What is the safest treatment for Systemic Lupus Erythematosus (SLE) in pregnancy?

From the Guidelines

The safest treatment for Systemic Lupus Erythematosus (SLE) in pregnancy is hydroxychloroquine, which should be continued throughout pregnancy and postpartum, as it helps control disease activity, reduces the risk of flares, and may lower the chance of pregnancy complications associated with lupus. According to the most recent and highest quality study, hydroxychloroquine is considered safe and effective for managing lupus symptoms while pregnant 1. Other relatively safe options, if needed, include low-dose prednisone (less than 20 mg/day) and azathioprine, however, these should be used judiciously and only when the benefits outweigh the potential risks 1. Some key points to consider when managing SLE in pregnancy include:

• Hydroxychloroquine should be continued throughout pregnancy and postpartum to control disease activity and reduce the risk of flares 1.
• Low-dose aspirin may be started before 16 weeks of gestation to reduce the risk of preeclampsia and intrauterine growth retardation 1.
• Glucocorticoids, azathioprine, tacrolimus, and cyclosporine are considered safe immunosuppressive treatments during pregnancy, but should be used with caution and under close monitoring 1.
• Methotrexate and mycophenolate mofetil should be avoided during pregnancy due to their potential harm to the fetus 1. It's crucial to work closely with both a rheumatologist and an obstetrician experienced in high-risk pregnancies, and regular monitoring of disease activity and fetal development is essential 1. Maintaining good disease control before and during pregnancy is key to ensuring the best outcomes for both mother and baby, and this often involves a combination of medication management and lifestyle measures, including stress reduction, adequate rest, and a healthy diet 1.

From the FDA Drug Label

Risk Summary Prolonged clinical experience over decades of use and available data from published epidemiologic and clinical studies with hydroxychloroquine sulfate use in pregnant women have not identified a drug-associated risk of major birth defects, miscarriage, or adverse maternal, or fetal outcomes Systemic Lupus Erythematosus: Pregnant women with systemic lupus erythematosus, especially those with increased disease activity, are at increased risk of adverse pregnancy outcomes, including spontaneous abortion, fetal death, preeclampsia, preterm birth, and intrauterine growth restriction Data from published epidemiologic and clinical studies have not established an association with hydroxychloroquine sulfate use during pregnancy and major birth defects, miscarriage, or adverse maternal or fetal outcomes

The safest treatment for Systemic Lupus Erythematosus (SLE) in pregnancy is hydroxychloroquine, as it has been shown to not be associated with major birth defects, miscarriage, or adverse maternal or fetal outcomes, and it can help manage the disease activity, reducing the risk of adverse pregnancy outcomes 2.

• Key benefits of hydroxychloroquine in pregnancy include:
  • No identified drug-associated risk of major birth defects, miscarriage, or adverse maternal or fetal outcomes
  • Helps manage SLE disease activity, reducing the risk of adverse pregnancy outcomes
• Important considerations:
  • Pregnant women with SLE are at increased risk of adverse pregnancy outcomes, especially with increased disease activity
  • Hydroxychloroquine readily crosses the placenta, but no retinal toxicity, ototoxicity, cardiotoxicity, or growth and developmental abnormalities have been observed in children exposed to hydroxychloroquine in utero

From the Research

Safety of Hydroxychloroquine in SLE Pregnancy

• The use of Hydroxychloroquine (HCQ) during pregnancy in patients with Systemic Lupus Erythematosus (SLE) has been studied extensively 3, 4, 5, 6, 7.
• The available data suggest that HCQ can be continued safely throughout pregnancy, with no increase in the rate of birth defects or retinal and ototoxicity in children 3, 4, 5.
• Stopping HCQ at the onset of pregnancy may result in exacerbation of SLE, which could be detrimental to both mother and fetus 3, 4.

Benefits of Continuing HCQ Treatment

• Continuing HCQ treatment during pregnancy is associated with lower risk of preeclampsia, preterm delivery, and fetal growth restriction 6.
• HCQ treatment is also associated with reduced disease activity and flare-ups during pregnancy 4, 6.
• The benefits of continuing HCQ treatment throughout pregnancy seem to outweigh the hypothetical risks associated with its use 3, 4, 5.

Comparison of Outcomes with and without HCQ Treatment

• Studies have compared maternal and neonatal outcomes in patients with SLE treated with and without HCQ during pregnancy 6, 7.
• The results show that HCQ treatment is associated with improved pregnancy outcomes, including reduced risk of preeclampsia and increased neonatal birth weight 6.
• However, one study found no differences in major maternal or neonatal outcomes between patients treated with and without HCQ 7.