A systematic review of the safety of non-tumour necrosis factor inhibitor and targeted synthetic drugs in rheumatic disease in pregnancy

Kawser Ahmed; Ian Giles; Hanh Nguyen; Julia Flint

doi:10.7861/clinmed.20-2-s98

Background

Despite increasing evidence to support safe use of tumour necrosis factor inhibitor (TNFi) drugs in pregnancy, there remains a paucity of evidence regarding non-TNFi and targeted synthetic disease-modifying anti-rheumatic drugs (tsDMARDs) in pregnancy. Therefore, we conducted a systematic review to summarise use of these drugs in pregnancy and breastfeeding.

Method

We performed a systematic search of databases including EMBASE, PubMed (MEDLINE) and Cochrane up to December 2018, using keywords including commonly prescribed non-TNFi and tsDMARDs, pregnancy, conception/pre-conception, lactation/breastfeeding, childhood and vaccination/infection.

Results

From an initial screen of 700 papers, 92 full-text papers were included in the final analysis. A summary of findings from known outcomes of pregnancy and breastfeeding exposures, as well as long-term follow-up of infants where available, is shown in Table 1. Overall, these data do not identify an increased risk of adverse pregnancy outcomes with these drugs in this population of patients.

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Table 1.

Summary of maternal exposure to non-tumour necrosis factor inhibitor and targeted synthetic disease-modifying anti-rheumatic drugs

Conclusion

These findings do not suggest an increased risk of non-TNFi and tsDMARDs in pregnancy. However, given that the total number of exposures remains limited, these drugs should only be considered in pregnancy if the benefit of maintaining disease control in the mother justifies any potential risk to the fetus. This body of evidence will be useful when counselling women about the potential risks of using these types of drugs during pregnancy and the breastfeeding period, as well as following accidental exposure to drugs at conception.