Taking medication for rheumatological diseases whilst pregnant or breastfeeding: Guidance published
Many women find themselves wishing to have children whilst taking medications to treat their rheumatic disease, which they worry may be harmful to their baby. There is very little research however, about the safety of medications during pregnancy, which leads to variation in the advice given to pregnant women. Whilst some rheumatic diseases improve during pregnancy, many do not and active rheumatic disease is now known to be harmful to the health of the developing baby. There is also a risk that the mother’s rheumatic disease may worsen immediately after pregnancy. Therefore, the risk of not taking enough medication to control the disease at this time has to be balanced against the potential risk that the medication might pose to the developing baby.
To help healthcare professionals and patients make these decisions; the British Society of Rheumatology has published a two-part guideline on this topic. The authors reviewed all relevant published evidence to produce recommendations about which drugs should be stopped before, during or after pregnancy and breastfeeding. They also reviewed which medicines may be used by men wishing to conceive.
The guidelines highlight which medications are not harmful so may be used to treat rheumatic disease in pregnancy. Where medicines should be stopped during pregnancy the guideline summarises relevant evidence and recommends whether they should be stopped before conception, or at a particular point after pregnancy has been confirmed. There was much less evidence available however, on which medicines are safe during breastfeeding or in fathers trying to conceive, so most of these recommendations were based on expert opinion.
Part I focusses on the use of corticosteroids and ‘disease modifying anti-rheumatic drugs’ that are commonly used to treat many different rheumatic diseases. It recommends that corticosteroids (such as prednisolone) and hydroxychloroquine may be continued throughout pregnancy and breastfeeding. In contrast, methotrexate, leflunomide, cyclophosphamide and mycophenolate mofetil all pose too much risk to a developing baby so should be stopped in advance of pregnancy. Other medications which may be used in pregnancy include sulfasalazine, azathioprine, ciclosprorin and tacrolimus with appropriate monitoring. For biologic medications the guideline recommended that infliximab, etanercept, adalimumab and certolizumab can be stopped part-way through pregnancy (instead of before pregnancy as was originally thought when these drugs were first introduced). Whilst accidental use of newer biologic drugs (such as rituximab, tocilizumab, anakinra, abatacept and belimumab) was considered unlikely to cause harm to the baby, there was not enough evidence to recommend their intentional use in pregnant women.
Part II concentrates on other drugs commonly used in patients with rheumatic disease. It recommends that pain killers (such as intermittent paracetamol, tramadol and codeine), as well as several anti-depressants (often used to treat chronic pain conditions) and two blood thinning medicines (aspirin and low molecular weight heparin) may be used in pregnancy. Another commonly used blood-thinner however, warfarin, is not safe in pregnancy and there is not enough information about the newer blood thinners (rivaroxaban and dabigatran) so their use is not currently recommended in pregnancy. Other medications are recommended to be stopped at different stages of pregnancy; as soon as pregnancy is confirmed for angiotensin converting enzyme inhibitors and at 32 weeks for non-steroidal anti-inflammatory drugs.
The take home message is that some medicines may cause harm in pregnant women and need to be stopped in a timely manner, but that unnecessarily withdrawing helpful medicines can also cause harm. So it is important that women and men taking such medicines talk to their health care providers before trying to start a family so that appropriate advice and care can be given before, during, and after pregnancy.
Julia D Flint and Ian Giles
University College London, UK
BSR and BHPR guideline on prescribing drugs in pregnancy and breastfeeding-Part I: standard and biologic disease modifying anti-rheumatic drugs and corticosteroids.
Flint J, Panchal S, Hurrell A, van de Venne M, Gayed M, Schreiber K, Arthanari S, Cunningham J, Flanders L, Moore L, Crossley A, Purushotham N, Desai A, Piper M, Nisar M, Khamashta M, Williams D, Gordon C, Giles I; BSR and BHPR Standards, Guidelines and Audit Working Group.
Rheumatology (Oxford). 2016 Jan 10
BSR and BHPR guideline on prescribing drugs in pregnancy and breastfeeding-Part II: analgesics and other drugs used in rheumatology practice.
Flint J, Panchal S, Hurrell A, van de Venne M, Gayed M, Schreiber K, Arthanari S, Cunningham J, Flanders L, Moore L, Crossley A, Purushotham N, Desai A, Piper M, Nisar M, Khamashta M, Williams D, Gordon C, Giles I; BSR and BHPR Standards, Guidelines and Audit Working Group
Rheumatology (Oxford). 2016 Jan 10