Background: Approximately 50% of patients with inflammatory arthritis (IA) experience worsening of disease activity during pregnancy. ^1,2 Given the evidence that increased disease activity immediately before or during pregnancy is associated with adverse pregnancy outcomes, it is imperative to maintain tighter disease control during this period. ³ Treatment options are limited to steroids or disease-modifying anti-rheumatic drugs (DMARDs) compatible with pregnancy. Certolizumab pegol (CZP) is a humanized TNF-alpha inhibitor with no to minimal transplacental transfer, making it a suitable option during pregnancy. ⁴ In patients who relapse while on treatment with a biologic, consideration can be given to optimizing the dose of the biologic. Studies in Crohn’s disease demonstrated that increasing the CZP dose from 400 mg Q4W to Q2W is a viable strategy for recapturing efficacy. ⁵ Similar data is not available for the rheumatology population or for pregnancy.

Objectives: To describe the successful control of juvenile inflammatory arthritis (JIA) flares using a reloading strategy with CZP in a pregnant patient with prior failure of multiple conventional systemic (cs)DMARDs and biologics.

Methods: This is a case report of a 31-year old female with JIA who presented with a disease flare in the 1 ^st trimester of her 2 ^nd pregnancy. The patient was treated with multiple csDMARDs and biologics since age 6. She experienced significant gastrointestinal side effects to subcutaneous methotrexate and leflunomide and inadequate response to hydroxychloroquine and sulfasalazine. Subsequently, she initiated and maintained treatment with etanercept for 14 years until she developed secondary loss of efficacy. She had primary non-response to golimumab and abatacept and experienced a severe allergic reaction to infliximab. Since 2017, she has been treated with CZP 200 mg Q2W with good control of disease activity.

Prior to conception, the patient had low disease activity ( Table 1 ). At 11 weeks gestation, the patient noted worsening of disease activity, with pain at 4/10, fatigue at 7/10, morning stiffness for 60 minutes, swollen joint count (SJC) 4/28, and tender joint count (TJC) 19/28. The patient global assessment of disease activity (PtGA) remained at 4/10 while physician global assessment of disease activity (PhGA) and health assessment questionnaire disability index (HAQ-DI) increased to 6/10 and 1.625, respectively ( Table 1 ). She reported that symptoms worsen one week after CZP injection with more joint pain and swelling in hands, wrists, and feet. The patient declined the addition of hydroxychloroquine, sulfasalazine, and steroids due to previous tolerability, lack of efficacy, and concerns about safety during pregnancy. The patient received 3 loading doses of CZP 400 mg Q2W. She then continued treatment with CZP 200 mg Q2W.

Results: On follow-up at 19 weeks gestation the patient reported 80% improvement in joint pain and swelling and reduction in morning stiffness ( Table 1 ). Pain and fatigue were rated as 2/10 and 5/10, respectively. PtGA score was 4/10, PhGA score was 2/10 and HAQ-DI score was 1.5 ( Table 1 ).

Conclusion: Reloading CZP to control increased IA disease activity during pregnancy may be a viable treatment option. To our knowledge, this is the first report of dose optimization in IA and in pregnancy in a patient treated with CZP.

REFERENCES:

[1]van den Brandt S, et al . Arthritis Res Ther 2017;19(1):64.

[2]Jethwa, H et al , Arthritis Rheumatol. 2016;68 (suppl 10).

[3]de Man Y, et al . Curr Opin Rheumatol. 2014;26:329–333.

[4]Mariette X, et al. Ann Rheum Dis. 2018 Feb;77(2):228-233.

[5]Sandborn WJ, et al . American College of Gastroenterology Annual Scientific Meeting. 2009; Abstract 699

Disclosure of Interests: Viktoria Pavlova Speakers bureau: Amgen, Abbvie, BMS, Jenssen, Lilly, Merk, Novartis, Roche, UCB, Pfizer, Consultant of: Amgen, Abbvie, BMS, Jenssen, Lilly, Merk, Novartis, Roche, UCB, Pfizer, Grant/research support from: UCB