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Are anti-TNF drugs safe for pregnant women with inflammatory bowel disease?

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THE TORONTO CONSENSUS GUIDELINES

The Toronto consensus guidelines strongly recommend continuing anti-TNF therapy during pregnancy in women with IBD who began maintenance therapy before conception.6

If a patient strongly prefers to stop therapy during pregnancy to limit fetal exposure, the Toronto consensus recommends giving the last dose at 22 to 24 weeks of gestation. However, this should only be considered in patients whose IBD is in remission and at low risk of relapse.6,9

Although anti-TNF drugs may differ in terms of placental transfer, agents should not be switched in stable patients, as switching increases the risk of relapse.10

BENEFITS OF CONTINUING THERAPY

Active IBD poses a significantly greater risk to the mother and the baby than continuing anti-TNF therapy during pregnancy.1,7 The primary benefit of continuing therapy is to maintain disease remission.

Among women with active IBD at the time of conception, one-third will have improvement in disease activity during the course of their pregnancy, one-third will have no change, and one-third will have worsening of disease activity. But if IBD is in remission at the time of conception, it will remain in remission in nearly 80% of women during pregnancy.1

Women with active IBD are at increased risk of preterm delivery, low birth weight, and intrauterine growth restriction.1,2,5 Also, women with IBD have an increased risk of venous thromboembolism, particularly if they have active disease during pregnancy.1 Therefore, achieving and maintaining remission are vital in the management of the pregnant patient with IBD.

CONSIDERATIONS AFTER BIRTH: BREAST-FEEDING AND VACCINATION

Breast-feeding is considered safe. Minuscule amounts of infliximab or adalimumab are transferred in breast milk but are unlikely to result in systemic immune suppression in the infant.7

Live-attenuated vaccines should be avoided for the first 6 months in infants exposed to anti-TNF agents in utero.1,7,11 All other vaccines, including hepatitis B virus vaccine, should be given according to standard schedules.6

OUR RECOMMENDATIONS

The goal of managing IBD in women of reproductive age is to minimize the risk of adverse outcomes for both mother and baby. We recommend a team approach, working closely with a gastroenterologist and a high-risk-pregnancy obstetrician, if available.

Patients should continue anti-TNF therapy during pregnancy because evidence supports its safety. If a woman wants to stop therapy and is at low risk of relapse, we recommend giving the last dose at 22 to 24 weeks of gestation, then promptly resuming therapy postpartum.

Live-attenuated vaccines (eg, influenza, rotavirus) should be avoided for the first 6 months in babies born to mothers on anti-TNF therapy.

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