Preconception Counseling for Patients Taking Methotrexate

Introduction to Methotrexate and Pregnancy

• Methotrexate is a category X medication according to the FDA, meaning it is contraindicated during pregnancy due to its teratogenic effects, and the American Gastroenterological Association recommends suspending methotrexate at least 3 months before attempting conception to minimize the risk of teratogenicity 1, 2, 3

Risks Associated with Methotrexate Exposure

• Exposure to methotrexate after conception is associated with an increased risk of:
• Methotrexate can also cause pregnancy loss, serving as an abortifacient 2

Pharmacokinetics and Elimination

• Methotrexate polyglutamate has an elimination half-life of 1.2 to 4.3 weeks, supporting the recommendation to wait at least 3 months before conception 1
• The time to undetectable levels of methotrexate is up to 10 weeks, further supporting the 3-month waiting period before attempting conception 1

Management of Methotrexate During Pregnancy

• If a woman becomes pregnant while taking methotrexate, the medication should be suspended immediately, and folic acid supplementation should be initiated or continued 1, 4
• Urgent obstetric consultation is recommended, and the risks of teratogenicity should be discussed with an obstetrician 1

Recommendations for Conception

• The American College of Rheumatology strongly recommends discontinuing methotrexate 3 months prior to conception attempts 3
• Men should wait 3 months after discontinuing methotrexate before attempting to conceive a child 2, 3, 4
• Women should discontinue methotrexate at least 3 months before attempting conception 2, 1
• Effective contraception should be used while taking methotrexate to prevent unintended pregnancy 2, 4

Family Planning and Pregnancy Prevention

• Regular pregnancy tests are recommended for women of childbearing potential 4
• Family planning should be discussed well in advance of conception attempts 3, 1
• Reproductive risks should be discussed with all patients of childbearing potential, and the need for contraception during treatment should be emphasized 4, 2

Breastfeeding and Methotrexate

• Breastfeeding is contraindicated during methotrexate therapy 4