What is the best management approach for a 36-year-old female with deforming rheumatoid arthritis, taking hydroxychloroquine (HCQ) and sulfasalazine, who is planning pregnancy and experiencing shoulder pain?

Management of Rheumatoid Arthritis During Pregnancy Planning with Shoulder Pain

For a 36-year-old female with deforming rheumatoid arthritis on hydroxychloroquine (HCQS) and sulfasalazine who is planning pregnancy and experiencing shoulder pain, both medications should be continued throughout pregnancy while adding appropriate pain management for the shoulder symptoms.

Current Medication Safety During Pregnancy

• Hydroxychloroquine (HCQS) is strongly recommended to be continued throughout pregnancy as it is considered safe and compatible with pregnancy 1, 2
• Sulfasalazine is also strongly recommended to be continued during pregnancy, but requires daily folic acid supplementation due to its inhibition of folate absorption 1, 2
• Both medications have extensive safety data supporting their use during pregnancy and are categorized as "strongly recommend continuing" in pregnancy guidelines 1
• The FDA label for hydroxychloroquine confirms that prolonged clinical experience has not identified drug-associated risks of major birth defects, miscarriage, or adverse maternal or fetal outcomes 3

Management of Shoulder Pain During Pregnancy Planning

• For shoulder pain management in this patient planning pregnancy:
  • NSAIDs can be used in the preconception period but should be discontinued if the patient is having difficulty conceiving 1
  • During pregnancy, NSAIDs can be continued in the first and second trimesters but must be discontinued in the third trimester 1, 2
  • Low-dose prednisone (less than 20 mg/day) can be conditionally recommended if needed for pain control 1
  • Physical therapy and non-pharmacological approaches should be incorporated into the treatment plan 4

Disease Activity Considerations

• Active rheumatoid arthritis increases the risk of adverse pregnancy outcomes, so optimal disease control should be achieved before conception 2, 5
• High disease activity has been associated with an increased risk of adverse pregnancy outcomes, making adequate disease control essential 4, 5
• Maintaining disease control with pregnancy-compatible medications is preferable to risking disease flares during pregnancy 6, 7

Treatment Algorithm for Shoulder Pain Management

1. Continue hydroxychloroquine and sulfasalazine throughout pregnancy planning and pregnancy 1
2. Add folic acid supplementation (5 mg/day) due to sulfasalazine use 2
3. For shoulder pain management:
   • First-line: Non-selective NSAIDs (ibuprofen preferred) during preconception and first/second trimesters 1
   • Second-line: Low-dose prednisone (<20 mg/day) if NSAIDs are insufficient 1
   • Consider local corticosteroid injection for the affected shoulder if pain is severe and localized 4
   • Incorporate physical therapy and other non-pharmacological approaches 7

Monitoring During Pregnancy

• Monitor disease activity at least once per trimester 1
• Assess for medication side effects and adjust dosages as needed 1
• Monitor for pregnancy complications, as women with rheumatoid arthritis have increased risk of preterm delivery and low birth weight infants 2, 5

Breastfeeding Considerations

• Both hydroxychloroquine and sulfasalazine are compatible with breastfeeding 1, 2
• NSAIDs can be used during breastfeeding, with ibuprofen being the preferred option 1, 2

Common Pitfalls to Avoid

• Discontinuing effective medications unnecessarily due to pregnancy planning can lead to disease flares 2, 7
• Failing to provide folic acid supplementation with sulfasalazine can lead to folate deficiency 2
• Continuing NSAIDs into the third trimester can cause premature closure of the ductus arteriosus 1, 2
• Overlooking the need for disease control before conception increases risks of adverse pregnancy outcomes 2, 5