Measuring multiple etanercept levels in the breast milk of a nursing mother with rheumatoid arthritis

Biologics During Pregnancy and Breastfeeding Among Women With Rheumatic Diseases: Safety Clinical Evidence on the Road

Females are generally more affected by autoimmune diseases, a fact that underlines the relationship with pregnancy and the safety of anti-rheumatic drugs in pregnancy and lactation. Biologic therapies are increasingly prescribed to treat and maintain remission in a significant number of systemic autoimmune rheumatic diseases. The experience with the use of biologics during gestation is extremely lacking because of the observational nature of the available studies and the difficulty in designing proper clinical trials in pregnancy. Among the studied biologics, more information was published on TNFα inhibitors and, in particular, on their potential passage through the placenta and impact on the fetus. Currently, a fragment of anti-TNFα monoclonal IgG, certolizumab pegol, is considered safe with almost no placental transfer. Subsequent observations are suggesting a comparable safety for the soluble TNFα receptor etanercept. Another biologic, eculizumab, the anti-C5a antibody used to treat complement-mediated microangiopathies, is also considered safe due to the unique engineered IgG2/4κ formulation that limits its passage through the placental barrier. Still, long-term data about children born to women treated with biologics in pregnancy are not attainable. Data on breastfeeding are currently available for several biologics. This article reviews the literature available about which drugs are considered safe during pregnancy and lactation, which are not, and on future prospects.

The use of biological drugs in psoriasis patients prior to pregnancy, during pregnancy and lactation: a review of current clinical guidelines

Introduction

Information on the possibility of using biological drugs in psoriasis patients planning to conceive, patients who are pregnant or during lactation is limited.

Aim

Presenting recommendations published in clinical guidelines regarding the use of biological drugs – adalimumab, brodalumab, certolizumab pegol, etanercept, guselkumab, infliximab, ixekizumab, risankizumab, secukinumab, tildrakizumab, and ustekinumab, by psoriasis patients in the period of planning pregnancy, during pregnancy or during lactation.

Material and methods

The paper was based on a comprehensive review of over 40 websites of HTA agencies, dermatological associations worldwide and medical databases (PubMed, Embase), the objective of which was to identify clinical guidelines relating to biological treatment of women of childbearing potential, published after 2018, which used GRADE – a system for rating the quality of a body of evidence.

Findings

Certolizumab pegol is recommended in women who are planning to conceive. Furthermore, guidelines indicate other TNF-α inhibitors as possible treatment. Certolizumab pegol is also recommended as first-line treatment in pregnant patients. Furthermore, for trimesters 2 and 3, guidelines allow using other TNF-α inhibitors. Treatment with secukinumab and ustekinumab should be discontinued when planning pregnancy or when pregnancy was diagnosed. Biological treatment during pregnancy and lactation (continuation or initiation of treatment) can be used only after an analysis of risks and benefits has been conducted.

Conclusions

TNF-α inhibitors seem to be the safest and most researched biological drugs used in psoriasis treatment of patients planning to conceive, during pregnancy or lactation. Given its non-existent or minimal placental permeability, most likely the safest alternative is certolizumab pegol.

2018 APLAR axial spondyloarthritis treatment recommendations

INTRODUCTION

Despite the availability of axial spondyloarthritis (SpA) recommendations proposed by various rheumatology societies, we considered that a region-specific guideline was of substantial added value to clinicians of the Asia-Pacific region, given the wide variations in predisposition to infections and other patient factors, local practice patterns, and access to treatment across countries.

MATERIALS AND METHODS

Systematic reviews were undertaken of English-language articles published between 2000 and 2016, identified from MEDLINE using PubMed, EMBASE and Cochrane databases. The strength of available evidence was graded using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. Recommendations were developed through consensus using the Delphi technique.

RESULTS

Fourteen axial SpA treatment recommendations were developed based on evidence summaries and consensus. The first 2 recommendations cover non-pharmacological approaches to management. Recommendations 3 to 5 describe the following: the use of non-steroidal anti-inflammatory drugs as first-line symptomatic treatment; the avoidance of long-term corticosteroid use; and the utility of conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs) for peripheral or extra-articular manifestations. Recommendation 6 refers to the indications for biological DMARDs (bDMARDs). Recommendation 7 deals specifically with screening for infections endemic to Asia, prior to use of bDMARDs. Recommendations 7 to 13 cover the role of bDMARDs in the treatment of active axial SpA and include related issues such as continuing therapy and use in special populations. Recommendation 14 deals with the utility of surgical intervention in axial SpA.

CONCLUSION

These recommendations provide up-to-date guidance for treatment of axial SpA to help meet the needs of patients and clinicians in the Asia-Pacific region.

