Medication Use in Pregnancy

Safe Medications

The American College of Rheumatology recommends that uncontrolled maternal disease often poses greater risks to both mother and fetus than appropriate medication use 1
Albuterol (salbutamol) is the preferred short-acting beta-agonist throughout all trimesters of pregnancy, with the most extensive safety data available 2
Budesonide is the preferred inhaled corticosteroid due to reassuring data from over 52,000 first-trimester exposures showing no increased risk of congenital malformations 3, 2
Hydroxychloroquine, azathioprine (up to 2 mg/kg/day), cyclosporine, tacrolimus, sulfasalazine (up to 2 g/day), and colchicine (1-2 mg/day) are all safe throughout pregnancy 3, 1
Sulfasalazine requires concomitant folic acid supplementation due to interference with folate absorption 1
Ursodeoxycholic acid, cholestyramine, rifampin, or S-adenosyl-L-methionine may be used for cholestasis-related pruritus 3
NSAIDs (particularly ibuprofen) can be used short-term (7-10 days) in the first and second trimester only, but must be discontinued after gestational week 28 due to risks of oligohydramnios and premature ductus arteriosus closure 1
Low-dose aspirin (100-162 mg/day) starting at 12-16 weeks gestation reduces preeclampsia risk 4

Methotrexate (discontinue 1-3 months before conception), mycophenolate (discontinue 1.5 months before), and cyclophosphamide (discontinue 3 months before) are proven teratogens causing miscarriage and major birth defects 1
ACE inhibitors and angiotensin receptor blockers cause fetal renal dysplasia, oligohydramnios, pulmonary hypoplasia, and intrauterine growth restriction and must be stopped at conception 4
Statins should be avoided throughout pregnancy 4
Chronic diuretic use is not recommended due to restricted maternal plasma volume 4

Liver test monitoring during each trimester is suggested for autoimmune hepatitis, with more frequent monitoring (every 2-4 weeks) for the first 6 months postpartum 3
Vitamin K supplementation may be needed with cholestyramine use due to risk of hypoprothrombinemia 3
Cyclosporine and tacrolimus should be used at the lowest effective dose with trough level monitoring 1
Insulin requirements drop dramatically after delivery and need immediate reassessment 4
Breastfeeding is not contraindicated with most pregnancy-compatible medications 3

The European Respiratory Society recommends the use of short-acting beta-agonists (SABAs) such as salbutamol (albuterol) and terbutaline throughout pregnancy, as they are considered safe 5
The European Respiratory Society prefers the use of salmeterol over formoterol for long-acting beta-agonists (LABAs) due to greater experience during pregnancy 5
Inhaled corticosteroids like budesonide and beclomethasone are preferred due to the most safety data, but fluticasone and other inhaled corticosteroids are also compatible with pregnancy 5
The American College of Rheumatology recommends the use of conventional DMARDs such as hydroxychloroquine, chloroquine, azathioprine, cyclosporine, tacrolimus, sulfasalazine, and colchicine during pregnancy 6, 7
The European Society of Gastroenterology recommends the use of mesalamine for inflammatory bowel disease during pregnancy 8
The European Society of Gastroenterology recommends the use of amoxicillin-clavulanic acid and metronidazole for GI infections during pregnancy 8

The American College of Rheumatology recommends discontinuing teratogenic medications such as methotrexate, mycophenolate, and cyclophosphamide before conception 6, 7
The European Heart Society warns against the use of angiotensin II receptor blockers, such as valsartan, due to risks of renal dysplasia, oligohydramnios, and growth retardation 9
The European Heart Society warns against the use of warfarin and other vitamin K antagonists due to risks of coumarin-embryopathy and bleeding 9

Failing to consider disease activity can pose greater risks to pregnancy outcomes than medication exposure, according to the European Respiratory Society and the American College of Rheumatology 5, 6
Discontinuing necessary medications can lead to disease flares, as stated by the American College of Rheumatology 6