What medications are recommended for managing Systemic Lupus Erythematosus (SLE) during pregnancy?

Medications for Managing SLE During Pregnancy

Hydroxychloroquine should be continued or initiated during pregnancy for all women with SLE as it reduces disease flares, improves pregnancy outcomes, and is considered safe for both mother and fetus. 1

First-Line Medications (Safe in Pregnancy)

Core Medications

1. Hydroxychloroquine (HCQ)

   • Strongest recommendation for all SLE patients during pregnancy 1
   • Benefits:
     • Reduces disease flares during pregnancy 2
     • Decreases risk of preeclampsia by approximately 90% 3
     • Improves birth weight outcomes 3
     • Reduces risk of intrauterine growth restriction 4
   • Should be continued if already taking it, or started if not contraindicated 1
   • Contraindications: allergy, adverse effects, or intolerance 1

2. Low-dose aspirin (81-100 mg daily)

   • Should be started before 16 weeks gestation (ideally by the end of first trimester) 1, 5
   • Particularly important for patients with:
     • Lupus nephritis
     • Positive antiphospholipid antibodies
     • History of preeclampsia 5
   • Continue until delivery (discontinuation timing should be determined by obstetrician/anesthesiologist) 5

Immunosuppressants Safe in Pregnancy

1. Glucocorticoids (oral)

   • Use lowest effective dose to control disease activity 1, 6
   • First-trimester use associated with increased risk of gestational diabetes and cleft palate 1

2. Azathioprine

   • Safe for maintenance therapy during pregnancy 1, 6
   • Can be continued if patient was on it before pregnancy
   • Can replace mycophenolate mofetil in patients planning pregnancy 1

3. Calcineurin inhibitors

   • Tacrolimus and cyclosporine A are considered safe 1, 6
   • Useful for lupus nephritis management during pregnancy

Medications for Moderate-to-Severe Flares During Pregnancy

1. High-dose glucocorticoids (including IV pulse therapy) 1
2. Intravenous immunoglobulin (IVIG) 1
3. Plasmapheresis - for severe flares or refractory nephrotic syndrome 1

Medications to Avoid During Pregnancy

1. Mycophenolate mofetil/mycophenolic acid - teratogenic 1, 6
2. Cyclophosphamide - avoid in first trimester (high risk of fetal loss); reserve for life-threatening conditions in 2nd/3rd trimesters 1
3. Methotrexate - teratogenic 1, 6
4. Leflunomide - teratogenic 1, 6
5. Belimumab - insufficient safety data; avoid unless benefit outweighs risk 1

Monitoring During Pregnancy

• Disease activity should be monitored at least once per trimester 1
• Laboratory monitoring:
  • Complete blood count with differential
  • Urinalysis and urinary protein:creatinine ratio
  • Anti-dsDNA, C3, C4 levels
  • Renal function parameters 1
• Test for antiphospholipid antibodies once before or early in pregnancy 1
• Fetal surveillance with Doppler ultrasonography and biometric parameters, particularly in third trimester 1
• Fetal echocardiography if maternal anti-Ro/SSA or anti-La/SSB antibodies are positive 1

Important Considerations

• SLE should be in remission for at least 6 months before conception 1
• Pregnancy should be avoided during active disease or when on teratogenic medications 1
• Women with SLE have higher risk of adverse pregnancy outcomes including preeclampsia, preterm birth, and fetal loss 4, 6
• Calcium, vitamin D, and folic acid supplementation should be offered as in the general population 1

Common Pitfalls to Avoid

• Discontinuing hydroxychloroquine during pregnancy (increases risk of flares) 2
• Starting aspirin too late (after 16 weeks) reduces effectiveness 5
• Using regular-dose aspirin instead of low-dose formulations 5
• Failing to switch from mycophenolate mofetil to azathioprine before conception
• Inadequate monitoring of disease activity during pregnancy

By following this medication management approach, the risk of maternal disease flares and adverse pregnancy outcomes can be significantly reduced in women with SLE.