New IBD guidelines urge biological therapy in pregnancy, childhood

By Will Boggs, MD

NEW YORK (Reuters Health) – Pregnant women and children with inflammatory bowel disease (IBD) should receive biological therapy to induce and maintain remission, according to the new London Position Statement of the World Congress of Gastroenterology.

“In both populations, the risk of the untreated disease is greater than the risk of most medications, which is the key thing to keep in mind,” Dr. Uma Mahadevan from UCSF Center for Colitis and Crohn’s Disease, San Francisco, California, told Reuters Health by email.

“Don’t be afraid to treat the patient with the medications that are felt to be effective and low risk,” Dr. Mahadevan said. “If you are concerned about the population you are treating, then refer them to an IBD specialist, as not doing anything and letting the disease run its course is much worse.”

Dr. Mahadevan and colleagues authored The London Position Statement of the World Congress of Gastroenterology on Biological Therapy for IBD with the European Crohn’s and Colitis Organization: Pregnancy and Pediatrics, which was published online December 14th in the American Journal of Gastroenterology.

Because the greatest risk to mother and fetus during pregnancy is active IBD and not the medication used to treat it, the authors advocate the use of infliximab, adalimumab, or certolizumab during pregnancy. Infliximab and certolizumab appear to be safe during breastfeeding, but there are no safety data for adalimumab with breastfeeding.

Children exposed to biological therapy in utero should receive their vaccines according to standard schedules, although live-virus vaccines should not be used if circulating biological agents are detectable.

For children with Crohn’s disease, infliximab is effective for inducing and maintaining response and remission, but scheduled infusions are more effective than episodic therapy for maintaining remission. Adalimumab and natalizumab are also effective for inducing and maintaining remission, whereas there are no published data on certolizumab use in children.

Infliximab and adalimumab are also effective for inducing and maintaining remission in children with ulcerative colitis.

Infliximab promotes growth improvement in prepubertal and early-pubertal children with Crohn’s disease and is effective for treating cutaneous extraintestinal manifestations and uveitis. Adalimumab effectively treats uveitis in children with Crohn’s disease.

Because biological agents carry an increased risk of infection, they should be used with caution in children. For children receiving biological therapy, inactivated vaccines are safe, but live-virus vaccines are contraindicated.

“The major concern in the pregnant patient is the health of the mother,” Dr. Mahadevan said. “If the mother is healthy then the pregnancy is more likely to be healthy. We need to balance the risk of the medications (which are generally quite low for azathioprine, aminosalicylates and biologics) with the high risk of disease activity or a flare during the pregnant period. The latter can lead to preterm birth and miscarriage.”

“In children, avoiding effective therapy and allowing disease to progress can impact physical and emotional growth and development of the child as shown in many studies,” Dr. Mahadevan added. “They have a very short window in which they can grow and reach their maximal height. If they have severe disease during that time, their growth will be stunted.”

SOURCE: http://bit.ly/eqRQWW