Patient Selection and Safety With TNF Inhibitors - Episode 11

Discontinuing/Switching of Biologics During Pregnancy

Marla Dubinsky, MD: I think the debate on whether you stop at 24 weeks versus continue with the non-certolizumab-based biologics will remain controversial. There are reports that the biggest risk is that the mother will flare in the third trimester. Again, going back to what I noted about inflammation, we want the baby to continue to grow in the third trimester. Inflammation has been shown to affect cognitive and emotional behavior in children born to mothers with active inflammation.

The idea of testing genes in the cord blood to show whether they’re at risk of increased development of abnormalities is a big thing. We’re just starting to catch up to what’s out there in terms of other diseases and in animal models. But for inflammation, from the time you’re thinking about it, you should follow that into breastfeeding and the postpartum period. We don’t want you to flare because the hormones change again. So it’s really complex. This is not something for which you can just say, “Oh, you’re pregnant. You can continue with your medications.” You need to have a really important educational discussion. Even a lot of physicians and patients are not up to speed on what is known about this because we’re not exposed to it that often. So being able to send patients to physicians who specialize in this, who are very interested in counseling women—this is a big passion of mine—is really important. There is so much that we don’t know.

Another question that I often get asked is, “Do you ever switch a patient from one therapy to another because of, for example, concern of placental transfer? I think if you’re starting a woman on a biologic, particularly TNF [tumor necrosis factor], which is where there is this distinction between certolizumab not crossing versus adalimumab and infliximab crossing, you should have that discussion with the patient. You can decide what the best drug is for the patient. You may look at the fact that she wants to conceive next year.

I see a lot of women for whom that decision had been made, and they come to me just to confirm that it’s the right treatment choice. I tell everybody that the most important solution is to choose the one that matches what the patient needs. If she ends up on certolizumab versus infliximab, I’ll deal with the timing of it thereafter. Just get her on the right drug. That’s my big push.

Would I ever intentionally switch someone who’s well on one over the other because she’s about to get pregnant or is? The answer is no. If you have a woman with control of her inflammation, keep her on that therapy. This goes back to the whole theme that inflammation control is what we focus on. Whatever it takes to get that female patient under control from the inflammation is what they need to be on during pregnancy.