Rheumatologists Should Discuss with Patients Use of Immunomodulatory Agents During Pregnancy

The decision to continue or discontinue immunomodulatory medications during pregnancy is a difficult one for both patients and physicians.
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The decision to continue or discontinue immunomodulatory medications during pregnancy is a difficult one for both patients and physicians. On the one hand, when left untreated, rheumatic conditions can cause harm to an unborn child, as well as to the pregnant mother. On the other hand, medications can be harmful to a developing fetus. In a high percentage of women with rheumatic disease, the decision is often to discontinue treatment during pregnancy, according to results from “Patterns and secular trends in use of immunomodulatory agents during pregnancy in women with rheumatic conditions,” which appeared in Arthritis & Rheumatology in May 2016.¹

Additional findings from the study highlighted the popularity of certain medications for rheumatic conditions. Steroids and hydroxychloroquine were the most frequently used agents in the study population over the 12-year study period. Regardless of the treatment or condition, a significant number of women stopped taking their medication during pregnancy.

“The most important finding of our study is the observation that many women on treatment with immunosuppressive agents prior to their pregnancy actually discontinued treatment during pregnancy,” says lead author Rishi J. Desai, MS, PhD, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston. “The rates of discontinuation were different across conditions, but overall there was the same trend.”

There is no simple answer for women who are being treated medically for rheumatic conditions if they become pregnant, but the key is to talk about options before taking action. “We hope that by highlighting this issue, our study will lead to more rheumatologists having conversations with their patients about the importance of continuing treatment during pregnancy,” Dr. Desai says. “I think it’s important to continue treatment in pregnancy, especially when [the disease is] severe enough to require management with medications prior to pregnancy.”

Pregnancy & Rheumatic Disease

The results from Dr. Desai’s study are comparable to results from previous research that showed steroids are the most commonly used immunomodulatory agents among women with RA from the U.S., the Netherlands and Norway, as well as Canadian women with systemic lupus erythematosus (SLE).

Another similarity between the present study and previous research is that the use of potentially teratogenic nonbiologic agents (i.e., methotrexate, mycophenolate mofetil, leflunomide) was found to be extremely low during pregnancy. This finding is “reassuring,” the researchers say. In contrast with the findings from Dr. Desai and his team, previous European research showed that sulfasalazine, not hydroxychloroquine, was the most commonly used nonbiologic agent during pregnancy in cohorts of women with rheumatoid arthritis (RA).