIVE

The present study was undertaken to study time to pregnancy (TTP) and factors associated with TTP in women with axial spondyloarthritis (SpA) compared to women with rheumatoid arthritis (RA).

METHODS

We included 274 women with axial SpA and 317 women with RA from the Norwegian nationwide registry RevNatus. For all the women, we had retrospectively collected data on TTP, and a subgroup also had prospectively collected data. We compared TTP in women with axial SpA to women with RA using Kaplan-Meier plots and a log rank test. To identify factors associated with TTP, we used Cox proportional hazards regression.

RESULTS

TTP exceeded 12 months in 21% of women with axial SpA. In the subgroup followed prospectively, 32% had TTP that exceeded 12 months. Longer TTP was associated with older age, nulliparity, and longer disease duration, with hazard ratios of 0.97 (95% confidence interval [95% CI] 0.94-1.00), 0.66 (95% CI 0.50-0.88), and 0.94 (95% CI 0.91-0.98), respectively. Disease activity, medication, and self-reported health-related quality of life were not associated with TTP. We found no statistically significant differences between axial SpA and RA in regard to TTP.

CONCLUSION

In women with axial SpA, longer TTP was associated with older age, nulliparity, and longer disease duration.

Decreased chance of a live born child in women with rheumatoid arthritis after assisted reproduction treatment: a nationwide cohort study

OBJECTIVES

No studies have examined the efficacy of assisted reproductive technology (ART) treatment in women with rheumatoid arthritis. Therefore, we examined the chance of live birth after ART treatment in women with rheumatoid arthritis compared with women without rheumatoid arthritis.

METHODS

Our cohort study is based on nationwide Danish health registries, comprising all women with an embryo transfer during 1 January 1994 through 30 June 2017. The cohorts comprised 1149 embryo transfers in women with rheumatoid arthritis, and 198 941 embryo transfers in women without rheumatoid arthritis. Our outcome was live birth per embryo transfer, and we controlled for multiple covariates in the analyses. In subanalyses, we examined a chance of biochemical/clinical pregnancy after ART and a possible impact of corticosteroid use prior to embryo transfer.

RESULTS

The adjusted OR (aOR) for a live birth per embryo transfer in women with rheumatoid arthritis, relative to women without rheumatoid arthritis, was 0.78 (95% CI 0.65 to 0.92). The aORs for biochemical and clinical pregnancies were 0.81 (95% CI 0.68 to 0.95) and 0.82 (95% CI 0.59 to 1.15), respectively. Corticosteroid prescription prior to embryo transfer increased the OR for live birth (aOR=1.32 (95% CI 0.85 to 2.05)).

CONCLUSIONS

The chance of a live birth was significantly reduced in women with rheumatoid arthritis receiving ART treatment, relative to women without rheumatoid arthritis, and our result suggested that the problem was related to an impaired chance of embryo implantation. The role of corticosteroid use prior to embryo transfer must be a subject for further research.

Age at natural menopause in women on long-term methotrexate therapy for rheumatoid arthritis

OBJECTIVE

The aim of the study was to compare the natural menopause ages of healthy women with those of women with methotrexate (MTX)-treated rheumatoid arthritis (RA), and to specifically assess the effect of disease onset and activity and the use of MTX on the age of the last menstruation.

METHODS

We performed a retrospective review of medical records to identify the ages at which menopause occurred in women with premenopausal RA treated with MTX and in women with postmenopausal onset, irrespective of therapy. Natural menopause ages were also compared between participants with and without RA.

RESULTS

Women with premenopausal onset of RA underwent menopause at a significantly younger age than did healthy women (P < 0.001) or those with postmenopausal disease onset (P = 0.001). Menopause also occurred at younger ages in participants with postmenopausal disease onset than in healthy controls (P = 0.012). The study suggested that menopause age was positively correlated with the age at which RA was diagnosed (R = 0.51; P < 0.001) in women with premenopausal RA onset, but was independent of the participant's age at menarche, number of pregnancies, or MTX therapy. Participants with RA onset at ≤ 35 years of age had a ninefold higher risk of premature menopause (P = 0.008).

CONCLUSIONS

The age at which menopause occurs in a patient with RA depends on the patient's age at the time of disease onset and its duration, but is not influenced by MTX treatment.

Fertility, Pregnancy, and Lactation in Rheumatoid Arthritis

Fertility is impaired in women with rheumatoid arthritis (RA), whereas less is known about male fertility problems. Pregnancy outcome in patients with RA is slightly less favorable compared with the general population, especially in patients with active disease. Disease activity usually improves during pregnancy, but less than previously thought. Although several antirheumatic drugs are contraindicated in pregnancy, more treatment options are available. There is evidence on the safety of TNF inhibitors in pregnancy. Given the impact of active disease on fertility and pregnancy outcome, a treat-to-target strategy is recommended for patients who are pregnant or have a wish to conceive.

