BARCELONA, Spain—Rheumatoid arthritis (RA) disease activity decreases in almost 40% of pregnant women with RA; 26% achieve remission by the third trimester. However, almost 35% of pregnant women with RA will flare in the postpartum period, according to data from the PARA (Physical Activity in Rheumatoid Arthritis) study presented at EULAR 2007 in Barcelona, Spain.1

"This is the first prospective study that shows a statistically significant improvement of RA during pregnancy as measured by DAS28-CRP-3."—Yael A. de Man, MD.
"This is the first prospective study that shows a statistically significant improvement of RA during pregnancy as measured by DAS28 [disease activity score 28], CRP [C-reactive protein]-3," said lead researcher Yael A. de Man, MD, a rheumatologist with Erasmus MC University Medical Center Rotterdam, in The Netherlands.

Exactly why RA improves during pregnancy is not fully understood. The changes in hyperimmune response activity during pregnancy have been regarded as beneficial. Previous retrospective studies have suggested that about 75% of pregnant patients with RA have shown a cytokine expression similar to that found in healthy pregnant women.

"This discrepancy [between the] present study [and the] literature has to be interpreted in the scope of modern antirheumatic treatment, which may cause lower disease activity in the first trimester, and fewer flares postpartum," Dr. de Man said.

Researchers of the PARA study followed 124 RA patients and calculated disease activity with DAS28-CRP with three variables (DAS28-CRP-3) and obtained information on patients' medication use at preconception, each trimester, and at 6, 12, and 26 weeks postpartum. The change between DAS28 at first and third trimester was used to categorize patients according to the EULAR response criteria into good, moderate, and nonresponders. The change between the DAS28 at 6 weeks and 12 or 26 weeks was used to determine if a severe flare or moderate flare was present with inverted EULAR response criteria. The changes in DAS28 during pregnancy and postpartum were tested for significance using a mixed linear model.

Patients had a mean age of 31.6 years and a median disease duration of 48 months. Of the cohort, 63% were RF positive, 61% were antiCCP positive and 68% had erosive disease. The mean pregnancy duration was 39.3 weeks.

Fluctuations in DAS28 during pregnancy and beyond

At preconception and first trimester, patients had a mean DAS28 of 3.7. Relapse occured around 12 weeks with a mean DAS28 of 3.7. By the third trimester, DAS28 decreased to 3.4, which was statistically significantly. Mean DAS28 was 3.4 at 6 weeks postpartum.

During pregnancy, 11% of patients were good EULAR responders, 40% were moderate EULAR responders, and 60% patients were nonresponders. Five percent of patients had a severe flare postpartum and 36% had at least a moderate flare. Moreover, 64% remained relatively stable or improved during the postpartum period.

During all trimesters, the percentages of disease modifying antirheumatic drugs used (DMARDs) were stable. Fifty seven percent of patients took DMARDs during pregnancy, however, 82% used DMARDs after pregnancy. Use of MTX, biologics and NSAIDs accounted for the rise.

The PARA study provides "data that supports our knowledge in this area," noted immediate past president of EULAR, Tore K. Kvien, MD, with Diakonhjemmet Hospital, in Oslo, Norway.

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Reference

1. de Man YA, Dolhain RJEM, van de Geijn FE, et al. Does rheumatoid arthritis improve during pregnancy? Results from a prospective nationwide cohort study (The PARA-study). Presented at: EULAR 2007 Meeting; June 13-16, 2007; Barcelona, Spain. Abstract OP0049.