Special aspects of biologics treatment in psoriasis: management in pregnancy, lactation, surgery, renal impairment, hepatitis and tuberculosis

Background of the article: Biologics are modern immunomodulatory drugs, whose use in the treatment of psoriasis has led to remarkable results in psoriatic patients. The administration of these agents in special population groups, such as patients with chronic infections and renal impairment, as well as perioperative, pregnant or lactating patients, has not been thoroughly addressed, mostly because these patients are excluded from clinical studies. Materials and methods: This report is an updated systematic overview of the use of biologics in the above-mentioned types of patients and was conducted according to the PRISMA Guidelines for systematic reviews. Articles derived from the databases PubMed, EMBASE and SCOPUS, published between 1999 and 2018, were analyzed for the study. Results: Research efforts as well as clinical reporting are necessary in order to provide more insight on the management of these therapeutic dilemmas. Conclusion: The aim of this review, other than providing a summarized update on the clinical knowledge on this special topic, is also to raise awareness for the need to conduct larger systematic studies in order to adequately evaluate the use of biologics in these special patient categories and therefore draw definite conclusions on their safety profile.

Systemic medications used in treatment of common dermatological conditions: safety profile with respect to pregnancy, breast feeding and content in seminal fluid

Prescribing for pregnant or lactating patients and male patients wishing to father children can be a difficult area for dermatologists. There is a lack of review articles of commonly used systemic medications in dermatology with respect to their effects on developing embryogenesis and their potential transfer across the placenta, in breast milk and in seminal fluid. This paper aims to provide an up to date summary of evidence to better equip dermatologists to inform patients about the effects of systemic medications commonly used in dermatology to treat conditions such as atopic dermatitis, psoriasis and acne, on current and future embryogenesis and fertility.

Not all TNF inhibitors in rheumatoid arthritis are created equal: important clinical differences

INTRODUCTION

Anti-TNF therapy has dramatically changed how we manage rheumatoid arthritis. There are many similarities among the five approved agents but also some important differences. Rheumatologists have 5 different options to choose from when they are ready to commence anti-TNF therapy. Although all block the TNF cytokine, there are important critical differences among them that affect their safety profile and clinical utility in certain scenarios. Unfortunately, there are no head to head trials to compare the different anti-TNF agents and none appear to be in the horizon. Areas covered: This article reviews the various clinical situations where it may be important to use a particular anti-TNF agent. The authors also give their expert opinion and future perspectives on the area. Expert opinion: Although there are many similarities among the five different TNFi that are clinically available, there are important clinical niches, where the limited data that are available, that clearly support the preferential use of a particular agent or class of agents. Assays or tests that allow us to find the 'sweet spot' of TNF inhibition at the level of each patient are long overdue.

Minimal to no transfer of certolizumab pegol into breast milk: results from CRADLE, a prospective, postmarketing, multicentre, pharmacokinetic study

Background

Women with chronic inflammatory diseases face uncertainty regarding the safety of biologics during breast feeding. CRADLE was the first industry-sponsored study to evaluate certolizumab pegol (CZP) concentrations in human breast milk and estimate average daily infant dose (ADID) of maternal CZP.

Methods

CRADLE (NCT02154425) was a pharmacokinetic study of lactating mothers receiving CZP. After ≥3 CZP doses, breast milk samples were collected across one dosing period (14 days for 200 mg every 2 weeks [Q2W]; 28 days for 400 mg every 4 weeks [Q4W]). Optimal analytical methods were developed to determine CZP and polyethylene glycol (PEG) levels in breast milk. ADID and relative infant dose (RID) were estimated. Safety events in mothers and infants were assessed.

Results

19 CZP-treated mothers were screened; 17 entered the sampling period: 16 on 200 mg Q2W, 1 on 400 mg Q4W. 77/137 (56%) breast milk samples had no measurable CZP. For 4/17 mothers, all samples were below the lower limit of quantification (LLOQ). Estimated ADID was 0–0.0104 mg/kg/day; median RID: 0.15%. PEG was undetectable in 134/137 samples (results could not be determined in three samples). Infants of CZP-exposed mothers had a safety profile consistent with that of unexposed similar-age infants.

Conclusion

When quantifiable, CZP concentrations were <3× LLOQ (<1% plasma concentration observed with therapeutic dose), indicating no/minimal CZP transfer from plasma to breast milk. RID was 0.15% of maternal dose; <10% is considered unlikely to be of clinical concern. No PEG transfer was observed. CZP absorption by infants via breast milk is unlikely due to its low oral bioavailability and Fc-­free molecular structure. These findings are reassuring and support continuation of CZP treatment during breast feeding.

Trial registration number

NCT02154425; Results.