Outcomes in mothers with rheumatic diseases and their offspring workshop

This conference report describes six presentations that were given during a Canadian Institutes for Health Research-funded workshop. The goal of the workshop was to discuss key knowledge gaps in the study of outcomes in mothers with rheumatic diseases and their offspring. Presentations focused on epidemiological and methodological issues associated with the reproductive and perinatal health of women with rheumatic diseases. Discussions of relevant recent research allowed for discovery of potential data sources that could facilitate interdisciplinary research and created the opportunity for future collaborations.

Management of rheumatoid arthritis during pregnancy: challenges and solutions

Rheumatoid arthritis, a chronic inflammatory autoimmune disease with significant physical disability, affects women three times more frequently than men, often in their childbearing years. Parenthood decisions can be challenging, often affected by perceptions of their disease state, health care needs, and complex pharmacological treatments. Many women struggle to find adequate information to guide them on pregnancy planning, lactation, and early parenting in relation to their chronic condition. The expanded availability and choice of pharmacotherapies have supported optimal disease control prior to conception and enhanced physical capabilities for women to successfully overcome the challenges of raising children but require a detailed understanding of their risks and safety in the setting of pregnancy and breastfeeding. This review outlines the various situational challenges faced by rheumatologists in providing care to men and women in the reproductive age group interested in starting a family. Up to date evidence-based solutions particularly focusing on the safe use of disease-modifying antirheumatic drugs and biologic response modifiers to assist rheumatologists in the care of pregnant and lactating women with RA are reviewed.

Pregnancy and rheumatoid arthritis

Fertility is impaired in female patients with rheumatoid arthritis (RA), which is related to disease activity and the use of certain medication. During pregnancy, disease activity usually improves, but less than previously thought. Especially in women with high disease activity, the pregnancy outcome is also impaired. All of this underscores the importance of strict control of disease activity in RA patients who wish to conceive. Management of RA disease activity during pregnancy might be a challenge as the treatment options are limited. Evidence is accumulating that tumor necrosis factor (TNF) blockers can be safely used during pregnancy, particularly during the first trimester and the beginning of the second trimester. Far less is known about the problems faced by male RA patients who wish to conceive, in terms of not only fertility and pregnancy outcome but also the safety of medication. In this paper, the fertility issues in patients with RA, the pregnancy-associated improvement of RA, the pregnancy outcomes, including the long-term effects on the offspring, and treatment options, including those during lactation and for male patients wishing to conceive, will be reviewed.

Reproductive outcomes and nononcologic complications after radioactive iodine ablation for well-differentiated thyroid cancer

BACKGROUND

Radioactive iodine (RAI) ablation is frequently performed after initial surgery for well-differentiated thyroid cancer (WDTC). We examined the frequency and timing of childbirth as well as nononcologic complications after RAI ablation for WDTC on a population level.

METHODS

A retrospective cohort study of 25,333 patients (18,850 women) with WDTC was performed using the California Cancer Registry and California Office of Statewide Health Planning and Development database, 1999-2008. The primary outcomes were birthrate and median time to first live birth among women of childbearing age. Secondary outcomes were nononcologic diagnoses occurring outside the acute setting (>30 days) after ablation.

RESULTS

RAI ablation did not affect birthrate among women in the full dataset. However, in subgroup analyses, birthrate among women age 35-39 was significantly decreased in those who received RAI versus those who did not (11.5 versus 16.3 births per 1000 woman-years, p<0.001). Median time to first live birth after diagnosis of WDTC was prolonged among women who received RAI compared to those who did not (34.5 versus 26.1 months; p<0.0001). When 5-year age groups were examined individually, delay to first live birth was observed in women age 20-39 (p<0.05). This remained significant after adjustment for tumor characteristics, socioeconomic status, and marital status. The only nononcologic, nonreproductive adverse effect associated with RAI ablation was an increased rate of nasolacrimal stenosis (RR 3.44, p<0.0001).

CONCLUSIONS

RAI ablation is associated with delayed childbearing in women across most of the reproductive lifespan, and with decreased birthrate in the late reproductive years. The underlying mechanism likely involves physician recommendation to delay pregnancy, as well as a potential impact of RAI on both reproductive choice and reproductive health. Further investigation is merited.

Fertility in women with rheumatoid arthritis: influence of disease activity and medication

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

TTP in RA is longer if patients are older or nulliparous, have higher disease activity, use NSAIDs or use prednisone >7.5 mg daily. Preconception treatment strategies should aim at maximum suppression of disease activity, taking account of possible negative effects of NSAIDs use and higher prednisone doses.