BSR Issues DMARD Prescribing Guidelines for Pregnancy Save

Treatment paradigms for managing pregnancy in rheumatoid arthritis (RA) have been challenged in recent years with the introduction of new agents and reclassification of drug safety during pregnancy by the FDA.

There is no consensus on best practices for drug management during pregnancy by rheumatologists. The British Society of Rheumatology (BSR) has released guidelines for DMARD use to assist medical practitioners who prescribe anti-rheumatic drugs in pregnancy and breastfeeding. (Citation source http://buff.ly/234mwZ3)

Tenets of the guideline include: the preference for prednisolone because of its compatibility during all trimesters. Hydroxychloroquine was advocated as safe prior to conception and throughout pregnancy. Similarly, sulfasalazine with folate supplementation can be used throughout the pregnancy. Other drugs compatible throughout pregnancy include azathioprine, cyclosporine and tacrolimus. But, leflunomide, mycophenolate and methotrexate (MTX) should be avoided. 

Even though the package insert says MTX should be stopped for one ovulatory cycle - the BSR recommends MTX be discontinued for three months prior to conception and avoidance of this medication during the entire pregnancy.  For TNF inhibitors (TNFi), certolizumab pegol is preferred based on limited evidence that it is compatible in all pregnancy trimesters. Other TNFi, adalimumab and etanercept should be avoided in the third trimester, and infliximab should be discontinued at 16 weeks of pregnancy. If these antibody-based TNFi are used later in pregnancy, live vaccinations should be avoided for the infant through age 7 months.