What medication adjustments are recommended for a patient with Systemic Lupus Erythematosus (SLE) on prednisolone, hydroxychloroquine, and mycophenolate mofetil (MMF) who wishes to become pregnant?

Medication Management for SLE Patient Planning Pregnancy

For a patient with SLE on prednisolone, hydroxychloroquine, and mycophenolate mofetil (MMF) who wishes to become pregnant, MMF should be discontinued and switched to azathioprine while continuing prednisolone and hydroxychloroquine. 1

Rationale for Medication Adjustments

Mycophenolate Mofetil (MMF)

• Must be discontinued: MMF is teratogenic and FDA pregnancy category D 2
• MMF is associated with increased risk of first trimester pregnancy loss and congenital malformations, especially facial abnormalities including cleft lip/palate and anomalies of limbs, heart, and nervous system 2
• MMF must be discontinued at least 6 weeks before conception 1

Azathioprine

• Preferred alternative: Azathioprine is considered safe during pregnancy 1
• The 2024 KDIGO guidelines explicitly state that for patients on maintenance therapy with MPAA (mycophenolic acid agents like MMF), "this must be discontinued or changed to azathioprine" for pregnancy 1
• KDIGO recommendation 12.11.4 states: "We recommend that LN patients who become pregnant while being treated with MMF be switched to azathioprine" (1B - strong recommendation) 1

Hydroxychloroquine

• Should be continued: Hydroxychloroquine is safe during pregnancy and should be maintained 1
• Continuation reduces risk of preterm birth and intrauterine growth restriction 1
• Withdrawal of hydroxychloroquine has been associated with lupus nephritis flares 1
• KDIGO recommendation 12.11.3: "We suggest that hydroxychloroquine be continued during pregnancy" (2B) 1

Prednisolone

• Should be continued: Glucocorticoids are considered safe during pregnancy 1
• Prednisolone should not be tapered during pregnancy or for at least 3 months after delivery 1
• First trimester use may be associated with increased risk of gestational diabetes and cleft palate, but benefits outweigh risks in SLE management 1

Transition Protocol

1. Pre-conception planning:

   • Switch from MMF to azathioprine at least 6 weeks before attempting conception
   • Initial azathioprine dose typically 1-2 mg/kg/day
   • Monitor for disease activity during transition period (13% risk of renal flare during transition) 3
   • Younger patients may have higher risk of flare during transition (median age 27 vs 30 years) 3

2. During pregnancy:

   • Continue hydroxychloroquine at pre-pregnancy dose
   • Continue prednisolone at effective dose
   • Add low-dose aspirin (≤100 mg/day) before 16 weeks gestation to reduce risk of preeclampsia and intrauterine growth restriction 1
   • Monitor disease activity each trimester with particular attention to renal function

Important Considerations

• Disease activity: Patients should ideally achieve disease remission for ≥6 months before conception 1
• Flare risk: Incidence of lupus nephritis flare during pregnancy is 11-28%, higher with low complement or high anti-dsDNA antibodies 1
• Monitoring: Regular assessment of disease activity, renal function, and fetal growth is essential
• Contraindications: Methotrexate (option A) is absolutely contraindicated in pregnancy and would be harmful 1
• Cyclosporine: While cyclosporine (option C) is considered safe in pregnancy, stopping prednisolone would likely lead to disease flare and is not recommended 1

Post-Delivery Considerations

• Continue medications for at least 3 months post-delivery 1
• Hydroxychloroquine, azathioprine, and prednisolone have limited transfer into breast milk and are considered safe during breastfeeding 1
• MMF remains contraindicated during breastfeeding 1

The evidence strongly supports option B (stopping MMF and starting azathioprine) as the correct management strategy for this patient with SLE planning pregnancy.