Year : 2014 | Volume
: 2 | Issue : 3 | Page : 216--218
Using etanercept to maintain remission of psoriatic arthritis during pregnancy
Ibrahim A Al-Homood1, Mansour Somaily2,
1 Department of medicine, College of Medicine, Al-Imam Mohammad Ibn Saud Islamic University, Riyadh, Saudi Arabia
2 Department of Medicine, Asir Central Hospital, Abha, Saudi Arabia
Ibrahim A Al-Homood
College of Medicine, Al-Imam Mohammad Ibn Saud Islamic University, P.O. Box: 75227, Riyadh 11578
In recent years, biological drugs have been widely administered to treat rheumatic diseases including psoriatic arthritis (PsA). However, the safety of these drugs has not been adequately established in pregnancy. We report a case of a pregnant PsA patient treated with etanercept, an anti-tumor necrosis factor (TNF-α) agent. She continued to receive etanercept treatment during pregnancy without any complications, finally giving successful birth to a baby girl at 39 weeks. This suggests that etanercept may be selected to treat PsA patients with active arthritis who desire pregnancy with lower risks.
|How to cite this article:|
Al-Homood IA, Somaily M. Using etanercept to maintain remission of psoriatic arthritis during pregnancy.Saudi J Med Med Sci 2014;2:216-218
|How to cite this URL:|
Al-Homood IA, Somaily M. Using etanercept to maintain remission of psoriatic arthritis during pregnancy. Saudi J Med Med Sci [serial online] 2014 [cited 2021 Jan 19 ];2:216-218
Available from: https://www.sjmms.net/text.asp?2014/2/3/216/142582
The safety of anti-tumor necrosis factor agents has not been adequately established in pregnancy. No controlled studies have been conducted to determine the risk of the administration of these agents to pregnant PsA patients. There are some studies that report successful outcomes using etanercept treatment in pregnant patients. , We report a pregnant PsA patient who received etanercept treatment during pregnancy and reported no complications.
A 28-year-old woman, married with three children, was diagnosed with plaque psoriasis in 2001 when she had skin psoriasis involving 2% of her scalp and less than 1% over the right upper limb. She was managed initially by a dermatologist with a topical treatment and responded very well. In 2005, she was diagnosed as having PsA with peripheral arthritis. Therefore, she was started on naproxen 500 mg twice/day and sulfasalazine 1 g twice/day. She continued to be symptomatic, so methotrexate (MTX) 10 mg weekly was added after 3 months. MTX dose was increased to 20 mg weekly to control her arthritis but despite that she continued to have active arthritis. After 8 months of treatment with MTX, she developed acute dactylitis in her right third hand digit. At that point, infliximab, TNF-α inhibitor, started to control her arthropathy. She responded very well to infliximab, and the arthritis and dactylitis resolved within few months. Infliximab was continued for 1 year, but she desired to get pregnant, so infliximab and MTX were discontinued. During pregnancy, a severe flare-up of arthritis at 16 weeks of gestation was treated with naproxen 500 mg twice/day resulting in a partial response. After she delivered, she was started on etanercept, TNF-α inhibitor, 50 mg subcutaneous (SQ) weekly as the patient preferred to be on SQ medication rather than intravenous. Thereafter, her disease was controlled very well.
In March 2011, she was discovered to be pregnant and she decided to continue her pregnancy. We advised her to stop etanercept immediately; however, she decided to continue on etanercept, because of the difficult time she experienced during her last pregnancy when she stopped her anti TNF-α agent. We continued following her regularly, along with her obstetrician. Fetal growth was satisfactory and ultrasounds detected no abnormalities.
In October 2011, she gave birth to a baby girl at 39 weeks with birth weight of 3 kg and Apgar score of 8; the child is now 22 months old and growing and developing normally. She has continued to take etanercept after delivery and feeding her baby with no problems.
Thus, her disease was well controlled, her pregnancy was uneventful, and her baby was healthy.
Psoriatic arthritis (PsA) is an inflammatory arthritis associated with psoriasis. It may progress rapidly and result in joint damage and significant disability.
Our patient did not respond well to non-steroid anti-inflammatory drugs, naproxen, and a combination of disease-modifying anti-rheumatic drugs (DMARD); as well, she developed dactylitis that indicated a need to start her on anti-TNF-α agent.
