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Management of RA medications in pregnant patients

Nature Reviews Rheumatology volume 5, pages 382–390 (2009)Cite this article

Abstract

A desire for children or the presence of pregnancy limits the drug therapy options for a woman with rheumatoid arthritis. Combination therapies that include methotrexate or new drugs that have not been studied or used in pregnant patients must be excluded, even though they might be highly efficacious. With few exceptions, the reason for this exclusion is not the proven teratogenicity of the drugs, but the absence of proven safety for the fetus. Whereas methotrexate, leflunomide, abatacept and rituximab must be withdrawn before a planned pregnancy, tumor necrosis factor inhibitors and bisphosphonates can be continued until conception. Antimalarial agents, sulfasalazine, azathioprine and ciclosporin are compatible with pregnancy, and so can be administered until birth. Corticosteroids and analgesics such as paracetamol (acetaminophen) can also be used throughout pregnancy. NSAIDs can be safely administered until gestational week 32. The most important consideration when managing rheumatoid arthritis medications during pregnancy is that therapy must be tailored for the individual patient according to disease activity.

Key Points

  • In patients with rheumatoid arthritis who are planning to become pregnant, remission or substantial improvements in disease activity should be achieved by use of the most effective therapy available

  • Potential teratogens or drugs that have not been proven safe for the fetus—including methotrexate, leflunomide, abatacept and rituximab—should be discontinued before pregnancy

  • Once pregnancy is recognized, withdrawal of tumor necrosis factor inhibitors and bisphosphonates is advised, owing to a lack of data on the long-term effects of antenatal exposure

  • Chloroquine, hydroxychloroquine, sulfasalazine, azathioprine and ciclosporin can be used throughout pregnancy, although many patients opt to discontinue all DMARDs and rely on corticosteroids, NSAIDs and analgesics to manage symptoms

  • Inadvertent exposure to potentially fetotoxic drugs is not an absolute indication for pregnancy termination; the decision should be based on careful assessment of the risk to the fetus

  • Disease flares can be effectively treated with intra-articular or oral corticosteroids; other options include analgesics and NSAIDs

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Figure 1: Algorithm of a treatment strategy for patients with RA planning a pregnancy.

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Acknowledgements

Charles P. Vega, University of California, Irvine, CA, is the author of and is solely responsible for the content of the learning objectives, questions and answers of the MedscapeCME-accredited continuing medical education activity associated with this article.

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  1. Department of Rheumatology, Clinical Immunology and Allergology, University Hospital Bern, Switzerland

    Monika Østensen & Frauke Förger

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Correspondence to Monika Østensen.

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M. Østensen declares that she has received speaker's bureau honoraria from Abbott, Essex, Sanofi–Aventis and Wyeth. F. Förger declares no competing interests.

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Østensen, M., Förger, F. Management of RA medications in pregnant patients. Nat Rev Rheumatol 5, 382–390 (2009). https://doi.org/10.1038/nrrheum.2009.103

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