Use of tumor necrosis factor-alpha inhibitors during pregnancy among women who delivered live born infants

Pharmacoepidemiol Drug Saf. 2019 Mar;28(3):296-304. doi: 10.1002/pds.4695. Epub 2018 Nov 14.


Purpose: To describe the use of tumor necrosis factor-alpha inhibitors (TNFis) among pregnancies ending in a live birth and with a diagnosis of ankylosing spondylitis (AS), Crohn's disease (CD), juvenile idiopathic arthritis (JIA), psoriasis (PsO), psoriatic arthritis (PsA), rheumatoid arthritis (RA), or ulcerative colitis (UC).

Methods: We identified pregnancies among women aged 15 to 54 years between 01/01/2004 and 09/30/2015 from 16 health plans participating in Sentinel. We inferred indication using ICD-9-CM codes in the 183-day period before conception. We assessed proportion of infliximab, etanercept, adalimumab, certolizumab pegol, and golimumab by calendar year, indication, and maternal age, and compared them to proportions in an age-matched, indication-matched, and date-matched non-pregnant cohort.

Results: Among 19 681 pregnancies with at least one chronic inflammatory condition, 2990 (15.2%) received a TNFi. In both pregnancies and matched non-pregnant cohort, TNFi use was highest (34.4%; 55.8%) for PsA patients and lowest (6.2%; 13.4%) for PsO patients. Etanercept was most frequently used among AS/JIA/PsA/PsO/RA patients, while infliximab was the preferred TNFi for CD/UC patients. Except for infliximab and certolizumab, TNFi use during pregnancy decreased after the first trimester. Pregnancies among older pregnant women (45-54 years) were more likely to be treated compared with the matched non-pregnant cohort.

Conclusion: There was a preference for etanercept among pregnancies with AS/JIA/PsA/PsO/RA, despite the availability of other TNFis. Decline in TNFi use after the first trimester may be related to the desire to reduce TNFis transplacental transfer and to minimize infection risk to the fetus or baby associated with live vaccine immunizations after birth.

Keywords: anti-tumor necrosis factor; pharmacoepidemiology; pregnancy; treatment selection; tumor necrosis factor inhibitor.

Publication types

  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adolescent
  • Adult
  • Antibodies, Monoclonal / therapeutic use
  • Antirheumatic Agents / supply & distribution
  • Antirheumatic Agents / therapeutic use*
  • Arthritis, Psoriatic / drug therapy
  • Arthritis, Rheumatoid / drug therapy
  • Case-Control Studies
  • Etanercept / therapeutic use
  • Female
  • Humans
  • Infant, Newborn
  • Infliximab / therapeutic use
  • Middle Aged
  • Pharmacoepidemiology
  • Pregnancy
  • Pregnancy Complications / drug therapy*
  • Pregnancy Trimesters
  • Prenatal Care*
  • Spondylitis, Ankylosing / drug therapy
  • Tumor Necrosis Factor-alpha / antagonists & inhibitors*
  • United States
  • Young Adult


  • Antibodies, Monoclonal
  • Antirheumatic Agents
  • Tumor Necrosis Factor-alpha
  • golimumab
  • Infliximab
  • Etanercept