In a meta-analysis evaluating 642 women with IBD with exposures to sulfasalazine, mesalazine, and olsalazine, there were no findings of increased risk of congenital abnormalities, spontaneous abortions, preterm delivery, or low birth weight.48 The largest individual study included in this meta-analysis utilized a Danish cohort of children born to mothers with Crohns disease with 179 births representing exposure to sulfasalazine. being able to get an erection, but not having it last long enough for sex. 2014 May. In the following sections, we discuss the risks and benefits and outline best practices in use of drug therapy in pregnant women with RA (Table 1 and Figure 1). Before Berger CT, Recher M, Steiner U, Hauser TM. Especially in women with high disease activity, the pregnancy outcome is also impaired. Harigai M. Growing evidence of the safety of JAK inhibitors in patients with rheumatoid arthritis. [QxMD MEDLINE Link]. Bernard N, Gouraud A, Paret N, Cottin J, Descotes J, Vial T. Azathioprine and breastfeeding: long-term follow-up. Best Pract Res Clin Obstet Gynaecol. Quinn C, Mulpeter K, Casey EB, Feighery CF. Content and format of labeling for human prescription drug and biological products; requirements for pregnancy and lactation labeling. Time to pregnancy was not found to be associated with rheumatoid factor (RF) or anti-citrullinated protein antibody status or disease duration.12, Women with RA are reported to have high rates of infertility treatment, but this may be biased by other risk factors. Vasiliauskas EA, Church JA, Silverman N, Barry M, Targan SR, Dubinsky MC. There was no difference in birth defects among women with exposure only in preconception and the two comparison groups. 1985 Jun. Rituximab combined with chemotherapy for lymphoma during pregnancy. Preterm delivery was the same between the RA groups but higher compared to those without RA. Inclusion in an NLM database does not imply endorsement of, or agreement with, What are the BSR-BHPR guidelines on the use of corticosteroids by pregnant women with rheumatoid arthritis (RA)? 2000 Dec. 62(6):385-92. Rey J, Coso D, Roger V, Bouayed N, Belmecheri N, Ivanov V, et al. Tofacitinib [package insert] 2015. [21], Medications in the antitumor necrosis factor (TNF)-alpha class (eg, etanercept, adalimumab, infliximab, golimumab, and certolizumab) are commonly used in the treatment of RA. In an updated report of the PARA study, in women with at least moderate disease activity in the first trimester, approximately half had no response, while the other had good/moderate response as defined by the European League Against Rheumatism (EULAR) response criteria for pregnancy.18 In the postpartum state, 36% of women had severe-to-moderate deterioration in disease activity, while 64% had no deterioration. Levy RA, Vilela VS, Cataldo MJ, et al. 2019 Feb 1. [QxMD MEDLINE Link]. 75 (5):795-810. NSAIDs are contraindicated in the third trimester, because they promote premature closure of the ductus arteriosus, leading to fetal pulmonary hypertension. Rituximab (Rituxan), a monoclonal antibody that inhibits CD20 antigen on B lymphocytes, is indicated for the treatment for moderate to severe RA. Periconceptional over-the-counter nonsteroidal anti-inflammatory drug exposure and risk for spontaneous abortion. At present, emerging . An additional 13 had an elective abortion, while the outcome in two was unknown. Individual drugs can be searched on this portal, and the resource is updated monthly. [QxMD MEDLINE Link]. Mahadevan U, Martin CF, Sandler RS, et al. Of the live births, 24% were premature with one death at 6 weeks of unclear etiology. [QxMD MEDLINE Link]. We discuss in this comprehensive review the numerous challenges faced by rheumatologists in their care of men and women of childbearing potential and outline potential evidence-based solutions to assist them in this formidable task. Mahadevan U, Wolf DC, Dubinsky M, et al. Delivery age and Apgar scores were higher in the HCQ group. As a library, NLM provides access to scientific literature. Is prednisone safe for breastfeeding women with rheumatoid arthritis (RA)? [47]. Is leflunomide (LEF) safe for pregnant women with rheumatoid arthritis (RA)? 