JIA disease activity in pregnancy

Welcome to the February edition of #ChatJRheum.

This month’s article for discussion will be of interest to both pediatric and adult rheumatologists. It updates our understanding of Juvenile Idiopathic Arthritis (JIA) disease activity during pregnancy and the postpartum period.

This prospective study included a total of 135 pregnancies in 114 women with JIA from a Norwegian database.  Median age was 29 years and median disease duration of 20 years. Key findings revealed that almost 80% of patients were in remission or had low disease activity as measured by DAS 28 CRP, throughout the study period.

Looking at medication use, there was a decrease in DMARD use (synthetic, biological, or both) from 55% in the year prior to pregnancy, to 22% during pregnancy. Only 18% of women used synthetic DMARDs throughout pregnancy, predominantly sulfasalazine and to a lesser extent hydroxychloroquine.  On the other hand, fewer than 5% used biologic DMARDs during pregnancy, all of whom used a tumor necrosis factor α-inhibitor. By one year postpartum, 40% of women were on systemic DMARD. Of note, 10 out of 47 women (21%) were taking oral steroids at the preconception visit; however, numbers increased to 24 out of 85 women (28%) in the first trimester and 30 out of 81 women (37%) at 6 months postpartum. Prednisolone doses were mostly kept < 10 mg daily.

It is interesting to consider whether pregnancy has a protective effect leading to improved disease control in JIA, similar to observations in rheumatoid arthritis. The authors note a drawback to the study was that most study participants had stable low disease activity.  While they could not exclude a potential beneficial effect of pregnancy on JIA, a larger study population with more active disease would be required to answer this question.  How might you apply this information to inform a JIA patient about a possible pregnancy?

It is also worth noting the number of patients who discontinued DMARD therapy in pregnancy, and the increased rates of steroid use.  This raises questions about the paucity of safety data on rheumatologic medications in pregnancy and the need for more work in this field.  How might this data affect your decisions around medication use for patients with JIA wishing to become pregnant?

I welcome your thoughts, comments or questions on this month’s #ChatJRheum forum.

- Sarah Troster, forum moderator