What medications are safe to take during pregnancy?

Safe Medications in Pregnancy

The following medications are considered safe for use throughout pregnancy based on current high-quality guidelines: hydroxychloroquine, azathioprine, sulfasalazine, colchicine, cyclosporine, tacrolimus, acetaminophen, short-acting beta-agonists (salbutamol/albuterol), inhaled corticosteroids (budesonide, beclomethasone), and mesalamine. 1, 2

Antirheumatic and Immunosuppressive Medications

Strongly Recommended as Compatible Throughout Pregnancy

• Hydroxychloroquine is safe throughout pregnancy at standard daily doses 1, 2
• Azathioprine/6-mercaptopurine can be used at doses up to 2 mg/kg/day in women with normal thiopurine metabolism 1, 2
• Sulfasalazine is safe at doses up to 2 g/day, but requires concomitant folic acid supplementation due to folate absorption inhibition 1, 2
• Colchicine is compatible at doses of 1-2 mg/day 1, 2

Conditionally Recommended as Compatible

• Calcineurin inhibitors (tacrolimus and cyclosporine) can be used at the lowest effective dose, monitored by trough levels 1, 2
• TNF inhibitors may be continued through pregnancy if disease is active, though they may be discontinued in the third trimester if disease is well-controlled 1
• Vedolizumab and ustekinumab continuation is not associated with adverse maternal or fetal outcomes 1
• Rituximab can be continued while trying to conceive 1

Pain and Fever Management

First-Line Analgesic/Antipyretic

• Acetaminophen is the first-line medication for pain and fever during pregnancy, considered safe when medically indicated 3, 2, 4, 5
• Recent observational studies suggesting associations with neurodevelopmental outcomes have important methodological limitations (self-reported use, recall bias, lack of dosage information), and systematic reviews conclude evidence is insufficient to establish causation 3, 6
• Use the lowest effective dose for the shortest possible time when medically indicated 3, 6

NSAIDs - Restricted Use

• Nonselective NSAIDs (particularly ibuprofen) can be used in the first and second trimester for short-term use (7-10 days) at the lowest effective dose 1, 2
• NSAIDs must be discontinued after gestational week 28 (end of second trimester) due to risks of premature ductus arteriosus closure, oligohydramnios, and other fetal complications 1
• Avoid NSAIDs during the first trimester when possible, and never use in the third trimester 1, 3
• COX-2 inhibitors should be avoided due to limited safety data 1

Respiratory Medications

Asthma Management

• Short-acting beta-agonists (salbutamol/albuterol, terbutaline) are safe throughout pregnancy 2
• Inhaled corticosteroids: budesonide and beclomethasone are preferred due to most extensive safety data, though fluticasone and other inhaled corticosteroids are also compatible 2
• Long-acting beta-agonists: salmeterol is preferred over formoterol due to greater pregnancy experience 2

Gastrointestinal Medications

Inflammatory Bowel Disease

• Mesalamine is safe for IBD during pregnancy 2
• Histamine H2 blockers and proton pump inhibitors have not demonstrated significant fetal effects 4, 5
• Medicines that are low risk in pregnancy are also low risk in breastfeeding and should be continued 1

Antibiotics

• Amoxicillin-clavulanic acid and metronidazole are safe for GI infections 2
• Beta-lactams, vancomycin, nitrofurantoin, metronidazole, clindamycin, and fosfomycin are generally considered safe and effective 7
• Fluoroquinolones and tetracyclines should be avoided 7

Corticosteroids

Systemic Glucocorticoids

• Nonfluorinated glucocorticoids (prednisone) should be used when needed 1
• Low-dose glucocorticoids (≤10 mg daily prednisone equivalent) can be continued if clinically indicated 1
• Higher doses should be tapered to <20 mg daily, adding pregnancy-compatible glucocorticoid-sparing agents if necessary 1

Antiemetics

Nausea and Vomiting

• Ondansetron: Published epidemiological studies show inconsistent findings regarding major birth defects, with important methodological limitations precluding definitive conclusions about safety 8
• Studies on cardiac septal defects and oral clefts show conflicting results, with relative risks ranging widely and associations not consistently confirmed across studies 8
• Ginger is considered safe and effective for treating nausea 4

Critical Medications to AVOID

Absolutely Contraindicated - Teratogenic

• Methotrexate must be discontinued 1-3 months before conception 1, 2
• Mycophenolate must be discontinued 1.5 months before conception 1, 2
• Cyclophosphamide must be discontinued 3 months before conception 1, 2
• Leflunomide requires cholestyramine washout if detectable serum levels exist 1
• JAK inhibitors (tofacitinib, filgotinib, upadacitinib) are contraindicated 1
• S1P modulators (ozanimod, etrasimod) are contraindicated 1

Cardiovascular Medications to Avoid

• ACE inhibitors and angiotensin receptor blockers cause fetal renal dysplasia, oligohydramnios, and growth restriction 3, 2
• Warfarin and vitamin K antagonists cause coumarin-embryopathy and bleeding 2

Important Clinical Principles

Disease Activity vs. Medication Risk

• Failing to control disease activity poses greater risks to pregnancy outcomes than most medication exposures 2
• Discontinuing necessary medications can lead to disease flares, which are more harmful than continuing pregnancy-compatible medications 1, 2
• For patients receiving appropriate advanced therapy, continue throughout pregnancy to minimize relapse risk and adverse outcomes associated with active disease 1

Preconception Planning

• Discuss medications well before attempting conception, allowing adequate time (minimum several months) for medication changes and demonstration of disease stability 1
• When teratogenic medications are discontinued, observe disease stability without medication or transition to pregnancy-compatible alternatives 1
• Inadvertent exposure to teratogenic medications requires immediate referral to maternal-fetal medicine specialist, pregnancy medication specialist, or genetics counselor 1

Breastfeeding Considerations

• Medications low risk in pregnancy are also low risk in breastfeeding 1
• For infants exposed to advanced therapy in utero, postpone live vaccinations (including BCG) for first 12 months 1
• Non-live vaccinations should follow standard schedule; breastfeeding while on biological therapy does not confer additional risk 1