46(4):695-8. The dosing of rituximab in case reports was 375 mg/m2 for 1-6 cycles. Arthritis Rheum. DURING PREGNANCY There are three general classes of drugs commonly used in the treatment of rheumatoid arthritis: non-steroidal anti-inflammatory agents (NSAIDs), corticosteroids, and disease modifying anti-rheumatic drugs (DMARDs). Patients on hydroxychloroquine (HCQ) may need an eye examination by an ophthalmologist to assess for drug toxicity. Pregnancy outcomes following exposure to abatacept during pregnancy. [Full Text]. Corticosteroids are an initial first step in pregnancy, and when possible, intra-articular administration is indicated to limit systemic side effects. Outcome of pregnancy in women receiving infliximab for the treatment of Crohns disease and rheumatoid arthritis. Careers, Unable to load your collection due to an error. These agents have been labeled as class B medications; animal studies have shown no harm to the fetus, An official website of the United States government. Upadacitinib: Limited human data on use in pregnant women are not sufficient to evaluate a drug-associated risk for major birth defects or miscarriage. Arthritis Rheum. Available from: Motta M, Tincani A, Faden D, et al. 2015 Oct. 80 (4):727-39. [Full Text]. Accessibility Immunol Today. Verstappen SM, King Y, Watson KD, Symmons DP, Hyrich KL. In the setting of a positive pregnancy test for a woman on treatment for RA, an individualized discussion for each medication should occur. Stopping bDMARDs at the beginning of pregnancy is associated with disease flares and preterm delivery in women with rheumatoid arthritis. The diagnosis of RA in a father is not associated with poor outcomes such as preterm birth or fetal growth measures for their children.22 However, there may be implications with regard to medications used for RA management on birth outcomes (Table 3). Murashima A, Watanabe N, Ozawa N, Saito H, Yamaguchi K. Etanercept during pregnancy and lactation in a patient with rheumatoid arthritis: drug levels in maternal serum, cord blood, breast milk and the infant's serum. Rheumatoid arthritis (RA) is a type of arthritis that mainly affects the joints, but can also affect other parts of the body. There were eleven infants with hematologic abnormalities, including leukopenia, thrombocytopenia, and anemia, and a separate four patients suffered neonatal infection. The authors report no conflicts of interest in this work. Due to the lack of data, lactation should be avoided. 14(7):869-71. Although the elimination is slow and there is a potential risk for accumulation in the infant, most experts believe that the drug may be continued during breastfeeding. Frisell T, Holmqvist M, Kallberg H, Klareskog L, Alfredsson L, Askling J. Familial risks and heritability of rheumatoid arthritis: role of rheumatoid factor/anti-citrullinated protein antibody status, number and type of affected relatives, sex, and age. Case report: fatal case of disseminated BCG infection in an infant born to a mother taking infliximab for Crohns disease. The absolute contraindication to methotrexate (MTX) (category X) during pregnancy is secondary to the risk of spontaneous abortion and MTX embryopathy characterized by a combination of abnormalities impacting the heart, central nervous system, and skeleton.38 There are case reports of exposure to low doses of MTX during the first trimester without untoward side effects,39,40 but unfortunately, there does not appear to be a low enough dose that a pregnant patient can be counseled on that the MTX exposure will not pose any risk. A few studies have demonstrated increased risk of preeclampsia among women with RA,13,20 while others have not been able to confirm this.1,14,19 It is unclear if this is reflective of different patient populations or preeclampsia case ascertainment. Vermillion ST, Scardo JA, Lashus AG, Wiles HB. Specifically for LEF, in the event of pregnancy, it is recommended that patients receive cholestyramine to eliminate the drug (washout procedure). Rigourd V, de Villepin B, Amirouche A, et al. For all women diagnosed with RA, it is important to get a reproductive history. Is methotrexate (MTX) safe for pregnant women with rheumatoid arthritis (RA)? Anti-TNF therapies and pregnancy: outcome of 130 pregnancies in the British Society for Rheumatology Biologics Register. In one study, women with RA were more likely to have been treated for infertility than those without RA (9.8% vs 7.6%) but were also older than women without RA.11 Another study demonstrated that assisted reproductive technology was more likely used for those with RA (5.6% vs 2.4%).13 Wallenius et al noted women with inflammatory arthritis utilizing assisted reproduction more often (3.9% vs 1.6% for reference subjects), but this was not statistically significant when adjusted for maternal age.14, Discussing with patients the impact of pregnancy on disease activity is helpful to form a basis for treatment recommendations. 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. 67 (7):1738-43. Angelberger S, Reinisch W, Messerschmidt A, et al. Teratogen update: reproductive risks of leflunomide (Arava); a pyrimidine synthesis inhibitor: counseling women taking leflunomide before or during pregnancy and men taking leflunomide who are contemplating fathering a child. A study comparing 311 women with varied indications for GCs use in the first trimester with women without use did not note a difference in major anomalies. [37, 38] but thus far, no randomized, blinded, placebo-controlled trials on potential teratogenicity in humans have been completed. 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