Tuesday, 12 April 2016

Closing the pregnancy-related information gap for women with rheumatoid arthritis

Associate Professor Ilana Ackerman from SPHPM has published an editorial in Rheumatology highlighting the evidence and resource gap for women with rheumatoid arthritis (RA) who are planning a family.

RA is an autoimmune disease that causes pain and inflammation of the joints. Other parts of the body can also be affected. Inflammation causes the joints to become painful, hot and swollen and movement to be restricted. The disease has a significant personal and societal impact, in terms of disability, quality of life, work participation and healthcare costs. It is the second most common form of arthritis and affects nearly half a million Australians and an estimated 57 per cent of people with RA are women.

For women in their reproductive years, living with RA presents a number of challenges relating to contraception, pregnancy, breastfeeding and early parenting and much of the educational resources for RA lack key information for women at this life stage.

In a study investigating the specific educational needs of women with RA who were recently pregnant, currently pregnant or were planning a pregnancy, many participants cited a lack of accessible and relevant information (particularly around the safety and toxicity of RA medications) and expressed a strong desire for practical strategies to assist them in meeting the daily challenges of caring for a young baby.

“Given the recent evidence around unmet educational needs and limited evidence for the effectiveness of educational interventions, it is clear that more needs to be done to support women with RA across the pregnancy and post-natal continuum,” Associate Professor Ackerman said.

In a recent systematic literature review, her team found that only one of 68 studies specifically evaluated pregnancy-focused education or self-management support for people with RA.

Associate Professor Ackerman and her collaborators have recently completed a national study designed to establish cross-discipline consensus on key messages that should be delivered to women with RA by health professionals regarding contraception, pregnancy, breastfeeding and early parenting.

It is hoped that these messages will assist rheumatologists, obstetricians and clinical pharmacists in providing consistent pregnancy-related advice to women with RA and their families. There is also an important role for arthritis consumer organisations to act as resource hubs for women with RA and their treating health professionals.

“This is an exciting opportunity to develop and evaluate targeted resources encompassing medication-focused information and pragmatic peer knowledge and skills that are clearly sought by this patient group,” said Associate Professor Ackerman.

This program of research was conducted in collaboration with Associate Professor Andrew Briggs (Curtin University and Arthritis and Osteoporosis Victoria) and Associate Professor Sharon Van Doornum (Melbourne Health and The University of Melbourne).

1 comment:

  1. This dilemma arises many times with regard to the TNF inhibitors, frankly because many medical, pharmacy and other health advisors haven't looked at the expert consensus, based on studies and accumulated clinical experience.
    The following summarises the situation as I understand it.
    With regard to teratogenic risks, anti-TNFs are large molecules so won’t cross the placenta in the critical first trimester.
    TNF Inhibitors consist of an Fc component and an anti-TNF fragment (Fc is a component of igG).

    Therefore, later in pregnancy, they may bind to the Fc receptor which the placenta produces to facilitate the transfer of IgG to the fetus to confer infant immunity , since they (TNF inhibitors) contain an FC component in their structure and:
    1. Get transferred across the placenta late in pregnancy and
    2. This binding to Fc prolongs the half-life of TNF inhibitors, so there may be a reduced immunity in the newborn infant. Also the TNF inhibitors may be detectable in the infant’s system up to 6 months after birth.
    If TNF inhibitors are used beyond the end of the 2nd trimester, the general advice is to avoid live vaccines in the infant for the first 6 months.

    (Certolizumab (Cimzia Brand) is the only one of this class of drugs that does not bind to the Fc receptor).

    I am also surprised by the reticence of health advisors with regard to the use of TNF inhibitors whilst breastfeeding. These drugs have a molecular weight of some 140,000, so any excretion into breast milk would be miniscule. But, most importantly, any drug residue present in the breastfeeding infant would be destroyed in the gastrointestinal tract! This fact is clearly delineated in various reference sources, including Lactmed ( The U.S. National Library of Medicine Database), and in AMH (Australian Medicines Handbook).

    Ron Batagol, pharmacist and Obstetric Drug Information Consultant, Nunawading Vic 3131




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