To stop or not to stop- that is the question
Kieran Murray, Louise Moore, Douglas Veale
Bone and Joint Unit, Saint Vincent's University Hospital
RB is a 28 year old woman with seropositive rheumatoid arthritis and childhood toxoplasma chorioretinitis. Originally from Brazil, she has worked as a childminder in Ireland for 10 years.
Diagnosed with rheumatoid arthritis (RA) in 2016, she was initially treated with methotrexate, which had limited benefit and caused neutropenia. This was switched to etanercept and remission achieved.
In February 2018, RB informed us that she was pregnant, which had not been planned.
In March, at seven weeks pregnant, she was reviewed in our multidisciplinary Rheumatology and Obstetric SErvice (ROSE) clinic. Her disease was in remission with 0/28 tender and swollen joints, CRP of 2mmol/L. Obstetrics were happy with her progress and advised adding folic acid. Toxoplasma IgG was positive and HIV test was negative. The Infectious Diseases team were happy with her management.
In a further review at 15 weeks pregnant, RB had 0/28 tender and swollen joints, CRP of 3 mmol/L and was keen to stop biologic therapy due to infection and vaccination risks for her baby. Her etanercept was held.
Two weeks later, she had pain and stiffness in her shoulders and the small joints of her hands which responded to restarting her etanercept. At her July review, she remained in remission.
Etanercept was chosen as it was felt to be a relatively safe option from an infection perspective in a patient frequently travelling to Latin America. Recent studies have shown certolizumab to have minimal transfer from mother to baby during pregnancy and breastfeeding. This may have been a better option, raising the issue of switching biologic agents in women contemplating pregnancy.
RA remits in almost 50% of pregnancies. However, this patient flared. Factors negatively associated with poor disease control include presence of autoantibodies (Rheumatoid factor, Anti-CCP). Should this woman’s flare have been predicted and etanercept continued?
Toxoplasma reactivation and fetal transmission are concerns in patients on anti-TNF therapy. There are published cases of cerebral toxoplasmosis and toxoplasma chorioretinitis on anti-TNF- agents. Congenital toxoplasmosis can cause hydrocephalus, chorioretinitis and hepatosplenomegaly. How should we manage prospective mothers with previous toxoplasma gondii infection who are on biologic therapy?