ACR 2020 Reproductive Guidelines - Lactation Guidance Save

The 2020 American College of Rheumatology (ACR) published guidelines on managing reproductive health issues in rheumatic disease (RMD) patients includes key guidance on preconception counseling, contraception, medication use and other unique scenarios. In this third excerpt from the ACR guidelines we present recommendations regarding the use of glucocorticoids and guidance on lactation and medication use post-partum.

The following is excerpted from the full manuscript. Please refer to the manuscript for more detail and evidence.

Use of Glucocorticoids During Pregnancy and Delivery 

• We conditionally recommend continuing chronic low dose (<10 mg daily of prednisone or non-fluorinated equivalent) during pregnancy if clinically indicated. 
• We strongly recommend tapering higher doses of non-fluorinated glucocorticoids to <20 mg daily of prednisone with the addition of a pregnancy-compatible immunosuppressive agent if needed.
• In women using chronic low dose glucocorticoids during pregnancy:
  • stress dose corticosteroids at the time of vaginal delivery are not recommended
  • We conditionally recommend treating with stress dose glucocorticoids at the time of Cesarean delivery.

Rheumatology Medications during Lactation for RMD Women 

• Women should be encouraged to breastfeed if desired and possible.
• Disease control should be maintained with medications compatible with lactation and risks/benefits reviewed with each patient for her particular situation.
• Traditional medication considerations:
  • We conditionally recommend that NSAIDs are compatible with breastfeeding
  • We strongly recommend that hydroxychloroquine is compatible with breastfeeding
  • We conditionally recommend that sulfasalazine is compatible with breastfeeding
  • We conditionally recommend that colchicine is compatible with breastfeeding
• Immunosuppressives
  • We strongly recommend against using leflunomide in breastfeeding women
  • We strongly recommend against using mycophenolate mofetil/ mycophenolic acid while breastfeeding 
  • We strongly recommend against using cyclophosphamide while breastfeeding
  • We strongly recommend against using thalidomide while  breastfeeding
  • We conditionally recommend against using methotrexate in breastfeeding women 
  • We conditionally recommend that azathioprine and 6 mercaptopurine are compatible with breastfeeding 
  • We conditionally recommend that cyclosporine is compatible with breastfeeding
  • We conditionally recommend that tacrolimus is compatible with breastfeeding 
• Biologics
  • We strongly recommend that TNF-inhibitors as a class: infliximab, etanercept, adalimumab, golimumab (no-data), certolizumab are compatible with breastfeeding 
  • We strongly recommend that rituximab is compatible with breastfeeding 
  • We conditionally recommend that anakinra is compatible with breastfeeding 
  • We conditionally recommend that belimumab is compatible with breastfeeding
  • We conditionally recommend that abatacept is compatible with breastfeeding 
  • We conditionally recommend that tocilizumab is compatible with breastfeeding 
  • We conditionally recommend that secukinumab is compatible with breastfeeding
  • We conditionally recommend that ustekinumab is compatible with breastfeeding 
• Glucocorticoids
  • We strongly recommend that prednisone <20mg a day (or non-fluorinated equivalent) is compatible with breastfeeding 
  • We strongly recommend that women using prednisone >20mg a day (or non-fluorinated glucocorticoid equivalent) delay breastfeeding or discard breast milk for the four hours following glucocorticoid administration 

Medication Use During Lactation

* delay breastfeeding or discard breast milk for 4 hours after steroid intake