[New horizons in the use of biological agents during pregnancy in patients with rheumatic disease]

Pregnancy in the presence of rheumatic diseases (RD) and adequate therapy before planned conception, during gestation, and after delivery during lactation is challenging. Advances in the treatment of RD are largely due to the clinical introduction of a new class of biological agents (BAs). There are less than two decades of experience in using BAs in rheumatology and to date there are no unified standards and accepted rules governing their use during pregnancy. According to the current requirements, information on a medicine should be given in three sections: 1) pregnancy; 2) lactation, and 3) use in men and women who are planning concept (the latter section has appeared for the first time). The present article summarizes data on the possible use of BAs in patients with RD during pregnancy planning, pregnancy, and breastfeeding.

Lactation and Management of Postpartum Disease

While much of the existing literature in the field of reproductive rheumatology focuses on fertility, preconception counseling, and pregnancy, there is limited information regarding the postpartum period and lactation. Evidence suggests that many rheumatologic disorders flare after delivery, which, along with limitations in medications compatible with breastfeeding, make this time period challenging for women with rheumatologic conditions. This article discusses rheumatologic disease activity during the postpartum period and reviews the safety during lactation of commonly used medications for the management of rheumatic diseases. Fortunately, many of the commonly used medications are compatible with breastfeeding.

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.

Safety of biological therapies for psoriasis: effects on reproductive potential and outcomes in male and female patients

The effects of biological therapies for psoriasis on pregnancy outcomes and lactation, and male fertility and mutagenicity are common concerns in the clinical setting. There is relatively little evidence to guide the clinician and patient. Here, we review the safety profile of the commonly used biological therapies for psoriasis in individuals of reproductive potential. Safety data were derived from large-scale registries, adverse event reporting databases, clinical trials and case reports. We assessed the effect of each therapy on adverse pregnancy outcomes including congenital malformations, and lactation with maternal administration, and male fertility and potential mutagenicity with paternal administration. We provide applicable guidance to inform clinician and patient before and after conception.

Biologic therapies and pregnancy: the story so far

Biologic therapies have revolutionized treatment outcomes for patients with inflammatory arthritis. However, there remains a concern regarding their safety during conception, pregnancy and breastfeeding. Data on the safety of these treatments are largely limited to uncontrolled case reports. Collective evidence from many hundreds of pregnancies in inflammatory arthritis and IBD have suggested that exposure to anti-TNF therapies at the time of conception or during the first trimester does not result in an increased risk of adverse pregnancy and fetal outcomes. Monoclonal antibodies, and to a lesser extent recombinant fusion proteins, do cross the placenta during the second and third trimester and are functional in the fetus, as evidence by lymphopaenia reported at birth in children exposed to rituximab in utero. In addition, live vaccines should be avoided in children with in utero exposure to biologics for at least the first 6 months of life. The longer-term effects of in utero exposure remain unknown. Studies suggest that many of these drugs do enter breast milk in small amounts, but the extent to which they are absorbed by the infant is less clear. Limited reports have not suggested adverse pregnancy outcomes in women whose partners were exposed to anti-TNF therapies or rituximab at the time of conception. Data on other biologic therapies, including anakinra, abatacept and tocilizumab, in both men and women remain extremely limited.

Safety of Tumor Necrosis Factor Inhibitors during Pregnancy and Breastfeeding

PURPOSE

Tumor necrosis factor (TNF) inhibitors are useful in the treatment of numerous inflammatory and immunologic disorders. Since many of these conditions occur in women of childbearing age, safety during pregnancy and breastfeeding is of considerable importance.

METHODS

This paper is a review of the literature on the safety of TNF inhibitors during pregnancy and breastfeeding published between 2001 and 2011.

CONCLUSIONS

TNF inhibitors do not appear to be associated with a high risk of teratogenicity or intrauterine death. However, a small magnitude increase in risk cannot be ruled out given the paucity of data on the subject. Although TNF inhibitor use may be associated with a higher rate of preterm delivery, this may in fact be due to an active, underlying disease. Therefore, the decision to use these medications should be made on a case-by-case basis. If the disease cannot be managed with first line agents, TNF inhibitors may be helpful in reducing the number of disease exacerbations. Nevertheless, when using TNF inhibitors, it is prudent to discontinue treatment around the third trimester when transfer across the placenta is greatest and to restart postpartum.

[Anti-TNFα therapy and its implication in gynecology and obstetrics]

Anti-TNFα treatments have modified the medical care, the course and the quality of life of the patients with autoimmune rheumatic, cutaneous or bowel inflammatory diseases. On the other hand, these treatments may have potential severe side effects during pregnancy (congenital malformations, fetal infections). Actually, many pregnancies have been reported during anti-TNFα exposures, with good maternal and neonatal outcomes. The introduction or the discontinuation of these treatments will always have to be discussed with the specialist of the chronic disease and, ideally, during a preconceptional counselling. In gynecology, anti-TNFα drugs may offer a new safe and effective approach to treating patients with recurrent miscarriages or unexplained or failed in vitro fertilization cycles. On the other hand, these treatments significantly increase the risk for serious infections or viral reactivations and may promote gynaecological malignancies. An adapted gynaecological survey is necessary.