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Crohn's Disease Forum » Pregnancy, Trying to Conceive & Breast Feeding with IBD » A brief article on anti-TNF agents & pregnancy


01-06-2011, 09:14 PM   #1
David in Seattle
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A brief article on anti-TNF agents & pregnancy

What Do I Do With a Woman Who Is Pregnant and on Biologics?

Sunanda V. Kane, MD, MSPH
Associate Professor of Medicine, Mayo Clinic, Rochester, Minnesota

"This is a question I am asked on a weekly basis. Women of childbearing age may be on biologic therapy for Crohn's disease, ulcerative colitis, rheumatoid arthritis, psoriatic arthritis, and other autoimmune disorders. When treating women who are pregnant or planning to become pregnant, it is important to understand the mechanism for immunoglobin transfer so the risk for exposure of the fetus to the therapeutic monoclonal antibody in utero will be minimized.[1]

Biologics are immunoglobulins, and most cross the placenta. However, they require specific receptors to cross and, thus, do not begin to cross until the second trimester, around week 20 of pregnancy. There is a logarithmic increase in rate of immunoglobulin G (IgG) transfer over time, with maximal IgG transfer between weeks 30 and 38 of pregnancy. Thus, if a pregnant woman is on infliximab, we instruct her to time her last dose around week 30-32 of pregnancy, and then re-dose her after delivery. Women on adalimumab should be instructed to self inject their doses until around week 33-34 of pregnancy. Interestingly, there are data to suggest that certolizumab pegol, because it is an Fc fragment, does not cross the placenta at all. Thus, a woman on certolizumab pegol does not have to hold any doses throughout pregnancy.

Experts do not endorse switching biologics during pregnancy solely for the reasons mentioned above. If a pregnant woman is sick, then we continue her biologic therapy because she needs to control her disease. The above recommendations are for women who are in remission. A common mistake we see is that women stop taking their biologic in the first trimester and end up sick, requiring steroids or re-dosing of the biologic. It is during the first trimester that the risk is the lowest for transfer, and the highest for disease flare. The benefits of controlling disease outweigh the risks to the unborn baby.

There does not appear to be any increased risk for infection following caesarean section if biologics are given right after delivery, as long as there is assurance that no placenta has been retained, which could be a source for infection.

Furthermore, there are data to show that biologics do not cross into breast milk, so breastfeeding is permitted for women on most biologic therapy. Infliximab and certolizumab pegol are compatible with breastfeeding, but safety data for adalimumab are pending.[2] "

References

1. Kane SV, Acquah LA. Placental transport of immunoglobulins: a clinical review for gastroenterologists who prescribe therapeutic monoclonal antibodies to women during conception and pregnancy. Am J Gastroenterol. 2009;104:228-233.
2. Mahadevan U, Cucchiara S, Hyams JS, et al. The London position statement of the World Congress of Gastroenterology on Biological Therapy for IBD with the European Crohn's and Colitis Organisation: Pregnancy and Pediatrics. Am J Gastroenterol. 2010 Dec 14. [Epub ahead of print]
04-16-2011, 11:38 AM   #2
Soybean
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Thank you for this article David. It is very informative and encouraging. It has helped somewhat to put my mind at ease. xx
04-16-2011, 02:46 PM   #3
dreamintwilight
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Good article, David. I wonder how it may differ for women who are on weekly doses of Humira.

I wanted to also mention that if a woman stays on their biologic through the entirety of their pregnancy...I read somewhere that there is a period of time that routine vaccinations should be delayed for the baby as they will have traces of the biologic and need it to clear from their bodies before they are given any live vaccine. I think it's 1-2 months. Of course, consult with your doctor about this before hand.
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Marisa
February 2010 - diagnosed with Crohn's disease.
January 2011 - Inflammation downgraded from moderate-severe to mild with no symptoms!
January 2014 - adopted a mostly Paleo diet
May 2015 - still in remission!


Currently Taking
Humira - 40mg/week
Imuran - 125 mg/day
Calcium magnesium citrate
Fermented cod liver oil/butter blend
Culturelle probiotics
Vitamin D
Vitamin C
Biotin
Allegra
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