USE OF ETANERCEPT IN PREGNANCY

Etanercept is a human tumour necrosis factor (TNF) receptor p75 Fc fusion protein monoclonal antibody. It is used in the treatment of rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, non-radiographic axial spondyloarthritis, and plaque psoriasis where other systemic therapies are ineffective or unsuitable.

Maternal autoimmune/inflammatory conditions are known to increase the risk of certain adverse pregnancy outcomes, including miscarriage, preterm delivery and low infant birth weight, particularly where the maternal condition is poorly controlled either around the time of conception and/or during pregnancy. Studies that have included disease-matched control groups suggest no additional increased risks relating to use of anti-TNFα therapies.

Studies that provide data on the safety of etanercept use in pregnancy collectively describe more than 1,200 exposed pregnancies, with first trimester exposure confirmed in 389. These data do not indicate that etanercept use in pregnancy increases the overall risk of congenital malformation, or any of specific malformation/pattern of malformations. The available evidence also does not suggest that increased risks of miscarriage, intrauterine death, preterm delivery or impaired fetal growth exist following etanercept use in pregnancy. A small number of uncontrolled case reports have described normal childhood development up to 3 years of age.

Use of immunosuppressant antibodies that actively cross the placenta during pregnancy could result in immunosuppression in the neonate and increase the risk of infection. Rare cases of fatal infection following BCG vaccination after in utero anti-TNFα exposure have been described in the literature. General guidance has been provided from a number of authorities around avoiding/deferring live vaccine use in infants exposed to etanercept in utero. These recommendations vary depending on both the circumstances of etanercept exposure and infant infection risk. UKTIS recommend a case-specific risk assessment approach when considering the use of live vaccines following in utero etanercept exposure. Discussion with UKTIS is recommended in all cases where use of a live vaccine is being considered in an infant <12 months of age where there has been in utero exposure to etanercept.

Pregnant women treated with etanercept are likely to be offered additional fetal growth monitoring due to their underlying medical condition; no additional fetal monitoring is required as a result of etanercept exposure specifically. Other risk factors may be present in individual cases which may independently increase the risk of adverse pregnancy outcome. Clinicians are reminded of the importance of consideration of such factors when performing case-specific risk assessments.