Australian inflammatory bowel disease consensus statements for preconception, pregnancy and breast feeding

Abstract

ObjectiveBecause pregnancy outcomes tend to be worse in women with inflammatory bowel disease (IBD) than in those without, we aimed to update consensus statements that guide the clinical management of pregnancy in patients with IBD.DesignA multidisciplinary working group was established to formulate these consensus statements. A modified RAND/UCLA appropriateness method was used, consisting of a literature review, online voting, discussion meeting and a second round of voting. The overall agreement among the delegates and appropriateness of the statement are reported.ResultsAgreement was reached for 38/39 statements which provide guidance on management of pregnancy in patients with IBD. Most medications can and should be continued throughout pregnancy, except for methotrexate, allopurinol and new small molecules, such as tofacitinib. Due to limited data, no conclusion was reached on the use of tioguanine during pregnancy. Achieving and maintaining IBD remission before conception and throughout pregnancy is crucial to optimise maternofetal outcomes. This requires a multidisciplinary approach to engage patients, allay anxieties and maximise adherence tomedication. Intestinal ultrasound can be used for disease monitoring during pregnancy, and flexible sigmoidoscopy or MRI where clinically necessary.ConclusionThese consensus statements provide up-to-date, comprehensive recommendations for the management of pregnancy in patients with IBD. This will enable a high standard of care for patients with IBD across all clinical settings.

First‐trimester exposure to tofacitinib in ulcerative colitis: A case report of a healthy newborn and literature review

“…Tofacitinib level in breast milk was found to exceed maternal serum levels 15 . Tofacitinib should be avoided in breastfeeding 4 …”

“…11,12 Tofacitinib use for IBD in pregnancy is not recommended, and cessation for 4-8 weeks is advised before conception; this is based on its foeticidal and teratogenic potential in animal studies and due to the lack of evidence of use in humans. 4,13 It is assumed that tofacitinib can cross the placenta due to its small molecular size, although this has yet to be formally tested and studied. Animal studies showed increased loss of pregnancy and lower mean foetal body weight.…”

“…Continuation of medical treatment for UC during pregnancy is recommended due to the increased risk of active disease and poor pregnancy outcomes associated with interruption of treatment. 4 In the interventional studies of tofacitinib in UC, there were 11 cases of maternal exposure, all patients were exposed during the first trimester, specific gestational age at the time of exposure could not be determined, and all patients except one were on 10 mg twice a day dose. Four healthy newborns 36.4%, two spontaneous abortions 18.2%, and two medication terminations 18.2% were reported, and three were pending or lost to follow-up 27.2%.…”

“…3 Until further advice is available, tofacitinib should be avoided in pregnancy. 4 We present a case of exposure to tofacitinib in the first trimester until 6 weeks of gestation in a patient with UC.…”

“…The only evidence for use in pregnancy in patients with inflammatory bowel disease (IBD) is from the registration studies, which revealed 11 maternal exposures with foeto‐maternal adverse events rates comparable to the general population and patients with similar conditions not taking tofacitinib; however, the number of cases was small, the comparison was indirect, and subjects received pre‐emptive pregnancy testing at every study visit to permit early treatment cessation 3 . Until further advice is available, tofacitinib should be avoided in pregnancy 4 …”