Medication Use
The guideline encourages both women and men to discuss medication use with their rheumatologist before conceiving, and to discuss future pregnancy plans before initiating treatment with medications that may affect fertility, such as cyclophosphamide. It also urges rheumatologists to counsel women who have inadvertent exposure to teratogenic medications during pregnancy to stop the drug immediately and refer these patients to a maternal-fetal medicine or genetics specialist.
Recommendations for men include:
- Discontinue cyclophosphamide 12 weeks before and thalidomide four weeks before attempting to conceive with his partner;
- Continue hydroxychloroquine, colchicine, azathioprine, tumor necrosis factor inhibitors, sulfasalazine, methotrexate, leflunomide, mycophenolate, cyclosporine, tacrolimus, anakinra and rituximab; and
- Consider semen analysis if a couple has trouble conceiving while the man is on sulfasalazine.
Patient panelists suggested rheumatologists counsel female patients on the risk of not taking pregnancy-compatible medications—that is the risk of uncontrolled rheumatic disease during pregnancy. The guideline’s many recommendations for pregnant women include:
- Discontinue cyclophosphamide, thalidomide, mycophenolate, methotrexate and leflunomide, with a “wash out” of leflunomide before pregnancy and immediately if pregnant;
- Consider stopping non-steroidal anti-inflammatory drugs (NSAIDs) if a woman has difficulty conceiving, and don’t use NSAIDs in the third trimester;
- Continue hydroxychloroquine, sulfasalazine, colchicine and azathioprine during pregnancy. Continue TNF-inhibitors during pregnancy if clinically necessary;
- Consider cyclophosphamide (in the second or third trimester) or rituximab during pregnancy in women with organ- or life-threatening disease; and
- In women on non-fluorinated steroid therapy, continue low-dose steroids if needed.
Good practice statements on breastfeeding: Rheumatologists should encourage their female patients to breastfeed if they desire, maintain disease control with medications compatible with lactation, and review the risks and benefits particular to each patient.
Other recommendations:
- While breastfeeding, women should avoid cyclophosphamide, thalidomide, mycophenolate, leflunomide and methotrexate;
- While breastfeeding, women should continue hydroxychloroquine, TNF inhibitors, rituximab and non-fluorinated steroids; and
- Women on higher (20 mg or more per day) steroid doses should avoid breastfeeding within four hours of taking their drug—and discard any milk pumped or expressed in that same window.
Susan Bernstein is a freelance medical journalist based in Atlanta, Ga.
References
- Sammaritano LR, Bermas BL, Chakravarty EE, et al. 2020 American College of Rheumatology guideline for the management of reproductive health in rheumatic and musculoskeletal diseases. Arthritis Rheumatol. [online first]
- Committee on Gynecologic Practice Long-Acting Reversible Contraception Working Group. Committee Opinion No. 642. Increasing access to contraceptive implants and intrauterine devices to reduce unintended pregnancy. Obstet Gynecol. 2015 Oct;126:e44–e48.
- American College of Obstetricians and Gynecologists—Committee on Practice Bulletins: Gynecology. Practice Bulletin No. 141: Management of menopausal symptoms. Obstet Gynecol. 2014 Jan;123(1):202–216.
- Buyon JP, Petri MA, Kim MY, et al. The effect of combined estrogen and progesterone hormone replacement therapy on disease activity in systemic lupus erythematosus: A randomized trial. Ann Intern Med. 2005 Jun 21;142(12 Pt 1):953–962.
- Miyakis S, Lockshin MD, Atsumi T, et al. International consensus statement on an update on the classification criteria for definite antiphospholipid syndrome (APS). J Thromb Haemost. 2006 Feb;4(2):295–306.
