Update on Use of Biologic and Targeted Synthetic Drugs in Pregnancy

The availability of biologic disease modifying anti-rheumatic drugs (bDMARDs) and the development of targeted synthetic (ts)DMARDs has led to a new treatment era for patients with inflammatory rheumatic disease (IRD). The advent of these therapies has multiplied the number of therapeutic options available to induce remission and thus improved opportunities for women with previously poorly controlled disease activity to consider pregnancy during low disease activity states. These IRDs include systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), psoriatic arthritis (PsA) and axial spondyloarthritis. Many of these conditions occur in women of reproductive age, and require use of traditional DMARDs and/or targeted biologic drugs to control and suppress active disease. Numerous studies have identified that women with IRD, particularly SLE, have an increased risk of experiencing adverse pregnancy outcomes (APOs), such as miscarriages, premature delivery, maternal hypertension or intrauterine growth restriction. The management of pregnancy in women with IRD is complicated by factors relating to disease, pregnancy, medication and patient concerns. Therefore, appropriate pre-pregnancy counselling and monitoring by a multidisciplinary team of obstetric and rheumatology specialists during pregnancy is essential to ensure that optimal control of maternal disease activity is achieved by appropriate use of compatible DMARDs before and during pregnancy, to enhance the chance for women with IRD to have successful pregnancy outcomes. In this chapter we aim to summarise and update current British and European evidence-based guidance on prescribing of bDMARDs and tsDMARDs during pregnancy and breastfeeding.