Medications and Pregnancy

Many people with Rheumatoid Arthritis (RA) may wish to have children. If this is you, please discuss this with your rheumatology team.

With careful treatment, most patients with RA can have healthy pregnancies and healthy babies.

Well-controlled RA improves the chance of healthy babies.

Remember with careful medical and obstetric management, most patients with RA can have successful pregnancies. If you have any questions please ask your rheumatologist.

More detailed information can be found on the Arthritis Australia or the American College of Rheumatology websites.

Your GP or other members of your care team may find the Australian Rheumatology Association (ARA) Prescriber's Information on Medications for Rheumatic Diseases in Pregnancy helpful.

Effect of RA on Pregnancy

  • Women with RA may take longer to get pregnant.
  • It’s uncertain whether there are increased miscarriages (pregnancy loss) in women with RA.
  • Women with RA are more likely to have smaller babies, premature babies (born too early) and caesarean section.

Effect of Pregnancy on RA

  • RA usually improves during pregnancy.
  • However, up to 1 in 5 women with RA worsen in pregnancy.

Good control of RA before you fall pregnant will give the best chance of falling pregnant, having a healthy pregnancy and a healthy baby.

 

Some very effective RA medications can be safely taken during pregnancy. However, some RA medications should not be taken if planning a pregnancy.

Labels and Categories

  • There is some confusion with Australian government labelling of which medications are safe in pregnancy.

Medications in Pregnancy

Pain management

  • Painkillers such as paracetamol and tramadol can be used if needed.
  • Morphine-type medications (narcotics) used at high doses close to the birth may be harmful to the baby.
  • Anti-inflammatories (NSAIDs) should not taken in the third trimester.

Corticosteroids, e.g. prednisone/prednisolone

  • Risks to mothers include:
    • High blood pressure, gestational diabetes, bone thinning and infection
  • Risks to babies include:
    • Prematurity (born too early), low birth weight and premature rupture of membranes
  • Corticosteroids should only be used when other medications do not control the RA or cannot be used.
  • Low doses (e.g. 5-7.5mg per day) can be used if the benefits outweigh the risk.
  • If used, the dose should be as low as possible.
  • It can be taken whilst breastfeeding, but if the dose is >20 mg/day, breastfeeding should be timed for 4 hours after dose.
  • In men, use is not linked with infertility or harm to the baby.

Disease Modifying Anti Rheumatic Drugs (DMARDs)

  • Hydroxychloroquine (HCQ)
    • Women who wish to become pregnant can use this medication.
    • It can be continued during pregnancy at doses of <400mg/day. Higher doses may be considered if the benefits outweigh the risks.
    • HCQ can be taken whilst breastfeeding.
    • There is no information in men but it is likely to be safe.
  • Sulfasalazine (SSZ)
    • Women who wish to become pregnant can use this medication. Folic acid supplementation of 2-5mg a day should be commenced at least 1 month prior to pregnancy planning and continued throughout pregnancy. 
    • It can be continued during pregnancy.
    • SSZ can be taken whilst breastfeeding.
    • As SSZ can cause reduced sperm movement, it should be stopped after 3 months of unsuccessfully trying for pregnancy.
  • Tumour Necrosis Factor Inhibitors (TNFi)
    • Women who wish to become pregnant can use these medications.
    • Check with your rheumatologist for the latest recommendations
    • If continuing a TNFi in the third trimester is needed, live vaccines should not be given to your baby until the baby is older than 6 months - please discuss with your rheumatologist and/or obstetric physician, and paediatrician.
    • TNFi can be taken whilst breastfeeding.
    • Information is limited but use in men is likely to be safe.
  • Non-TNFi biological DMARDs including abatacept, rituximab, tocilizumab
    • Due to limited information, it is currently recommended to avoid these medications during pregnancy.
    • If an unplanned pregnancy occurs, you should see a specialist in the field to discuss the pregnancy.
    • Breastfeeding information is limited, but the amount in milk is likely to be very low, and it is probably destroyed in the baby’s gut.
    • Information is limited but use in men is likely to be safe. 
  • Janus Kinase Inhibitors - baricitinib, tofacitinib, upadacitinib
    • Due to limited information it is currently recommended to avoid these medicines in pregnancy.
    • If an unplanned pregnancy occurs the medication should be stopped and you should see a specialist in the field to discuss the pregnancy.
    • Breastfeeding is not recommended whilst on these medicines.
    • There is no information on which to base recommendation for men planning to father a child but they are likely to be safe.

DMARDs that should be AVOIDED during pregnancy

  • Methotrexate (MTX)
    • This medication can harm the baby
    • It should be stopped 3 months before trying to become pregnant
    • If unplanned pregnancy occurs, MTX should be stopped immediately, 5 mg folic acid daily started and a specialist in the field should be seen to discuss the pregnancy.
    • Breastfeeding should be avoided.
    • Based on recent information, low-dose MTX appears safe for men planning to father a child.
  • Leflunomide (LEF)
    • LEF is not recommended for use in pregnancy.
    • It should be stopped 2 years before trying to fall pregnant or a cholestyramine washout is recommended.
    • If unplanned pregnancy occurs, LEF should be stopped immediately, cholestyramine washout should be started and a specialist in the field should be seen to discuss the pregnancy.
    • Avoid breastfeeding.
    • Based on limited information LEF may be safe for men planning to father a child but further studies to confirm are needed.