Critical review of the current recommendations for the treatment of systemic inflammatory rheumatic diseases during pregnancy and lactation

Roger A Levy; Guilherme R de Jesús; Nilson R de Jesús; Evandro M Klumb

doi:10.1016/j.autrev.2016.07.014

Critical review of the current recommendations for the treatment of systemic inflammatory rheumatic diseases during pregnancy and lactation

Autoimmun Rev. 2016 Oct;15(10):955-63. doi: 10.1016/j.autrev.2016.07.014. Epub 2016 Aug 1.

Authors

Roger A Levy¹, Guilherme R de Jesús², Nilson R de Jesús³, Evandro M Klumb⁴

Affiliations

¹ Department of Rheumatology, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil; Pós-graduação em Ciências Médicas (PGCM), Faculdade de Ciências, Médicas, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil. Electronic address: roger.a.levy@gmail.com.
² Department of Obstetrics, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil; Department of Obstetrics, Instituto Fernandes Figueira, FIOCRUZ, Rio de Janeiro, Brazil; Pós-graduação em Ciências Médicas (PGCM), Faculdade de Ciências, Médicas, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil.
³ Department of Obstetrics, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil.
⁴ Department of Rheumatology, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil; Pós-graduação em Ciências Médicas (PGCM), Faculdade de Ciências, Médicas, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil.

PMID: 27490204
DOI: 10.1016/j.autrev.2016.07.014

Abstract

The crucial issue for a better pregnancy outcome in women with autoimmune rheumatic diseases is appropriate planning, with counseling of the ideal timing and treatment adaptation. Drugs used to treat rheumatic diseases may interfere with fertility or increase the risk of miscarriages and congenital abnormalities. MTX use post-conception is clearly linked to abortions as well as major birth defects, so it should be stopped 3months before conception. Leflunomide causes abnormalities in animals even in low doses. Although in humans, it does not seem to be as harmful as MTX, when pregnancy is detected in a patient on leflunomide, cholestyramine is given for washout. Sulfasalazine can be used safely and is an option for those patients who were on MTX or leflunomide. Azathioprine is generally the immunosuppressive of choice in many high-risk pregnancy centers because of the safety profile and its steroid-sparing property. Cyclosporine and tacrolimus can also be used as steroid-sparing agents, but experience is smaller. Although prednisone and prednisolone are inactivated in the placenta, we try to limit the dose to the minimal effective one, to prevent side effects. Antimalarials have been broadly studied and are safe during pregnancy and breastfeeding. Among biologic disease modifying anti-rheumatic agents (bDMARD), the anti-TNFs that have been used for longer are the ones with greater experience. The large monoclonal antibodies do not cross the placenta in the first trimester, and after conception, the decision to continue medication should be taken individually. The experience is larger in women with inflammatory bowel diseases, where anti-TNF is generally maintained at least until 30weeks to reduce fetal exposure. Live vaccines should not be administrated to the infant in the first 6months of life. Pregnancy data for rituximab, abatacept, anakinra, tocilizumab, ustekinumab, belimumab, and tofacitinib are limited and their use in pregnancy cannot currently be recommended.

Keywords: Anti-TNF; Autoimmune diseases; DMARD; Lactation; Pregnancy; Rheumatic diseases.

Publication types

Review

MeSH terms

Animals
Antirheumatic Agents / therapeutic use*
Female
Humans
Immunosuppressive Agents / therapeutic use
Inflammatory Bowel Diseases / drug therapy
Lactation
Practice Guidelines as Topic
Pregnancy
Pregnancy Complications / drug therapy*
Pregnancy Outcome
Rheumatic Diseases / drug therapy*

Substances

Antirheumatic Agents
Immunosuppressive Agents