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The EULAR points to consider for use of antirheumatic drugs before pregnancy, and during pregnancy and lactation
  1. Carina Götestam Skorpen1,2,3,
  2. Maria Hoeltzenbein4,
  3. Angela Tincani5,
  4. Rebecca Fischer-Betz6,
  5. Elisabeth Elefant7,
  6. Christina Chambers8,
  7. Josè da Silva9,
  8. Catherine Nelson-Piercy10,
  9. Irene Cetin11,
  10. Nathalie Costedoat-Chalumeau12,13,
  11. Radboud Dolhain14,
  12. Frauke Förger15,
  13. Munther Khamashta16,
  14. Guillermo Ruiz-Irastorza17,
  15. Angela Zink18,
  16. Jiri Vencovsky19,
  17. Maurizio Cutolo20,
  18. Nele Caeyers21,
  19. Claudia Zumbühl22,
  20. Monika Østensen1,2
  1. 1National Service for Pregnancy and Rheumatic Diseases, Department of Rheumatology, Trondheim University Hospital, Trondheim, Norway
  2. 2Department of Neuroscience, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
  3. 3Department of Rheumatology, Ålesund Hospital, Ålesund, Norway
  4. 4Berlin Institute for Clinical Teratology and Drug Risk Assessment in Pregnancy, Charité-Universitätsmedizin Berlin, Berlin, Germany
  5. 5Department of Clinical and Experimental Science Rheumatology and Clinical Immunology Unit, Spedali Civili and University of Brescia, Brescia, Italy
  6. 6Department of Rheumatology, University Hospital of Düsseldorf, Duesseldorf, Germany
  7. 7Centre de Référence sur les Agents Tératogènes (CRAT), Groupe Hospitalier Universitaire Est, Hôpital Armand Trousseau, Paris, France
  8. 8Department of Pediatrics, University of California San Diego, La Jolla, USA
  9. 9Department of Rheumatology, University Hospital, Coimbra, Portugal
  10. 10Women's Health Academic Centre, St Thomas’ Hospital, London, UK
  11. 11Department of Mother and Child, Hospital Luigi Sacco, University of Milano, Milano, Italy
  12. 12Université Paris-Descartes, Paris, France
  13. 13Service de médecine interne, AP-HP, Hôpital Cochin, Centre de référence maladies auto-immunes et systémiques rares, Paris, France
  14. 14Department of Rheumatology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
  15. 15Department of Rheumatology, Immunology and Allergology, University Hospital of Bern, Bern, Switzerland
  16. 16Graham Hughes Lupus Research Laboratory, Division of Women's Health, King's College London, The Rayne Institute, St Thomas’ Hospital, London, UK
  17. 17Autoimmune Diseases Research Unit, Department of Internal Medicine, Biocruces Health Research Institute, University Hospital Cruces, University of the Basque Country, Bizkaia, Spain
  18. 18Epidemiology Unit, and Department for Rheumatology, German Rheumatism Research Centre, Charité University Medicine, Berlin, Germany
  19. 19Institute of Rheumatology, Praha, Czech Republic
  20. 20Research Laboratories and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Genova, Italy
  21. 21EULAR Social Leagues Patients’ representative, Leuven, Belgium
  22. 22EULAR Social Leagues Patients’ representative, Zürich, Switzerland
  1. Correspondence to Professor Monika Østensen, National Service for Pregnancy and Rheumatic Diseases, Department of Rheumatology, Trondheim University Hospital, Trondheim 7006, Norway; monika.ostensen{at}gmail.com

Abstract

A European League Against Rheumatism (EULAR) task force was established to define points to consider on use of antirheumatic drugs before pregnancy, and during pregnancy and lactation. Based on a systematic literature review and pregnancy exposure data from several registries, statements on the compatibility of antirheumatic drugs during pregnancy and lactation were developed. The level of agreement among experts in regard to statements and propositions of use in clinical practice was established by Delphi voting. The task force defined 4 overarching principles and 11 points to consider for use of antirheumatic drugs during pregnancy and lactation. Compatibility with pregnancy and lactation was found for antimalarials, sulfasalazine, azathioprine, ciclosporin, tacrolimus, colchicine, intravenous immunoglobulin and glucocorticoids. Methotrexate, mycophenolate mofetil and cyclophosphamide require discontinuation before conception due to proven teratogenicity. Insufficient documentation in regard to fetal safety implies the discontinuation of leflunomide, tofacitinib as well as abatacept, rituximab, belimumab, tocilizumab, ustekinumab and anakinra before a planned pregnancy. Among biologics tumour necrosis factor inhibitors are best studied and appear reasonably safe with first and second trimester use. Restrictions in use apply for the few proven teratogenic drugs and the large proportion of medications for which insufficient safety data for the fetus/child are available. Effective drug treatment of active inflammatory rheumatic disease is possible with reasonable safety for the fetus/child during pregnancy and lactation. The dissemination of the data to health professionals and patients as well as their implementation into clinical practice may help to improve the management of pregnant and lactating patients with rheumatic disease.

  • DMARDs (biologic)
  • DMARDs (synthetic)
  • Nursing
  • Treatment
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