Page 15 - Fertility in Women with Rheumatoid Arthritis Vruchtbaarheid van vrouwen met reumatoïde artritis

remission or alternatively a state of low disease activity. Methotrexate (MTX), a folic 1 acid antagonist, is the treatment of rst choice. Other synthetic DMARDs include sulfasalazine, leflunomide, and antimalarial drugs such as hydroxychloroquine. Combination therapy with several synthetic DMARDs has been proven to be more
effective than monotherapy.16,17 Since in general DMARD therapy starts to be effective after 6 to 12 weeks, the fast-acting glucocorticoids can be added as a bridging therapy to the DMARDs for a short period of time to enhance the anti-rheumatic effect.15 When therapy with synthetic DMARDs does not result in low disease activity or remission, biologic DMARDs such as tumor necrosis factor (TNF) inhibitors are the next treatment option.15 When a patient achieves persistent remission, anti- rheumatic drugs can be tapered with caution, one by one, always aiming at sustained remission for each individual patient.18
Aside from synthetic or biologic DMARDs, RA patients often use non-steroidal antiinflammatory drugs to manage pain and stiffness. However, the use of NSAIDs does not prevent long term damage in RA.1
Anti-rheumatic treatment during the preconception period
When a woman with RA wishes to conceive, the most common rst-step treatment, the folic acid antagonist MTX, is contra-indicated because of teratogenicity.19 Because of insuf cient evidence of the safety of numerous other anti-rheumatic drugs, such as leflunomide, abatacept, rituximab, tocilizumab, ustekinumab and anakinra, expert advice has been to discontinue these agents.20,21 In a subgroup of patients, anti-rheumatic treatment is stopped completely during the preconception period or in early pregnancy.22 However, it is advised not to stop all anti-rheumatic treatment completely, because active disease in the mother can lead to a less favourable outcome of pregnancy. A higher disease activity during pregnancy has been associated with a lower birth weight, and an increased risk for delivery through caesarean section.23 Recently, an EULAR task force on anti-rheumatic drugs before, during and after pregnancy has reported that active disease can be treated effectively with reasonable safety for the foetus or newborn during pregnancy and lactation.20
In daily practice, many rheumatologists have been reluctant of prescribing medication during pregnancy, due to possible teratogenicity or adverse effects during pregnancy.21 Therefore, over the last decade pregnant women with RA were mainly treated with steroids, sulfasalazine, and hydroxychloroquine, or did not receive any anti-rheumatic treatment despite active disease during the preconception period
General introduction
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