Treat-to-target is appropriate for women with RA during pregnancy

For women with rheumatoid arthritis, low disease and remission are an attainable goal during pregnancy

INTRODUCTION
Rheumatoid arthritis is a chronic inflammatory disease that affects a person’s joints, and may cause pain and disability. Rheumatoid arthritis can affect people of all ages, but it most often starts between the ages of 30 and 50 – although this can depend on where you live. Rheumatoid arthritis is more common in women than men.

A previous study on rheumatoid arthritis and pregnancy called PARA showed that more than half of women
with rheumatoid arthritis had active disease during pregnancy. Active disease is associated with a longer time to get pregnant, and there is a higher chance of having an underweight baby. The PARA study took place from 2002 to 2010. At that time, treatment of rheumatoid arthritis in pregnant women was very cautious because there was not enough information about the impact of rheumatoid arthritis medicines on malformations, breastfeeding, or the long-term effects on children whose mothers took the medicines when they were pregnant.

Since the PARA study, many new medicines for rheumatoid arthritis have been developed. For example,
tumour necrosis factor inhibitors (TNFi) – a type of medicine called a biologic disease-modifying antirheumatic drug (often shortened to bDMARD). TNFi are now considered safe to use during pregnancy, because there is evidence to show that they do not cause birth defects or complications.

WHAT DID THE AUTHORS HOPE TO FIND?
The authors wanted to show the effect of a modern treatment approach in women with rheumatoid arthritis
who are pregnant, or who want to get pregnant.

WHO WAS STUDIED?
The study looked at 309 women with rheumatoid arthritis. Everyone who took part wanted to conceive a baby, or was already pregnant. The study was called PreCARA. It started in 2011 at one hospital in the Netherlands which specialises in rheumatic diseases and pregnancy.

HOW WAS THE STUDY CONDUCTED?
This was a prospective study collecting information about pregnancy and rheumatic diseases. The participating women did not receive any particular drug, but were given normal care, and their data was recorded. Everyone in the study was treated with a modern approach called treat-to-target. This is in line with current recommendations. The aim was remission, where there are no clinical signs or symptoms of the disease.

Women visited the clinic every 3 months before pregnancy, during each trimester, and then at 6, 12 and 26 weeks after giving birth. At every visit, women had a joint examination and blood tests, filled in questionnaires, and data on disease activity and the medicines being taken were collected. At every study visit, they were seen by a rheumatologist for management of their disease, and a specialist rheumatology nurse for counselling and support.

The results were compared to those for women in the PARA study – the historic reference group.

WHAT WERE THE MAIN FINDINGS OF THE STUDY?
The main finding was that the normal treatment goals of low disease activity or remission are still suitable targets for women in pregnancy.

In the historic reference group, half of women with rheumatoid arthritis had active disease during pregnancy. For women in the modern group, only around 10% had active disease during pregnancy. Overall, almost half of the women used a TNFi medicine at some point during pregnancy.

ARE THESE FINDINGS NEW?
Yes. This study is the first to look at the effect of a modern treatment approach in pregnant women with rheumatoid arthritis and show that it is feasible.

WHAT ARE THE LIMITATIONS OF THE STUDY?
This study was performed in a single treatment hospital. Also, this analysis included only women with rheumatoid arthritis, so the results cannot be extended to pregnant women with other types of rheumatic disease. It is also worth noting that the women in the historical cohort had slightly different characteristics compared to the modern population.

WHAT DO THE AUTHORS PLAN ON DOING WITH THIS INFORMATION?
The authors plan to study the disease outcomes of a modern treatment approach in other rheumatic diseases such as spondyloarthritis, psoriatic arthritis, and juvenile idiopathic arthritis. They will also study outcomes such as birth weight of the babies that were born to mothers taking part in the PreCARA study, and will perform long-term follow up studies of these children to see how they do.

WHAT DOES THIS MEAN FOR ME
If you have rheumatoid arthritis, achieving low disease activity before, during and after pregnancy is a feasible goal. Modern treatment approaches can be used while you are pregnant. If you are planning to get pregnant, it is a good idea to talk to your doctor so your treatment plan can be changed if needed to one that is safe for you and your baby.

If you have any concerns about your disease or its treatment, you should talk to your doctor.

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Date prepared: June 2021
Summary based on research article published on: 10 February 2021
From: Smeele HT, et al. Modern treatment approach results in low disease activity in 90% of pregnant rheumatoid arthritis patients: the PreCARA study. Ann Rheum Dis 2021;80:859–864. doi:10.1136/annrheumdis-2020-217209

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