Management of rheumatoid arthritis during pregnancy: challenges and solutions

Figures & data

Figure 1 Approach to management of patient with RA in reproductive age group.

Abbreviations: RA, rheumatoid arthritis; MTX, methotrexate; LEF, leflunomide; DAS28, Disease Activity Score in 28 joints; NSAIDs, nonsteroidal anti-inflammatory drugs; GCs, glucocorticoids; DMARD, disease-modifying antirheumatic drug; HCQ, hydroxychloroquine; SSZ, sulfasalazine; TNF, tumor necrosis factor; AZA, azathioprine.

Table 1 Approach to disease-modifying therapy for pregnant women with RA (or for women wishing to conceive)

Preferred medications (if required)	Medications relatively safe to use (require individualized approach)	Contraindicated medications	Inadequate data to support safety
Glucocorticoids (B)a	TNFα inhibitors (B)	Methotrexate (X)	Anakinra (B)
NSAIDs (B)b	Azathioprine (D)	Leflunomide (X)	Abatacept (C)
Hydroxychloroquine (C)			Tocilizumab (C)
Sulfasalazine (B)			Tofacitinib (C)
			Rituximab (C)c

Notes: The US FDA pregnancy category¹²⁵ for each drug is quoted in parenthesis: A: controlled human studies show no risk; B: no evidence of risk in studies; C: risk cannot be ruled out; D: positive evidence of risk; and X: contraindicated in pregnancy.

a Counseling advised regarding possible cleft lip/palate abnormalities.

b Avoid in third trimester due to risk of premature closure of ductus arteriosus.

c Recommendation is to avoid in pregnancy due to hematologic abnormalities and infection risk.

Abbreviations: RA, rheumatoid arthritis; TNF, tumor necrosis factor; NSAIDs, nonsteroidal anti-inflammatory drugs; FDA, Food and Drug Administration.

Table 2 Approach to medications for women with RA who are breastfeeding

Preferred medications (if required)	Insufficient data to support safe use	Contraindicated medications
Glucocorticoids	TNFα inhibitors	Methotrexate
NSAIDs	Anakinra	Leflunomide
Hydroxychloroquine	Abatacept	Azathioprineb
Sulfasalazinea	Rituximab
	Tocilizumab
	Tofacitinib

Notes:

a Caution is advised in the setting of prematurity, hyperbilirubinemia, and glucose-6-phosphate dehydrogenase deficiency.

b Avoidance is recommended by the manufacturer and expert opinion which is primarily based on theoretical risk.

Abbreviations: RA, rheumatoid arthritis; TNF, tumor necrosis factor; NSAIDs, nonsteroidal anti-inflammatory drugs.

Table 3 Medication management in male patient with RA interested in planning a family

Drug	Recommendation
Methotrexate	Hold 3 months prior to contraception due to sperm life cycle
Sulfasalazine	If difficulty with fertility, consider holding as it has been associated with reversible infertility
Azathioprine	No data to suggest adverse outcomes
Leflunomide	Insufficient data, but no adverse outcomes reported
TNFα inhibitors	Varied data regarding spermatogenesis but overall favorable outcomes
Rituximab	Insufficient data, but adverse outcomes reported
Abatacept	Insufficient data, but adverse outcomes reported

Abbreviations: RA, rheumatoid arthritis; TNF, tumor necrosis factor.

Food and Drug Administration Code of Federal Regulations Title 21 Available from: http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfCFR/CFRSearch.cfm?fr=201.57Accessed January 5, 2014

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