Autoimmun Rev. 2016 Oct;15(10):955-63. doi: 10.1016/j.autrev.2016.07.014. Epub 2016 Aug 1.
- 1Department
of Rheumatology, Universidade do Estado do Rio de Janeiro, Rio de
Janeiro, Brazil; Pós-graduação em Ciências Médicas (PGCM), Faculdade de
Ciências, Médicas, Universidade do Estado do Rio de Janeiro, Rio de
Janeiro, Brazil. Electronic address: roger.a.levy@gmail.com.
- 2Department
of Obstetrics, Universidade do Estado do Rio de Janeiro, Rio de
Janeiro, Brazil; Department of Obstetrics, Instituto Fernandes Figueira,
FIOCRUZ, Rio de Janeiro, Brazil; Pós-graduação em Ciências Médicas
(PGCM), Faculdade de Ciências, Médicas, Universidade do Estado do Rio de
Janeiro, Rio de Janeiro, Brazil.
- 3Department of Obstetrics, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil.
- 4Department
of Rheumatology, Universidade do Estado do Rio de Janeiro, Rio de
Janeiro, Brazil; Pós-graduação em Ciências Médicas (PGCM), Faculdade de
Ciências, Médicas, Universidade do Estado do Rio de Janeiro, Rio de
Janeiro, Brazil.
Abstract
The
crucial issue for a better pregnancy outcome in women with autoimmune
rheumatic diseases is appropriate planning, with counseling of the ideal
timing and treatment adaptation. Drugs used to treat rheumatic diseases
may interfere with fertility or increase the risk of miscarriages and
congenital abnormalities. MTX use post-conception is clearly linked to
abortions as well as major birth defects, so it should be stopped
3months before conception. Leflunomide causes abnormalities in animals
even in low doses. Although in humans, it does not seem to be as harmful
as MTX, when pregnancy is detected in a patient on leflunomide,
cholestyramine is given for washout. Sulfasalazine can be used safely
and is an option for those patients who were on MTX or leflunomide.
Azathioprine is generally the immunosuppressive of choice in many
high-risk pregnancy centers because of the safety profile and its
steroid-sparing property. Cyclosporine and tacrolimus can also be used
as steroid-sparing agents, but experience is smaller. Although
prednisone and prednisolone are inactivated in the placenta, we try to
limit the dose to the minimal effective one, to prevent side effects.
Antimalarials have been broadly studied and are safe during pregnancy
and breastfeeding. Among biologic disease modifying anti-rheumatic
agents (bDMARD), the anti-TNFs that have been used for longer are the
ones with greater experience. The large monoclonal antibodies do not
cross the placenta in the first trimester, and after conception, the
decision to continue medication should be taken individually. The
experience is larger in women with inflammatory bowel diseases, where
anti-TNF is generally maintained at least until 30weeks to reduce fetal
exposure. Live vaccines should not be administrated to the infant in the
first 6months of life. Pregnancy data for rituximab, abatacept,
anakinra, tocilizumab, ustekinumab, belimumab, and tofacitinib are
limited and their use in pregnancy cannot currently be recommended.
Copyright © 2016 Elsevier B.V. All rights reserved.
KEYWORDS:
Anti-TNF; Autoimmune diseases; DMARD; Lactation; Pregnancy; Rheumatic diseases
