Is Remission a Feasible Goal for Patients With RA During Pregnancy?
In the first study of a treat-to-target (T2T) approach among patients with rheumatoid arthritis (RA) who were pregnant or wanted to become pregnant, researchers demonstrated that more than 90% of patients in their third trimester had achieved low disease activity (LDA) using a “modern approach” including anti-tumor necrosis factor (TNF) agents, low-dose prednisone, and a combination of disease-modifying antirheumatic drugs, researchers from The Netherlands reported.
The Preconception Counseling in Active RA (PreCARA) research program applied a modified T2T approach for the management of RA, to ensure appropriate accounting for the normal restrictions of pregnancy. The investigators then compared the results of the PreCARA study with those of the Pregnancy-induced Amelioration of Rheumatoid Arthritis (PARA) study, in which participants received standard of care for the period 2002 through 2010. Differences in disease activity over time between the 2 cohorts were tested using a linear mixed model.
Of patients with RA who participated in the PreCARA study (N = 309), 47.3% received treatment with an anti-TNF therapeutic at some point during their pregnancies. These patients gave birth to 188 neonates. Researchers found that in the PreCARA cohort, mean disease activity over time was lower than in the PARA cohort (p<0.001), with 75.4% of the patients achieving LDA or remission prior to pregnancy. Among the PreCARA cohort, 90.4% were at LDA or in remission by the third trimester. Patients in the PARA cohort showed prepregnancy rates of LDA or remission of 33.2%, rising to 47.3% in the third trimester.
The study team noted that while rheumatologists had previously assumed that all patients with RA go into remission regarding of therapy, an examination of medical literature showed that more than half of all patients with RA had active disease during their pregnancies. In addition, no patients in the PreCARA cohort had a severe increase in RA disease activity after giving birth, compared with 5.7% of the PARA cohort; 12.2% of the PreCARA patients showed a moderate increase in disease activity compared with 21.0% of the PARA cohort postpartum.
“The findings of our study should be applied in daily clinical practice. We advise clinicians to apply a T2T approach, including prescribing TNF inhibitors, in all patients with a wish to conceive and during pregnancy,” the researchers stated.
Further, they added, “This first study on a modern treatment approach in pregnant patients with RA shows that LDA and remission are an attainable goal during pregnancy, with 90.4% of patients achieving this in the third trimester.”
Smeele HTW, Röder E, Wintjes HM, Kranenburg-van Koppen LJC, Hazes JMW, Dolhain RJEM. Modern treatment approach results in low disease activity in 90% of pregnant rheumatoid arthritis patients: the PreCARA study. Ann Rheum Dis. Published online February 10, 2021. doi:10.1136/annrheumdis-2020-219547