Can tacrolimus and low-potency corticosteroids be used together during the periconception period?

Tacrolimus and Low-Potency Corticosteroids in the Periconception Period

Yes, tacrolimus combined with low-dose corticosteroids can be used during the periconception period and should be continued throughout pregnancy for appropriate indications, as both medications are considered compatible with pregnancy.

Tacrolimus Safety Profile

Tacrolimus is classified as compatible with pregnancy and can be safely continued during the periconception period and throughout gestation 1. The key evidence supporting this includes:

• No significant malformation risk has been identified with tacrolimus use in pregnancy, though it crosses the placenta at concentrations of 30-60% of maternal levels 1
• Tacrolimus has been associated with hypertension, preeclampsia, and preterm birth, requiring close monitoring but not contraindication 1
• The American Association for the Study of Liver Diseases and European guidelines strongly recommend not stopping tacrolimus in pregnant women who require immunosuppression 1

Low-Dose Corticosteroid Safety

Low-dose corticosteroids (prednisone <20 mg daily) are compatible with pregnancy and the periconception period 1:

• Only 10% of maternal corticosteroid dose reaches the developing fetus 1
• While older data suggested associations with cleft lip/palate in first trimester, more recent studies have not supported this concern 1
• The American College of Rheumatology conditionally recommends continuing low-dose glucocorticoids during pregnancy for disease control 1

Critical Monitoring Requirements

When using this combination during periconception and pregnancy, implement the following surveillance:

• Monitor blood pressure closely throughout pregnancy due to tacrolimus-associated hypertension and preeclampsia risk 1
• Screen for gestational diabetes mellitus in women taking glucocorticoids 1
• Check renal function regularly, as preconception estimated glomerular filtration rate <90 mL/minute predicts preterm delivery 1
• Monitor tacrolimus trough levels to maintain therapeutic range while minimizing toxicity 1

Dosing Considerations

• Maintain minimal effective immunosuppression without reduction during pregnancy to prevent disease flares 1
• For corticosteroids, limit to <20 mg daily prednisone equivalent when possible 1
• Women taking >5 mg prednisolone daily for >3 weeks are at risk for adrenal suppression and may require stress-dose glucocorticoids at delivery 1

Common Pitfalls to Avoid

• Do not discontinue tacrolimus due to pregnancy concerns, as uncontrolled disease poses greater risks than medication exposure 1
• Avoid abrupt corticosteroid withdrawal, which can precipitate adrenal crisis in women on chronic therapy 1
• Do not overlook the need for increased glucocorticoid dosing at delivery or during intercurrent illness in women on chronic corticosteroid therapy 1
• Failing to monitor for preeclampsia in tacrolimus-exposed pregnancies can lead to serious maternal-fetal complications 1

Disease-Specific Context

The combination of tacrolimus and low-dose corticosteroids is particularly relevant for:

• Autoimmune liver disease and transplant recipients, where maintaining immunosuppression is critical 1
• Refractory autoimmune conditions requiring calcineurin inhibitor therapy 2, 3
• Conditions where disease activity itself poses greater pregnancy risks than medication exposure 1