Navigating Pregnancy, Dermatology, and Drug Safety

As more pregnant patients are being considered for clinical trials, Katherine Economy, MD, maternal fetal medicine specialist at Brigham and Women’s Hospital in Boston, Massachusetts, shares pearls for her colleagues in dermatology to consider. Economy led the session “Drug Safety in Pregnancy: Immunosuppressive and Biologic Agents” during the 2024 Masterclasses in Dermatology conference to discuss challenges and opportunities to utilize drugs for a variety of skin conditions that can be exacerbated during pregnancy.

Science RF/Adobe Stock

In a Q&A with Dermatology Times, Economy delves into biologics in pregnancy, postpartum and breastfeeding considerations, the success of certain TNFα inhibitors, and opportunities for further research.

Dermatology Times: What should dermatology clinicians consider when a pregnant patient walks through the door?

Economy: Pregnant patients get the same types of dermatologic conditions that non-pregnant people do. They end up with sometimes having very restricted treatment, because either there isn't information about the drugs or sometimes these diseases can be exacerbated in pregnancy. But what we know is that patients who don't receive treatment during pregnancy have worse outcomes from both obstetric and skin dermatologic hematologic standpoint.

It's really important when you see a patient who comes into pregnancy on an immunosuppressive or a biologic, that you have a comprehensive review of what the medication they're taking, how that medication may affect their pregnancy, and how to keep them safe during pregnancy. The important thing is to really do patient-centered decision making. So to look at sort of the risks and benefits of the medication they're taking, understanding that if you withdraw their medication, then they'revery likely to flare and become ill. Then that will result in a worse outcome for them. Try and find the safest regimen for them, understanding that pregnant people have different metabolism, different drug clearance. So their kidneys are working differently, and their livers working differently during pregnancy. All of this may conspire that you need a different dose as well as tailoring medication for pregnancy friendly treatment.

Dermatology Times: What are the challenges and opportunities of utilizing biologics in the treatment of pregnant patients for skin conditions?

Economy: I think the important thing is that there are so many biologics, and the ones that we have information on are actually successful suggests that many of them will be safe, particularly the TNFα inhibitors, we find that we have used these in pregnancy with great success. Sometimes we stop them as you move into the second or third trimester because they can have an effect on the baby's vaccine schedule when the baby's born. So in the same way that they can dial down the immune system of the mother, they can dial down the immune system of the baby, not in a way that's harmful to the baby at birth, but in a way that you may have to work with your pediatrician to figure out the vaccine schedule for your baby. So TNFα medications tend to be now used fairly comfortably during pregnancy. We tend to use steroids. We tend to use a lot of the immunosuppressives. And then there are the newer ones that we're still investigating, and the data that we've had thus far on a lot of them are quite reassuring. So again, it's a very personalized discussion with the patient looking at their goals and preferences and really tried to focus on patient-centered decision making.

Dermatology Times: What should clinicians be cognizant of postpartum and if the patient is breastfeeding?

Economy: I think we try to do everything we can to support breastfeeding, we know about the benefits of breastfeeding both for the mother and the baby. Many medications are passed into breast milk. Some are concentrated into breastmilk,some are passed invery lowdoses into breast milk.Soit's really important to look at the individual agent that they're on. But again, most of the data is reassuring, and most patients can safely stay on these medications while breastfeeding.

Dermatology Times: What is one thing you would like everyone to keep in mind as treatment options evolve for pregnant patients?

Economy: It's really important to include pregnant women in drug trials so that we can get adequate information so that we can treat women well during pregnancy and not let them get sicker because we don't have information about the drug.