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Drug Insight: anti-tumor necrosis factor therapy for inflammatory arthropathies during reproduction, pregnancy and lactation

Abstract

Tumor necrosis factor (TNF) antagonists are widely used to reduce disease activity and joint damage, and to improve health-related quality of life in patients suffering from rheumatoid arthritis, ankylosing spondylitis, or psoriatic arthritis. To date, no increased risk of embryotoxicity or teratogenicity, or adverse pregnancy outcome (such as birth defects, premature birth, and low birth weight) has been reported in patients with inflammatory arthropathies treated with anti-TNF therapy, compared with the general population. However, the available data are limited, and methotrexate, which is commonly used in combination with anti-TNF drugs, is teratogenic. Until more data are available, no firm conclusions can be reached regarding the safety of anti-TNF therapy in pregnancy. Nevertheless, in selected cases where there is high disease activity, anti-TNF therapy might be recommended, depending on the results of individual risk–benefit analyses. Fully informed consent from the mother is needed in such cases. Anti-TNF agents are not usually used during lactation, although the risk of toxicity is probably negligible.

Key Points

  • No increased risk of adverse pregnancy outcome has been demonstrated in patients treated with anti-tumor necrosis factor (anti-TNF) drugs

  • In general, anti-TNF therapy should be stopped before pregnancy, as there are limited data concerning the risk to the fetus

  • Anti-TNF therapy might, however, be used in selected patients with inflammatory arthropathies where there is high disease activity, according to an individual risk–benefit analysis (perhaps other possible drugs are teratogenic), until early pregnancy is detected (although this might result in possible exposure in early pregnancy)

  • Although toxicity from anti-TNF therapy during lactation is probably negligible, breastfeeding should so far only be carried out as part of a clinical study in women undergoing anti-TNF therapy

  • Methotrexate treatment should be stopped at least 3 months before planned conception and folate supplementation should be continued throughout pregnancy

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Correspondence to Johan F Skomsvoll.

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Skomsvoll, J., Wallenius, M., Koksvik, H. et al. Drug Insight: anti-tumor necrosis factor therapy for inflammatory arthropathies during reproduction, pregnancy and lactation. Nat Rev Rheumatol 3, 156–164 (2007). https://doi.org/10.1038/ncprheum0426

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