DMARDs Safe During Pregnancy and Preconception Planning

Safe DMARDs for Pregnancy and Preconception

The American College of Rheumatology recommends hydroxychloroquine, sulfasalazine, azathioprine, cyclosporine, tacrolimus, and colchicine as safe DMARDs during pregnancy, which should be continued for maintenance of remission or treatment of disease flares in pregnant women with rheumatic diseases 1, 2
Hydroxychloroquine can be safely continued throughout pregnancy and is strongly recommended for SLE patients, according to the European League Against Rheumatism 1, 2, 3
Sulfasalazine is safe at doses up to 2 g/day throughout pregnancy, but requires daily folic acid supplementation due to its inhibition of folate absorption, as suggested by the American College of Rheumatology 1, 2
Azathioprine can be used at doses up to 2 mg/kg daily in women with normal thiopurine metabolism, based on guidelines from the European League Against Rheumatism 1, 4
Cyclosporine and tacrolimus can be used during pregnancy at the lowest effective dose, which may be monitored by trough levels, according to the American College of Rheumatology 1, 5
Colchicine is compatible with pregnancy at doses of 1-2 mg/day, as recommended by the European League Against Rheumatism 1

The American College of Rheumatology suggests that all TNF inhibitors can be used throughout pregnancy based on individualized risk-benefit assessment, with certolizumab having minimal placental transfer and can be continued throughout pregnancy 2, 6
Infliximab, etanercept, adalimumab, and golimumab should be continued through first and second trimesters but discontinued in the third trimester, according to the European League Against Rheumatism 2

Methotrexate is teratogenic and must be discontinued 1-3 months before conception, as recommended by the American College of Rheumatology 1, 2
Mycophenolate is teratogenic and should be discontinued before pregnancy, according to the European League Against Rheumatism 1
Cyclophosphamide is teratogenic and should be discontinued at least 12 weeks prior to conception, as suggested by the American College of Rheumatology 1, 2

The American Academy of Pediatrics recommends that hydroxychloroquine, sulfasalazine, azathioprine, colchicine, cyclosporine, tacrolimus, NSAIDs, and all TNF inhibitors are compatible with breastfeeding 2, 6

Active rheumatic disease increases risk of adverse pregnancy outcomes, so optimal disease control should be achieved before conception, according to the American College of Rheumatology 5, 6
When discontinuing teratogenic DMARDs, transition to pregnancy-compatible alternatives should be completed before conception, as recommended by the European League Against Rheumatism 1, 2
Folic acid supplementation is essential when using sulfasalazine due to its inhibition of folate absorption, as suggested by the American College of Rheumatology 1
Treatment choices before, during, and after pregnancy should involve both healthcare providers and the patient, according to the American College of Rheumatology 1, 5

The American College of Rheumatology recommends that hydroxychloroquine, azathioprine, colchicine, TNF inhibitors, and NSAIDs are safe for men planning conception 2
Cyclophosphamide, methotrexate, and mycophenolate require discontinuation before conception, according to the European League Against Rheumatism 2
Sulfasalazine may affect male fertility, and semen analysis is recommended if conception is delayed, as suggested by the American College of Rheumatology 2

Abrupt discontinuation of medications when pregnancy is diagnosed can harm both mother and fetus, and disease flares can be prevented by continuing compatible medications, according to the American College of Rheumatology 4, 5
Overlooking folic acid supplementation with sulfasalazine can lead to folate deficiency, as recommended by the European League Against Rheumatism 1
Delayed planning and not controlling disease activity before conception can increase the risk of adverse pregnancy outcomes, according to the American College of Rheumatology 5
Ignoring breastfeeding benefits and discouraging women from breastfeeding while taking compatible medications can be harmful, as suggested by the American Academy of Pediatrics 4, 5