Pregnancy in Lupus Nephritis and RA: Managing risks and treating to target Save

A significant proportion of patients with rheumatologic disease are of reproductive age, therefore, navigating reproductive health is now widely recognized as a fundamental component of modern rheumatology care. 

Day three of the APLAR 2026 congress included sessions on Women’s Health and Reproductive Issues in RMDs starting off with a presentation by Prof. Vinod Ravindran on the newly published APLAR Consensus Statements on the Management of Reproductive Issues in Autoimmune Rheumatic Diseases. This initiative stemmed from the growing unmet needs of reproductive health in the region including the unique differences of APLAR countries from other neighboring regions in terms of epidemiology, genetics, culture and access to healthcare including drug availability and accessibility. The succeeding portions of this article highlights key practical points from the lectures regarding pregnancy issues in lupus nephritis and rheumatoid arthritis. 

In her presentation on lupus nephritis and pregnancy, Dr. Samar Al Emadi advocated for preconception counseling, further emphasizing the goal of aiming for > 6 months quiescent disease of nephritis because disease activity at conception remains the single strongest predictor of outcome. Other key takeaways include the continuous use of hydroxychloroquine throughout pregnancy, utilizing azathioprine and tacrolimus as backbone immunosuppressive therapies while discontinuing mycophenolate, cyclophosphamide, methotrexate and ACEi/ARBs before conception. Dr. Al Emadi also highlighted getting baseline, preconception anti-Ro/La APLs in anticipation for congenital heart block surveillance and guiding aspirin/anticoagulation treatment. Furthermore, knowledge on the physiologic proteinuria of pregnancy allows for careful attribution of rising levels to active lupus nephritis. She underscored the crucial need for distinguishing a lupus nephritis flare from pre-eclampsia by using complement levels, anti-dsDNA trends, urinary sediments and sFlt-1/PIGF ratio (if available). 

Following this, Dr. Uthpala Dissanayake discussed treat-to-target strategies for rheumatoid arthritis (RA) in pregnancy. According to her, disease control matters because active RA impacts maternal health, pregnancy outcomes and the postpartum period. A key message from her talk emphasizes that the management of pregnancy in RA starts before conception, thus, the crucial role of pre-pregnancy planning apart from treating the active disease. Drawing on regional and international reproductive health guidelines - EULAR 2024, ACR 2020, BSR 2023 – including the newly published APLAR consensus, Dr. Dissanayake outlined pregnancy-compatible treatment options, as detailed below. Methotrexate, leflunomide and JAK inhibitors should be discontinued before conception to avoid teratogenicity. Consistent with the three guidelines mentioned above, the APLAR consensus recommends stopping methotrexate 1–3 months, leflunomide more than 3.5 months, and JAK inhibitors more than 2 weeks prior to conception. 

As glucocorticoids may play a role in controlling disease flares, weighing the benefits and risks of glucocorticoid use in pregnancy should be considered. Key points on glucocorticoid use were: preference of non-fluorinated compounds, using the lowest effective dose for the shortest duration, addition of steroid-sparing therapy if continuing treatment is required and the regular monitoring of maternal BP, blood sugar and steroid-related adverse effects. The APLAR consensus statements specifically included hydrocortisone and methylprednisolone as the preferred non-fluorinated steroid options apart from prednisone with IV methylprednisolone pulses reserved for severe disease. Additionally, limiting steroid exposure to a much lower target of <5mg/day of prednisone is recommended to decrease maternal risk of infection and gestational diabetes mellitus. Finally, reassuring evidence exist for TNF inhibitors and these may be continued if indicated while adapting an individualized risk-benefit assessment. 

With most rheumatic disease patients in their reproductive years, the rheumatologist's role extends far beyond standard disease management to encompass the entire reproductive journey. Ultimately, ensuring the best possible pregnancy outcomes requires proactive, multidisciplinary collaboration with specialties such as maternal-fetal medicine and nephrology.