What are the safe Disease-Modifying Antirheumatic Drugs (DMARDs) for Rheumatoid arthritis during pregnancy?

Safe DMARDs for Rheumatoid Arthritis During Pregnancy

Hydroxychloroquine, sulfasalazine (up to 2 g/day with folic acid), azathioprine (up to 2 mg/kg/day), cyclosporine, tacrolimus, and colchicine are safe DMARDs that should be continued throughout pregnancy for rheumatoid arthritis. 1

Conventional Synthetic DMARDs (csDMARDs)

Safe Options to Continue Throughout Pregnancy

• Hydroxychloroquine can be safely continued throughout all trimesters and is strongly recommended for maintaining disease control 1, 2

• Sulfasalazine is safe at doses up to 2 g/day throughout pregnancy, but you must prescribe daily folic acid supplementation (1 mg daily) because sulfasalazine inhibits folate absorption 1, 3

  • Start folic acid at least 3 months before conception and continue throughout pregnancy 3
  • Current evidence shows no increased rate of congenital malformations with sulfasalazine use 3

• Azathioprine can be used at doses up to 2 mg/kg daily in women with normal thiopurine metabolism 1

• Cyclosporine and tacrolimus can be used during pregnancy at the lowest effective dose, monitored by trough levels 1

• Colchicine is compatible with pregnancy at doses of 1-2 mg/day 1

Teratogenic DMARDs That Must Be Stopped

• Methotrexate is teratogenic and must be discontinued 1-3 months before conception 1, 4

• Leflunomide is teratogenic and should be discontinued before pregnancy 1, 4

• Mycophenolate is teratogenic and should be discontinued before pregnancy 1

• Cyclophosphamide is teratogenic and should be discontinued at least 12 weeks prior to conception 1

Biologic DMARDs (bDMARDs)

TNF Inhibitors

• All TNF inhibitors can be used throughout pregnancy based on individualized risk-benefit assessment 1

• Certolizumab has minimal placental transfer and can be continued throughout all three trimesters 1

• Infliximab, etanercept, adalimumab, and golimumab should be continued through first and second trimesters but discontinued in the third trimester 1

• TNF inhibitors can be continued until conception if disease control requires it 4

Other Biologics to Avoid

• Abatacept, rituximab, and tocilizumab should be withheld prior to pregnancy due to absence of proven safety data 5, 4

Critical Preconception Planning

• Achieve optimal disease control before conception because active rheumatic disease increases risk of adverse pregnancy outcomes more than the medications themselves 1

• Transition from teratogenic DMARDs to pregnancy-compatible alternatives should be completed before conception, not after pregnancy is discovered 1

• Abrupt discontinuation of medications when pregnancy is diagnosed harms both mother and fetus through disease flares, so continue compatible medications 1

Breastfeeding Compatibility

• Hydroxychloroquine, sulfasalazine, azathioprine, colchicine, cyclosporine, tacrolimus, NSAIDs, and all TNF inhibitors are compatible with breastfeeding 1

Paternal Considerations

• Hydroxychloroquine, azathioprine, colchicine, TNF inhibitors, and NSAIDs are safe for men planning conception 1

• Sulfasalazine may affect male fertility, so obtain semen analysis if conception is delayed 1

• Cyclophosphamide, methotrexate, and mycophenolate require discontinuation before conception in men 1

Common Pitfalls to Avoid

• Forgetting folic acid supplementation with sulfasalazine leads to folate deficiency—always prescribe 1 mg daily 1, 3

• Stopping all medications when pregnancy is discovered causes preventable disease flares that harm pregnancy outcomes more than continuing safe medications 1

• Not planning ahead and failing to control disease activity before conception increases adverse pregnancy outcomes 1

• Discouraging breastfeeding while taking compatible medications deprives mother and baby of breastfeeding benefits 1