Rheumatoid arthritis and pregnancy: safety considerations in pharmacological management

Pregnancy can pose a challenge to the physician caring for women with rheumatoid arthritis (RA). While many women with RA experience a spontaneous improvement in joint pain and inflammation during pregnancy, in others it remains active and they continue to need ongoing therapy. It is important to tailor the treatment regimen so that the disease is stabilized prior to conception and to use medications that are safe throughout pregnancy and lactation. The use of immunomodulating medications considered low risk during pregnancy allows for optimal outcomes. NSAIDs should be avoided in the third trimester. Corticosteroids may be used throughout pregnancy in the lowest effective dose. Antimalarial agents, sulfasalazine and azathioprine are safe options, but methotrexate and leflunomide are contraindicated as they are teratogenic and must, therefore, be withdrawn before a planned pregnancy. The risk for some of the newer biological therapies for RA is not necessarily their proven teratogenicity, but the absence of proven safety for the fetus. As such, it is recommended that abatacept, rituximab and tocilizumab be withheld prior to pregnancy; however, tumour necrosis factor inhibitors and anakinra may be continued until conception. In this review, we provide an overview of the RA treatment issues pre-conception, during pregnancy and in the post-partum period with respect to breastfeeding, and we provide guidelines for drugs that may be used relatively safely for RA management in pregnant women. Where available, pre-conception guidelines for men using these medications for RA are also discussed.