Table 4

Consensus on statements and expert opinion on use of non-steroidal anti-inflammatory drugs (NSAIDs) and immunosuppressive drugs in clinical practice in pregnant and lactating patients

PregnancyBreast feeding
DrugStatement on compatibility of drug with pregnancy based on evidencePercentage of agreement with statementExpert opinion on use of drug in clinical practice*Statement on compatibility of drug with breast feeding based on evidencePercentage of agreement with statementExpert opinion on use of drug
during breast
feeding†
Non-selective COX inhibitors
(classical NSAIDs)
Current evidence indicates no increased rate of congenital malformationsNon-selective COX inhibitors can be continued during the first and second trimesters92Embedded ImageNon-selective COX inhibitors are compatible with breast feeding88Embedded Image
Selective COX II inhibitorsCurrent evidence is insufficientSelective COX II inhibitors should be avoided in pregnancy100Embedded ImageAmong COX II inhibitors only celecoxib has been sufficiently studied; celecoxib is compatible with breast feeding, other COX II inhibitors should be avoided during lactation94Embedded Image
PrednisoneCurrent evidence indicates no increased rate of congenital malformations Prednisolone/prednisone can be continued at the lowest effective dose throughout pregnancy100Embedded ImageGlucocorticoids are compatible with breast feeding100Embedded Image
Intra-articular/intramuscular glucocorticoidsCurrent evidence indicates no increased rate of congenital malformationsIntra-articular/
intramuscular glucocorticoids can be given, when required, throughout pregnancy
100Embedded Image
Intravenous glucocorticoidsCurrent evidence indicates no increased rate of congenital malformations Intravenous glucocorticoids can be given, when required, throughout pregnancy100Embedded Image
Fluorinated glucocorticoidsCurrent evidence indicates that fluorinated glucocorticoids should be used with caution because they are less metabolised by the placentaThey should only be used to treat fetal problems100Embedded Image
HydroxychloroquineCurrent evidence indicates no increased rate of congenital malformations Hydroxychloroquine can be continued throughout pregnancy100Embedded ImageHydroxychloroquine is compatible with breast feeding100Embedded Image
ChloroquineCurrent evidence indicates no increased rate of congenital malformations Chloroquine can be continued throughout pregnancy100Embedded ImageChloroquine is compatible with breast feeding88Embedded Image
Mepacrine (quinacrine)Current evidence is insufficientMepacrine should be avoided in pregnancy100Embedded ImageNo data exist regarding mepacrine in breast milk, therefore mepacrine should be avoided in breast feeding100Embedded Image
SulfasalazineCurrent evidence indicates no increased rate of congenital malformations Sulfasalazine can be continued at doses up to 2 g/day with concomitant folate supplementation throughout pregnancy100Embedded ImageSulfasalazine is compatible with breast feeding in the healthy, full-term infant94Embedded Image
LeflunomideCurrent evidence is insufficientIn a planned pregnancy, a washout procedure should be completed before pregnancy Leflunomide should be avoided in pregnancy100Embedded ImageNo data exist regarding leflunomide in breast milk, therefore leflunomide should be avoided in breast feeding100Embedded Image
AzathioprineCurrent evidence indicates no increased rate of congenital malformations Azathioprine can be continued at doses up to 2 mg/kg/day throughout pregnancy100Embedded ImageAzathioprine is compatible with breast feeding94Embedded Image
MethotrexateCurrent evidence indicates an increased rate of congenital malformationsIn a planned pregnancy, methotrexate should be withdrawn 1–3 months before pregnancy100Embedded ImageOnly small amounts of methotrexate appear in breast milk, but data are limited, therefore methotrexate should be avoided in breast feeding100Embedded Image
CyclophosphamideCurrent evidence indicates an increased rate of congenital malformations Cyclophosphamide must be withdrawn before a planned pregnancy100Embedded ImageThere are limited data regarding cyclophosphamide in breast milk, therefore cyclophosphamide should be avoided in breast feeding94Embedded Image
CyclophosphamideThe use of cyclophosphamide might be justified to treat life-threatening conditions in the second and third trimesters100Embedded Image
CiclosporinCurrent evidence indicates no increased rate of congenital malformations Ciclosporin can be continued throughout pregnancy at the lowest effective dose100Embedded ImageCiclosporin is compatible with breast feeding100Embedded Image
TacrolimusCurrent evidence indicates no increased rate of congenital malformations Tacrolimus can be continued throughout pregnancy at the lowest effective dose using trough levels100Embedded ImageTacrolimus is compatible with breast feeding94Embedded Image
Mycophenolate mofetil (MMF)Current evidence indicates an increased rate of congenital malformationsIn a planned pregnancy, MMF should be withdrawn 1.5 months before pregnancy100Embedded ImageNo data exist regarding MMF in breast milk, therefore MMF should be avoided in breast feeding100Embedded Image
ColchicineCurrent evidence indicates no increased rate of congenital malformations Colchicine can be continued at doses up to 1 mg/day throughout pregnancy100Embedded ImageColchicine is compatible with breast feeding100Embedded Image
Intravenous immunoglobulinIntravenous immunoglobulin can be used throughout pregnancy100Embedded ImageIntravenous immunoglobulin is compatible with breast feeding100Embedded Image
TofacitinibCurrent evidence is insufficientIn a planned pregnancy treatment with tofacitinib should be stopped 2 months before conception100Embedded ImageNo data exist regarding tofacitinib in breast milk, therefore tofacitinib should be avoided in breast feeding100Embedded Image
  • *As an expert in the field.

  • I would recommend the drug in the same way as if the patient was not pregnant.

  • I would only recommend the drug if I feared at least moderate disease activity in its absence.

  • I would only recommend the drug if I feared at least severe disease activity in its absence.

  • I would never recommend the drug in pregnancy.

  • †As an expert in the field.

  • I would recommend the drug in the same way as if the patient did not breastfeed.

  • I would only recommend the drug if I feared at least moderate disease activity in its absence.

  • I would only recommend the drug if I feared at least severe disease activity in its absence.

  • I would never recommend the drug while the woman was breast feeding.