Medications and 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 sections.
• Having good control of your rheumatoid arthritis pre-pregnancy can help with reducing these risks.

• RA usually improves during pregnancy.
• However, up to 1 in 5 women with RA may worsen in pregnancy.
• There is an increased risk of flare following childbirth (post-partum), so having a flare plan and an appointment with your rheumatologist post-partum is recommended.

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 so please talk with your rheumatology team.

• There is confusion with Australian government labelling of which medications are safe in pregnancy.
• Please note some of the historical labels and categories of rheumatology medicines have not been updated by relevant bodies. Always check with your obstetrician, rheumatologist and treating doctors to see which medicines are safe to continue in pregnancy.
   

Pain management

• Painkillers such as paracetamol and tramadol as well as nerve pain medicines (e.g. amitriptyline) 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 be avoided in pregnancy unless under medical supervision. 
• Some NSAIDs (e.g. ibuprofen) can be safely used in breastfeeding; check with your rheumatologist for more information.

Corticosteroids, e.g. prednisone/prednisolone

• Risks to mothers include:
  • High blood pressure, high sugar levels during pregnancy (gestational diabetes), bone thinning and infection
• Risks to babies include:
  • Prematurity (born too early), low birth weight, premature rupture of membranes and low sugar levels (neonatal hypoglycaemia).
• Because of the above risks, corticosteroids should only be used when other medications for RA are ineffective 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.
• 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 up to 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 12 months of unsuccessfully trying to father a child.
• Tumour Necrosis Factor Inhibitors (TNFi) eg adalimumab, etanercept, golimumab 
  • Women who wish to become pregnant can use these medications.
  • Check with your rheumatologist for the latest recommendations.
  • If you need to continue a TNFi in the third trimester, please discuss this with your rheumatologist and/or obstetric physician, and paediatrician. 
  • The rotavirus vaccine can be given to babies of mothers who have continued TNFis during pregnancy and in the first 6 months of life.
  • TNFi can be taken whilst breastfeeding.
  • TNFi use in men (paternal exposure) is 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.
  • Breastfeeding is not recommended whilst on these medicines.
  • Based on limited evidence, JAKi are likely to be safe for men planning to father a child.

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 an unplanned pregnancy occurs, MTX should be stopped immediately, 5 mg folic acid daily started and a specialist in the field should be seen.
  • Avoid use if breastfeeding.
  • MTX (up to 25mg/week) use in men is safe.
• Leflunomide (LEF)
  • LEF is not recommended for use in pregnancy.
  • It should be stopped 2 years before trying to fall pregnant or it is recommended to give a medication (cholestyramine) to washout the LEF.
  • If an unplanned pregnancy occurs, LEF should be stopped immediately, cholestyramine washout should be started and a specialist in the field should be seen.
  • Avoid use if breastfeeding.
  • Leflunomide use in men is safe.