Biologics and small molecules in the management of psoriatic arthritis: Reproduction related issues in female and male patients

STRACT

Background: Psoriatic arthritis (PsA) is the musculoskeletal manifestation of psoriatic disease, an inflammatory systemic disease with a high incidence in the reproductive years. Biologic and targeted synthetic disease-modifying antirheumatic drugs (DMARDs) as well as ‘small molecules’, are increasingly used to treat subtypes of PsA. Safety concerns exist in the field of fertility for PsA patients since the literature shows discordant results toward the influence of anti-psoriatic drugs.

Areas covered: This comprehensive review critically reviews the available data on the safety of biologics and small molecules in PsA including pregnancy and lactation and men who want to father a child. TNF inhibitors (TNFi) are best studied in relation to reproduction. For other biologics and small molecules, no prospective, controlled studies are available.

Expert opinion: No contraindications appear for TNFi in pregnancy, lactation, and paternal exposure. For biologics other than TNFi and small molecules, prospective controlled studies on outcomes after exposure in early and late pregnancy are urgently needed. Potential effects of all biologics on immune function, infection rates, and vaccine responses in prenatally exposed children need to be expanded. Until more data become available, small molecules should be avoided during pregnancy and breastfeeding. More reproduction-related data are expected from various national and international registries in the future

KEYWORDS:

• Psoriasis
• psoriatic arthritis
• pregnancy
• breastfeeding
• male reproduction
• biologics
• small molecules
• TNF inhibitors

Article highlights

• Multifaceted psoriatic disease, comorbidities and lifestyle factors impact reproductive function in male and female patients with psoriatic disease.

• Well-controlled disease activity before, during and after pregnancy predicts successful outcomes in patients with psoriatic arthritis.

• Untreated active psoriatic disease has a negative influence on spermatogenesis which may normalize under effective drug therapy.

• Among biologic drugs, TNF inhibitors have shown no negative effects on female or male fertility and can be used during pregnancy and lactation.

• For abatacept and ustekinumab data on human reproduction are limited; in selected cases, administration until the second trimester of pregnancy may be considered in the absence of effective alternative therapies.

• Data for IL-17 inhibitors, IL-23p19 inhibitors, JAK inhibitors and apremilast in human pregnancy are sparse or not available, they should be avoided in pregnancy.

Declaration of interest

R. Fischer-Betz has received speaker’s fees and consultant fees from Abbvie, Biogen, BMS, Chugai, GSK, Janssen, Lilly, Medac, MSD, Novartis, Roche, Sanofi and UCB. M Østensen has received speaker’s fees and consultant fees from Abbott/Abbvie, New Bridge, Pfizer, Roche and UCB. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.