Effect of treat-to-target strategies on maternal and neonatal outcomes of rheumatoid arthritis: a multicentre real-world ANSWER cohort study

OBJECTIVES: We evaluated real-world disease activity, treatment patterns and pregnancy outcomes in women with rheumatoid arthritis (RA) utilizing a multicentre Japanese cohort. Feasibility and impact of a treat-to-target (T2T) approach during pregnancy were also examined. METHODS: A retrospective observational study analysed 118 pregnancies in patients with RA from the multicentre ANSWER cohort (2013-2023) across eight Japanese academic institutions. Clinical characteristics, treatment regimens and RA Disease Activity Scores of 28 joints based on C-reactive protein (DAS28-CRP) were assessed at preconception, during each trimester and postpartum. Pregnancy and neonatal outcomes were analysed. RESULTS: Of 118 pregnancies, 92.8% achieved full-term deliveries (median birthweight: 2949 g). Remission or low disease activity was maintained in ∼85% of patients throughout pregnancy, with increased postpartum disease activity. Patients who continued biologic disease-modifying antirheumatic drugs (bDMARDs) during pregnancy (n = 35) exhibited significantly lower DAS28-CRP scores during the second and third trimesters compared with those who discontinued (n = 24) (P = 0.007 and P = 0.0002, respectively). Etanercept or certolizumab pegol use was associated with favourable disease control. Tocilizumab (n = 6) or abatacept (n = 2) was not associated with adverse maternal or neonatal outcomes. Glucocorticoid use was associated with increased disease activity. Salazosulfapyridine use correlated with increased birth weight (P = 0.003) and gestational age (P = 0.051). CONCLUSION: T2T management, including selective continuation of bDMARDs, was associated with favourable maternal disease control and reassuring pregnancy outcomes. Although the absence of long-term follow-up is a limitation, these findings provide real-world evidence supporting this approach. Larger prospective studies are required to confirm maternal and neonatal safety beyond the early postpartum.