Anti-TNF-α agents have been proven to be effective in the treatment of PsA. Etanercept has been shown to be effective in the treatment of psoriatic arthritis in different randomized control trials. ,
Pregnancy for young women is a major family concern when treatment with drugs is required. The clear aim of the treating physician is to render any disease inactive when possible. Drug safety in pregnancy is an important issue as most pregnancies are unplanned or recognized late. Thus, the rheumatologist and the young female patient frequently face the dilemma of pregnancy and the potential risk of an exposure to a medication that has already occurred early in pregnancy, or of making the decision to continue or discontinue a medication regimen during a planned pregnancy. The safety of etanercept during pregnancy in PsA has not been studied adequately.
No evidence of embryotoxicity or teratogenicity has been observed in animal studies.  However, animal studies are not always predictive of human pregnancy risks. Fetal and neo-natal complications are sometimes reported after anti-TNF-α use. Carter et al. described a patient with psoriasis and psoriatic arthritis who took 50 mg etanercept SQ twice weekly throughout her pregnancy and gave birth to a child with VATER association.  These manifestations fit the vertebral anomalies, anal atresia, tracheo-esophageal fistula, radial and renal anomalies (VATER) pattern. Verstappen et al. reported the outcome of 130 pregnancies receiving anti-TNF-α in the British Society for Rheumatology Biologics Register. Of 85 live births there were 4 reports of congenital malformations, 2 in patients who received anti-TNF-α at the time of conception (congenital dislocation of the hip and pyloric stenosis) and 2 in patients receiving the drugs prior to conception (winking jaw syndrome and strawberry birth mark).  However, normal deliveries and live births have been reported also in women with rheumatoid arthritis (RA) exposed to etanercept for the first trimester and throughout the pregnancy. , Another report also described a case of normal delivery of a healthy infant after pre-ovulatory administration of etanercept for RA.  Murashima also has reported that three pregnant RA patients were treated with etanercept and all of these cases showed successful outcomes. 
Anti-TNF-α agents are classified as category B (no documented human toxicity) by the FDA. Human experience of anti-TNF is still limited, particularly in patients with PsA. The potential risk of their use should be balanced against the known risks associated with DMARDs and steroid therapy. Reported cases and large registries are needed in order to be able to build up the recommendations as prospective studies in pregnant women with PsA can't be done for ethical reasons.
We report the case of PsA patient who had a normal and uncomplicated delivery while using etanercept. However, the safety of etanercept has not yet been fully established. Further studies will demonstrate the risks of and benefits from biologics in pregnant patients.
|1||Sinha A, Patient C. Rheumatoid arthritis in pregnancy: Successful outcome with anti-TNF agent (Etanercept). J Obstet Gynaecol 2006;26:689-91.|
|2||Sills ES, Perloe M, Tucker MJ, Kaplan CR, Palermo GD. Successful ovulation induction, conception, and normal delivery after chronic therapy with etanercept: A recombinant fusion anti-cytokine treatment for rheumatoid arthritis. Am J Reprod Immunol 2001;46:366-8.|
|3||Mease PJ, Goffe BS, Metz J, VanderStoep A, Finck B, Burge DJ. Etanercept in the treatment of psoriatic arthritis and psoriasis: A randomised trial. Lancet 2000;356:385-90.|
|4||Mease PJ, Kivitz AJ, Burch FX, Siegel EL, Cohen SB, Ory P, et al. Etanercept treatment of psoriatic arthritis: Safety, efficacy, and effect on disease progression. Arthritis Rheum 2004;50:2264-72.|
|5||Giroir BP, Peppel K, Silva M, Beutler B. The biosynthesis of tumor necrosis factor during pregnancy: Studies with a CAT reporter transgene and TNF inhibitors. Eur Cytokine Netw 1992;3:533-8.|
|6||Carter JD, Valeriano J, Vasey FB. Tumor necrosis factor-alpha inhibition and VATER association: A causal relationship. J Rheumatol 2006;33:1014-7.|
|7||Verstappen SM, King Y, Watson KD, Symmons DP, Hyrich KL. Anti-TNF therapies and pregnancy: Outcome of 130 pregnancies in the British Society for Rheumatology Biologics Register. Ann Rheum Dis 2011;70:823-6.|
|8||Scioscia C, Scioscia M, Anelli MG, Praino E, Bettocchi S, Lapadula G. Intentional etanercept use during pregnancy for maintenance of remission in rheumatoid arthritis. Clin Exp Rheumatol 2011;29:93-5.|
|9||Murashima A. Treatment of patients with rheumatoid arthritis who desire to become pregnant - successful pregnancy in three cases treated with etanercept. Nihon Rinsho 2008;66:2215-20.|