The half-life of the drug, however, was noted to be very short and TNF levels were not reported. (TNF) medications have revolutionized the treatment of inflammatory arthritis. When the first biologic drugs for arthritis, infliximab and etanercept, were approved by the Food and Drug Administration (FDA) in 1999, they raised the hopes for a life Xanthiazone without pain and disability for many patients. Our standards for acceptable joint inflammation increased dramatically, no longer expecting patients to have chronic inflammation and damage but now modifying treatment with the goal of eliminating active arthritis. Many patients with inflammatory arthritis, especially rheumatoid arthritis, are women in their reproductive years. These women maintain fertility and often wish to build families of similar size to women without arthritis. With increasing use of anti-TNF drugs to treat arthritis in young women, questions about the safety of these agents for the developing fetus and breastfed infant have arisen. Animal data regarding pregnancy are benign, earning these agents an FDA Pregnancy Classification of B, meaning no animal reproductive concerns but limited human data. Human data are slowly being accumulated and published, with largely reassuring results. It does appear, however, that significant amounts of anti-TNF medication cross the placenta in the third trimester. This review will detail the human clinical data for pregnancy outcomes and fetal health following anti-TNF medication exposure. In addition, it will discuss lactation during anti-TNF medication use. Clinical utility of anti-TNF medications Anti-TNF medications have decreased pain, joint erosions, and disability in many people with inflammatory arthritis. In rheumatoid arthritis (RA), these drugs dramatically slow the accumulation of radiographic damage. Studies show that the most clinical benefit is derived from the combination of anti-TNF medications and methotrexate; alone, anti-TNF medications or methotrexate have similar degrees of benefit. 1 Of patients taking the combination of infliximab plus methotrexate, over 60% will get 20% better, about 50% will get 50% better, Rabbit Polyclonal to CDC25A (phospho-Ser82) and over 30% will get 70% better. Between 10% and15% will even get 90% better.1 All of Xanthiazone the anti-TNF medications perform similarly with roughly equivalent improvement across studies.2 Anti-TNF medications are typically indicated when inflammation from rheumatoid arthritis or psoriatic arthritis can not be controlled with oral agents, including methotrexate, hydroxychloroquine, or sulfasalazine. In clinical practice in the United States, an estimated 40% of patients with long-standing rheumatoid arthritis and 25% with Xanthiazone early RA (<3 years duration) are taking anti-TNF medications, 70% of the time with another disease-modifying antirheumatic drug (DMARD).3 During pregnancy, the options for arthritis therapy are limited. Both methotrexate and leflunomide are FDA Class X during pregnancy, indicating that the fetal risk outweighs any benefit to the mother. Methotrexate is a known teratogen and cessation of this drug is recommended 3 months prior to conception. The reported number of pregnancies exposed to the low weekly dose used in rheumatology is small, however. In a recent review of 6 reports including a total of 101 pregnancies, of those not electively terminated, 23% resulted in a miscarriage, and 66% in a live birth. Only 5 had a minor neonatal malformation.4 A report of prospectively collected pregnancies in women taking leflunomide at the time of conception shows a low rate of congenital anomalies (5%) that is comparable to prospectively collected rheumatoid arthritis and healthy control pregnancies.5 Despite these findings, it is still recommended that women discontinue these medications prior to conception. The use of NSAIDs during pregnancy is typically restricted to occasional use in the first half of pregnancy. Use in the third trimester can cause premature closure of the ductus arteriosis. NSAIDs may also promote oligohydramnios (low amniotic fluid levels) by restricting fetal renal blood flow. For this reason, most women are encouraged to take acetaminophen for pain during pregnancy. This, however, is often ineffective for the pain of inflammatory arthritis. Medications considered relatively safe in pregnancy include corticosteroids, sulfasalazine, and hydroxychloroquine. Prednisone can promote maternal hypertension, diabetes, and excessive weight gain, all significant problems during pregnancy. It may also lead to a lower birth weight and preeclampsia.6,7 Sulfasalazine is considered relatively safe during pregnancy and can be continued. 7 Hydroxychloroquine is also relatively safe, though less effective in treating inflammatory arthritis.7 With medications limited during pregnancy, the anti-TNF medications take on a greater importance to women with inflammatory arthritis. Fortunately, up to 75% Xanthiazone of women with RA will improve during pregnancy, with half of them having mild disease.8,9 However, half of women remain with moderate to severe RA activity throughout pregnancy. Women with psoriatic arthritis and ankylosing spondylitis do not generally improve during pregnancy. For these women, pregnancy can be a debilitating period marked by worsening joint pain, inflammation, and damage. A high degree of inflammatory joint activity may promote an early delivery of a small infant.10 Up to a.
