Use of medications during pregnancy and breastfeeding for Crohn’s disease and ulcerative colitis

ABSTRACT

Introduction: The peak age of diagnosis of inflammatory bowel disease (IBD) occurs during childbearing years, therefore management of IBD during pregnancy is a frequent occurrence. Maintenance of disease remission is crucial to optimize pregnancy outcomes, and potential maternal or fetal toxicity from medications must be balanced against the risks of untreated IBD.

Areas covered: This review summarizes the literature on safety and use of medications for IBD during pregnancy and lactation.

Expert opinion: 5-aminosalicylates, corticosteroids and thiopurines are safe for use during pregnancy, while methotrexate and tofacitinib should only be used with extreme caution. Anti-TNF agents (except certolizumab), vedolizumab, ustekinumab and tofacitinib readily traverse the placenta via active transport, therefore theoretically may affect fetal development. Certolizumab only undergoes passive transfer across the placenta, thus has markedly lower cord blood levels making it likely the safest biologic agent for infants. There is reasonable evidence to support the safety of anti-TNF monotherapy and combination therapy during pregnancy and lactation. Vedolizumab and ustekinumab are also thought to be safe in pregnancy and lactation, while tofacitinib is generally avoided due to teratogenic effects in animal studies.

KEYWORDS:

• Inflammatory bowel disease
• pregnancy
• immunosuppression
• biologic therapy
• medication safety
• breastfeeding

Article highlights

• 5-aminosalicylates, corticosteroids, thiopurines and anti-TNF agents can be used safely during pregnancy and breastfeeding

• Vedolizumab and ustekinumab are likely to be safe for use during pregnancy and lactation, although data is scarce

• Most data suggest that co-therapy with anti-TNF agents and thiopurines does not increase the risk of adverse pregnancy outcomes

• Methotrexate and tofacitinib should only be used with extreme caution during pregnancy and breastfeeding

• Medication decisions during pregnancy should be made on an individual basis, particularly for women who have failed multiple lines of therapy in whom treatment cessation may confer greater risks

This box summarizes key points contained in the article.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

A reviewer on this manuscript has disclosed that they are an advisor to Gilead Sciences and Pfizer. All other peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.