QD103 Biologics And Pregnancy Save

This is QD Clinic. I'm Jack Cush with RheumNow. QD Clinic is brought to you by RheumNow's virtual coverage where we give you a front row seat to what everyone's saying about virtual ACR twenty twenty. That includes key opinion leaders, RheumNow faculty, people you know and trust. Today's case is biologics in pregnancy.

Saw recently a 19 year old gal who has Still's disease is taking anakinra and a DMARD, let's just say hydroxychloroquine. And the question is, what do I do? I'm twelve weeks pregnant or I'm three weeks pregnant, and should I stop my medicine? Should I continue my medicine? And, of course, the OBGYN is not going to know.

If you have a great OBGYN, they will call you. If you've got a well trained patient, they will call you. I think the issue here is what are you going to do to get the right ask or direction when they do get pregnant? That is training, meaning that is a discussion between you and your patient who's of childbearing potential saying, if you get pregnant, call me, I'll tell you what to do. If you get pregnant, tell your OBGYN to call me, I'll tell them what to do.

So, this was easy. The patient, has well controlled disease, she was told to continue her medicines which are safe during pregnancy. And basically, most of our biologics are safe during pregnancy, although there are no studies to truly prove that. There's a lot of data on TNF inhibitors in pregnancy, and it looks very, very good. There's a lot of data on a lot of DMARDs.

The only drugs you shouldn't use that are absolutely verboten during pregnancy is number one number one, number two, number five, mycophenolate. That's our biggest offender. That's our biggest teratogen. Most people think methotrexate and leflinamide. Yes.

You don't take those during pregnancy because of what they might do to the baby. But in fact, are a lot of case reports of successful pregnancies conceived on leflunomide and on methotrexate, not so much so for mycophenolate. Same can be said for cytotoxin and other cytotoxic agents. But everything else, you know, azathioprine, cyclosporine, you know, and all the biologics have been fairly well studied, and it seems like that's something that you need to do. Here are the things you need to know about managing one of your patients who becomes pregnant and is taking anti rheumatic therapy and or a biologic.

Number one, the most important thing is to ensure the mater the mother's health and stability. And you know this from managing your lupus patients. They have to go into pregnant pregnancy being stable, unstable meds. Otherwise, they're gonna flare, their lupus is gonna flare, the baby's gonna have a bad outcome. The baby's outcome is directly tied to maternal health, more so than the drug that the mother's taking.

So the drug you use to manage the mother is important in keeping the mother healthy, so you continue it so they'll do well. And so, again, most people think about, oh, the drugs and all the drugs, we need to stop that. You know, first time moms don't wanna be on any drugs. Funniest thing I ever heard, smartest thing I ever heard was Megan Clouse and I were on a a discussion panel once, and she was talking about first time mothers are like, no. I don't want nothing.

I'm taking everything off. On on the other hand, third time mothers, multi multiparous women, they're like, give me the drugs. I'll take them, and because they know they're gonna make a baby and they wanna make sure that their disease is well controlled. Second issue, if they're in remission, then you have to make the really difficult decision about whether to stop the drug once they become pregnant or to continue it. There is a reflex, and I must say most rheumatologists with TNF inhibitors, for instance, would let the person get pregnant, and then once it's they're pregnant, they stop.

There is a fair amount of observational research out there that shows the women who stop versus the women who continue, the women who continue do better. The women who stop tend to have a few more complications of pregnancy, not so much, you know, dangerous things happening to the fetus, but, you know, more problems in the pregnancy, premature delivery, abnormal delivery, things like that. So, might be better to continue a medicine that's working really, really well. Don't rock the boat. Something that most rheumatologists don't think about, and that is once you're beyond week ten of the pregnancy, you can use any drug you want to use, including cytotoxics, because you don't want to have those drugs on board during organogenesis.

And that's really the first eight weeks. So, beyond ten weeks, beyond twelve weeks, you can start abatacept, you can start cyclosporine, you can start tacrolimus, you can start whatever you need to start to control the disease because remember, maternal disease control is paramount to making a good baby. Next, nonsteroidals. You can use them throughout. You can use them to conceive, probably not celecoxib.

Some negative data about conception and celecoxib. But the FDA came out with a recent guideline saying no nonsteroidals should be used in the third trimester. It promotes a lot of maternal disease including hypertension, proteinuria, and then, of course, premature closure of, the ductus arteriosus leads to problems with the baby in and around delivery. So nonsteroidal beyond the third trimester really should be, off the table. Again, I think it's important to you that you see the patient during pregnancy.

Often when they get pregnant, we never we don't see them until, you know, they're flaring postpartum because all drugs are stopped. I think it's important that you see the patient throughout the pregnancy, each trimester, and in the least, during the first trimester to give them education about what to expect, what's gonna come up, and in the last trimester, and then lastly, postpartum. Usually about six to twelve weeks postpartum unless problems arise. There is no specific magical drug to take during pregnancy. If you're on a TNF inhibitor, yes, Cimzia would be better than Enbrel, and Enbrel will be better all than all the rest of them.

But you can pretty much be on any of them, and just have to watch the child in and around birth. And lastly, ACR came out with a guideline paper on reproductive health. The paper was authored first author was Lisa Samaritano from HSS in New York. I was on the the guidelines group. It was a a long, arduous, very difficult, task that the faculty, that the authors who comprise that group worked really, really hard.

Again, my congratulations to Lisa and her core of leaders that we, helped out on in coming up with a really big, big, big paper. It's dense with information. You should download it and have it on your desk so you can refer to it. It's got all the information you need about, preplanning, counseling the patients prior to pregnancy, conception, you know, things like preserving sperm and eggs and what to do postpartum and breastfeeding, it's all in there. It's a it's a again, a great evidence based document that you should all know about.

That's it. Be sure to follow us during ACR next week. You give us two hours. We'll give you the meeting. Tune in for more QD clinics.