Duke Health Referring Physicians

Quick Case Study

Pregnant Patient With Severe RA Seeks Relief

After an unsuccessful pregnancy that ended at 33 weeks, a woman in her mid-20s with severe rheumatoid arthritis (RA) symptoms and type 1 diabetes mellitus (T1DM) sought the counsel of Megan E.B. Clowse, MD, MPH, a Duke rheumatologist who operates a clinic dedicated to treating women with inflammatory diseases who are pregnant or considering pregnancy.

The loss of the baby was probably not related to the RA, Clowse determined, but she adjusted the patient’s medication to treat a severely inflamed right ankle and limited range-of-motion in both wrists. They also discussed the possibility of a future pregnancy.

Clowse prescribed infliximab to reduce the inflammation. When the drug became less effective, she switched the patient to tofacitinib citrate, which relieved more symptoms. Although she cautioned the patient to avoid getting pregnant while taking the drug, the patient returned to the clinic after becoming pregnant unexpectedly.

Question: What steps did Clowse take to relieve pain and ensure a safe and successful pregnancy?

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Answer: Calming the patient’s anxiety about a second pregnancy, Clowse stopped the tofacitinib citrate immediately and switched the patient to certolizumab pegol.

After her first experience, the patient was worried that she had done something wrong or her medications had caused the unsuccessful outcome. “She was very hesitant to take medications during the second pregnancy,” Clowse says.

But, like several new anti-inflammatory drugs, certolizumab pegol does not cross the placenta, Clowse notes, and is not a concern for breastfeeding. Other safe formulations include adalimumab and infliximab. “I was able to give her peace of mind by sharing safety data about these relatively new formulations that can help pregnant women,” Clowse says.

A key feature of Clowse’s practice is her knowledge and use of anti-inflammatory drugs that help relieve symptoms of rheumatologic disease during pregnancy. Her dedicated clinic—1 of only “a handful” in the country, she says—is based in the Duke Rheumatology and Immunology Division. Clowse encourages the use of medications that effectively reduce inflammation and are safe for mother and fetus.

“In this patient’s case, the medication worked relatively well,” Clowse says. “Her ankle mobility was increased and her pain diminished. She was better, not fantastic, but she delivered a healthy baby at term. She was able to breast feed, and the patient and baby are doing well.” Both the patient and the baby have continued to enjoy a normal, healthy course after delivery.

A long-held sentiment among rheumatologists, Clowse says, is that symptoms of RA usually improve during pregnancy, so medications are stopped. But she cautions that the approach is outdated. While arthritis might improve somewhat during pregnancy, the improvement is not comparable to the effectiveness of modern medications.

“We often see the converse reaction,” she says. “When you stop the medications, patients often experience flares and suffer from even more inflammatory conditions during pregnancy,” she says.

Clowse is a consultant for UCB, the Atlanta-based pharmaceutical that manufactures certolizumab. She was the lead author on a 2017 paper published in conjunction with UCB about the drug in breastfeeding as well a 2015 paper about pregnancy outcomes.