Sp0148 does Pregnancy Really Ameliorate Disease Activity of Women With Chronic Arthritis? Old Beliefs vs New Paradigms

Abstract

Rheumatoid arthritis (RA) and Spondyloarthritis (SpA) are chronic inflammatory diseases whose onset can occur during childbearing age. Juvenile Idiopathic Arthritis (JIA) can be active still during adulthood. Therefore, the disease course during pregnancy has been a topic of interest over the decades [1]. The approach towards the management of pregnancy in the rheumatic diseases has greatly changed in the last 30 years, as it became evident that active maternal disease is associated with adverse pregnancy outcomes, such as miscarriage, pre-term birth, small-for-gestational age babies. A well-controlled maternal disease during pregnancy is associated with a better pregnancy outcome: the key-point is the treatment of maternal disease with drugs which are not harmful for the fetus. To achieve this “ideal setting” is of fundamental importance to perform a preconception counselling a tailor the management of the patient according to the individual risk stratification [2].Historically, pregnancy has been considered to have a beneficial effect upon RA, with around 90% of women improving and up to 75% going into remission, followed by flares in puerperium in about 80% [3]. Modern prospective studies using validated measures of disease activity reveal less impressive ameliorative effects of pregnancy on RA [4]. A recent systematic review of prospective studies, using serial and objective evaluations of inflammatory disease, reported that RA improves in 60% of patients through pregnancy and flares in 46.7% of cases after delivery [5].What are the possible explanations for this shift in the course of RA during pregnancy over decades? 1) methodological issues are obviously present (different study design; different patient population in terms of disease subset, duration, and severity); 2) disease activity as a “self-reported outcome” vs use of validated indices [6]; 3) change in treatment strategies over time: in the ‘80s women with RA were likely to be treated with steroids only and probably those women with active disease despite treatment were not able to carry out a pregnancy, therefore it is possible that only patients with mild-moderate form of RA were observed during pregnancy. Conversely, the current wide therapeutic armamentarium allows to reach disease remission also in patients with aggressive forms of RA, therefore it is likely to observe disease flares (rather than amelioration) during pregnancy if the drug is stopped at conception. Interestingly, among 75 prospectively-followed RA pregnancies, in patients treated with tumor necrosis factors inhibitors (TNFi) before conception, the discontinuation of the TNFi early in pregnancy resulted in increased risk for disease flares during pregnancy [7]. On the other hand, if disease is well controlled with drugs which are maintained during pregnancy, then there is little room to detect any improvement during pregnancy.Spondyloarthritis (SpA) is a heterogeneous group of diseases and limited data are available about the disease course of different subsets (axial SpA –axSpA-...