Pain Pharmacotherapy Changes For RA During Pregnancy

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NSAIDs are generally not used after 32 weeks of gestation due to their potential for causing premature closure of the ductus arteriosus
NSAIDs are generally not used after 32 weeks of gestation due to their potential for causing premature closure of the ductus arteriosus

Rheumatoid arthritis (RA) is a progressive and chronic inflammatory disease that preferentially attacks the joint synovium.1 Like other rheumatic diseases, RA is more prevalent in women than men, with a female-to-male ratio of 3:1.While the onset of RA usually occurs in women after the age of 40 years, a substantial number of women with RA are of childbearing age.3  While the course of disease in pregnant RA patients is generally good, this population presents unique challenges to the practicing clinician.

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Remission During Pregnancy

Decreases in RA disease activity during pregnancy have been reported in 75% to 90% of patients, and disease activity returns to baseline in 90% of pregnant patients postpartum.4,5 The phenomenon of RA remission during pregnancy, first described in 1938, has been ascribed to immunologic alterations that prevent rejection of the fetus.6  The widespread belief that RA remits in pregnancy may have given false assurance to clinicians whose approach to pregnant patients with RA was to weithhold medication entirely, a practice that persists among some clinicians today.4


Recent studies indicate that pregnancy is associated with clinical improvement in only 40% to 66% of RA patients.1 UK researchers who used standardized assessments to measure disease activity found that just 16% of patients achieved complete remission during pregnancy.7 

Determining which patients may develop flares during pregnancy and immediately after presents a challenge, according to Bindee Kuriya, MD, a rheumatologist and researcher from the University of Toronto, who has a special interest in RA and pregnancy. In an email interview with Rheumatology Advisor, Dr Kuriya stated, “Since most women will choose to stay off medications or hold them during pregnancy, coming up with a plan to resume DMARDs/therapies postpartum is crucial, especially in those who will be at high risk for disease flares.”

Fertility and RA

Although most offspring of women with RA are of normal birth weight and gestational age, an increase in prematurity and a decrease in birth weight have been noted in children born of mothers with RA.8  Additionally, women with RA are more likely than normal controls to use assisted reproductive technology, like in vitro fertilization, suggesting a higher baseline rate of infertility.9

Higher rates of infertility are noted among patients with RA, resulting in longer times to pregnancy (TTP).10  One study from Denmark found that 25% of patients with RA were more likely to have taken longer than 12 months to conceive compared with 15.6% of controls.11 A national cohort study found that TTP in women with RA was longer if patients were older or nulliparous, had higher disease activity, used nonsteroidal anti-inflammatory drugs (NSAIDs), or used prednisone >7.5 mg/d.9  

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