SpA in Pregnancy — SCE Rheumatology MCQ

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ModerateSpondyloarthropathySpA in PregnancySCE Rheumatology

A 30-year-old woman with radiographic axial spondyloarthritis previously had good disease control with secukinumab. She stopped treatment when pregnancy was confirmed and, at 22 weeks' gestation, has developed a major inflammatory flare despite non-pharmacological measures. A biologic is required, and she wishes to minimise fetal drug exposure while maintaining treatment throughout the remainder of pregnancy. Which biologic is the most appropriate choice?

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Correct answer: A — Certolizumab pegol

Certolizumab pegol is the best answer. Current EULAR guidance permits TNF inhibitors throughout pregnancy after individualised risk-benefit assessment. Certolizumab is an Fc-free, PEGylated Fab′ fragment and therefore lacks FcRn-mediated active placental transport. UK SmPC and prospective pharmacokinetic data demonstrate no or minimal fetal exposure, making it particularly suitable when treatment must continue and minimising placental transfer is a priority. Adalimumab and infliximab are Fc-containing IgG1 antibodies and undergo increasing active transfer later in pregnancy. Etanercept has less placental transfer than conventional monoclonal TNF inhibitors but more than certolizumab. Secukinumab is effective for axial spondyloarthritis, and non-TNF biologics may sometimes be considered when necessary, but its UK SmPC advises preferential avoidance during pregnancy because adequate human data are lacking. Other TNF inhibitors remain pregnancy-compatible; certolizumab is selected here specifically for minimal fetal exposure.

Reference: Cimzia 200 mg solution for injection, UK Summary of Product Characteristics, section 4.6 Fertility, pregnancy and lactation, revised April 2026: https://www.medicines.org.uk/emc/product/7387/smpc