Challenges and treatment options for rheumatoid arthritis during pregnancy

ABSTRACT

Introduction: Rheumatoid arthritis (RA) can spontaneously improve during pregnancy. However, a considerable proportion of patients can experience a flare and high disease activity has been associated with an increased risk of adverse pregnancy outcome. Thus, the treatment of RA in pregnant women should be selected taking into account both the potential harmful effects of the treatment and the risk associated with discontinuation.

Areas covered: Recent publications regarding safety of the most important disease modifying anti-rheumatic drugs (DMARDs) during pregnancy has been reviewed. A systematic literature search of MEDLINE was conducted using pregnancy, teratogenicity, adverse effects, embryo/foetal-toxicity as key search terms for each DMARD.

Expert opinion: A great body of evidence suggest that hydroxychloroquine, sulfasalazine, and non-fluorinated steroids can be continued throughout pregnancy, while methotrexate and leflunomide should be discontinued 3 months before pregnancy. Continuation of TNFi during the first part of pregnancy should be considered when benefits outweigh the potential risk of teratogenicity. Data regarding other biologics are scant and, at present, they should be stopped before pregnancy.

KEYWORDS:

• Abatacept
• glucocorticoids
• hydroxychloroquine
• leflunomide
• methotrexate
• pregnancy
• rituximab
• teratogenicity
• TNF inhibitors
• tocilizumab

Article highlights

• A very tight control of disease activity in RA pregnant women is advisable to minimize the risk of adverse pregnancy outcome

• The need of an effective therapy should be balanced with the potential embryo- and foeto-toxic effects of medications

• HCQ, SSZ and non-fluorinated GCs can be continued throughout pregnancy

• NSAIDs have several adverse effects on pregnancy and should be used very cautiously

• MTX and LFN have been demonstrated to be potentially teratogenic and should be discontinued at least 3 months before gestation

• Continuation of TNFi during the first part of pregnancy should be considered in case of very aggressive and active disease, when benefits outweigh the potential risk of teratogenicity

• Data regarding other biologics are scant and, at present, they should be stopped before pregnancy.

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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.