The Autoimmune Connection: Essential Information for Women on Diagnosis, Treatment, and Getting On With Your Life by Rita Baron-Faust, Jill Buyon Page A
Authors: Rita Baron-Faust, Jill Buyon
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well-controlled studies in humans—or there have been neither animal nor human studies of the drug. Finally, there are drugs that have shown risks to the fetus in studies of pregnant women, but sometimes the benefits of a drug may outweigh the risks for a particular woman. As you can see, prescribing drugs in these categories during pregnancy must be individualized.
Drugs that you take during pregnancy, including those considered safe, may cross the placenta, and many pass into breast milk. According to rheumatologists, the most sensitive time during pregnancy for any drug effects is the first trimester, when the embryo is growing into a fetus. This is the period where birth defects are likely to occur. The third trimester, since it is closest to delivery, carries different risks.
In general, experts say NSAIDs appear safe during most of pregnancy, but physicians try to avoid their use too close to delivery since they inhibit hormones called prostaglandins, which affect uterine contractions and can prolong labor. Corticosteroids are generally considered safe at any time during pregnancy but carry a slight risk of infections.
Azathioprine can cause fetal harm and should not be given during pregnancy unless the benefits strongly outweigh the risks. However, it should be emphasized that women taking azathioprine after organ transplants who have become pregnant have had successful pregnancies. Still, its use is not recommended in nursing mothers. Methotrexate should never be used during pregnancy.
A recent study from Italy suggests that TNFα inhibitors can be considered safe in the “peri-conception” period, making them a possible choice for women hoping to become pregnant. However, the Italian researchers caution that reports of anti-TNFα exposure during the second or third trimesters are “still limited” and they urge caution. Experience with abatacept, tocilizumab, anakinra and rituximab in pregnancy is insufficient, they add. 34 A review of many hundreds of pregnancies in inflammatory arthritis suggest that exposure to anti-TNF therapies at the time of conception or during the first trimester do not result in an increased risk of adverse pregnancy or fetal outcomes. 35
For Remicade, Azulfidine, penicillamine, and Enbrel, no harmful effects have been seen on a developing fetus, but since risk can’t be completely ruled out, the FDA advises that they should be given to pregnant women only if clearly needed. Remicade is usually not detectable in breast milk, but sulfa drugs like Azulfidine are excreted in breast milk and can cause liver toxicity in infants.
Data are extremely limited about pregnancy outcomes of women exposed to newer biologic DMARDs, including anakinra, abatacept, and tocilizumab. Manufacturers’ guidelines suggest abatacept be discontinued for at least 14 weeks prior to conception and between 3 months (tocilizumab) and 12 months (rituximab) prior to pregnancy for other biologics.
You’ll need to discuss the use of these drugs with your physician. Carefully read every package insert that comes with any medication, and always ask questions.
Menopause and Beyond
The peak years for a diagnosis of RA are those just before and after menopause, and opinions are divided over whether menopause itself affects the disease.
“The age of diagnosis seems to be creeping up,” remarks Dr. Bykerk, with many women now diagnosed around age 53. “Women in early menopauseare also more often seropositive” for rheumatoid factor and anti-CCPs, she adds.
While some studies find that RA diagnosed after menopause may progress at a faster rate, recent research suggests that earlier menopause may be linked to milder disease, such as rheumatoid-factor negative RA. 36 “Hormonal changes may influence pathways that are distinct from those leading to severe, progressive disease,” Swedish researchers wrote in a study published in Arthritis Research & Therapy in 2012.
One study from Sweden found a strikingly
Drugs that you take during pregnancy, including those considered safe, may cross the placenta, and many pass into breast milk. According to rheumatologists, the most sensitive time during pregnancy for any drug effects is the first trimester, when the embryo is growing into a fetus. This is the period where birth defects are likely to occur. The third trimester, since it is closest to delivery, carries different risks.
In general, experts say NSAIDs appear safe during most of pregnancy, but physicians try to avoid their use too close to delivery since they inhibit hormones called prostaglandins, which affect uterine contractions and can prolong labor. Corticosteroids are generally considered safe at any time during pregnancy but carry a slight risk of infections.
Azathioprine can cause fetal harm and should not be given during pregnancy unless the benefits strongly outweigh the risks. However, it should be emphasized that women taking azathioprine after organ transplants who have become pregnant have had successful pregnancies. Still, its use is not recommended in nursing mothers. Methotrexate should never be used during pregnancy.
A recent study from Italy suggests that TNFα inhibitors can be considered safe in the “peri-conception” period, making them a possible choice for women hoping to become pregnant. However, the Italian researchers caution that reports of anti-TNFα exposure during the second or third trimesters are “still limited” and they urge caution. Experience with abatacept, tocilizumab, anakinra and rituximab in pregnancy is insufficient, they add. 34 A review of many hundreds of pregnancies in inflammatory arthritis suggest that exposure to anti-TNF therapies at the time of conception or during the first trimester do not result in an increased risk of adverse pregnancy or fetal outcomes. 35
For Remicade, Azulfidine, penicillamine, and Enbrel, no harmful effects have been seen on a developing fetus, but since risk can’t be completely ruled out, the FDA advises that they should be given to pregnant women only if clearly needed. Remicade is usually not detectable in breast milk, but sulfa drugs like Azulfidine are excreted in breast milk and can cause liver toxicity in infants.
Data are extremely limited about pregnancy outcomes of women exposed to newer biologic DMARDs, including anakinra, abatacept, and tocilizumab. Manufacturers’ guidelines suggest abatacept be discontinued for at least 14 weeks prior to conception and between 3 months (tocilizumab) and 12 months (rituximab) prior to pregnancy for other biologics.
You’ll need to discuss the use of these drugs with your physician. Carefully read every package insert that comes with any medication, and always ask questions.
Menopause and Beyond
The peak years for a diagnosis of RA are those just before and after menopause, and opinions are divided over whether menopause itself affects the disease.
“The age of diagnosis seems to be creeping up,” remarks Dr. Bykerk, with many women now diagnosed around age 53. “Women in early menopauseare also more often seropositive” for rheumatoid factor and anti-CCPs, she adds.
While some studies find that RA diagnosed after menopause may progress at a faster rate, recent research suggests that earlier menopause may be linked to milder disease, such as rheumatoid-factor negative RA. 36 “Hormonal changes may influence pathways that are distinct from those leading to severe, progressive disease,” Swedish researchers wrote in a study published in Arthritis Research & Therapy in 2012.
One study from Sweden found a strikingly
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