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Rheumatology

Prescribing in pregnancy

Quick reference guide

Visual summary of the 2022 BSR guideline on prescribing immunomodulatory antirheumatic drugs during pregnancy and breastfeeding

Quick reference guide


Summary of drug compatibility in pregnancy and breastmilk exposure

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Prednisolone


Periconception
1st Trimester
2nd/3rd Trimester
Breastfeeding
Paternal exposure
Periconception
1st Trimester
2nd/3rd Trimester
Breastfeeding
Paternal exposure

Hydroxychloroquine

≤400mg/day

Periconception
1st Trimester
2nd/3rd Trimester
Breastfeeding
Paternal exposure
Periconception
1st Trimester
2nd/3rd Trimester
Breastfeeding
Paternal exposure

Methotrexate

≤25mg/week

Periconception

Stop ≥1 month pre-conception

1st Trimester
2nd/3rd Trimester
Breastfeeding
Paternal exposure
Periconception

Stop ≥1 month pre-conception

1st Trimester
2nd/3rd Trimester
Breastfeeding
Paternal exposure

Sulfasalazine

with folic acid 5 mg/day in first trimester

Periconception
1st Trimester
2nd/3rd Trimester
Breastfeeding

In the healthy, full-term infant only

Paternal exposure

If conception is delayed by >12months, consider stopping sulfasalazine alongside investigation of other causes of infertility

Periconception
1st Trimester
2nd/3rd Trimester
Breastfeeding

*In the healthy, full-term infant only

Paternal exposure

*If conception is delayed by >12months, consider stopping sulfasalazine alongside investigation of other causes of infertility

Leflunomide


Periconception

*Cholestyramine washout

1st Trimester
2nd/3rd Trimester
Breastfeeding
Paternal exposure
Periconception

Cholestyramine washout

1st Trimester
2nd/3rd Trimester
Breastfeeding
Paternal exposure

Azathioprine


Periconception
1st Trimester
2nd/3rd Trimester
Breastfeeding
Paternal exposure
Periconception
1st Trimester
2nd/3rd Trimester
Breastfeeding
Paternal exposure

Ciclosporin


Periconception
1st Trimester

*Suggested monitoring of maternal blood pressure, renal function, blood glucose and drug levels.

2nd/3rd Trimester

*Suggested monitoring of maternal blood pressure, renal function, blood glucose and drug levels.

Breastfeeding
Paternal exposure
Periconception
1st Trimester

*Suggested monitoring of maternal blood pressure, renal function, blood glucose and drug levels.

2nd/3rd Trimester

*Suggested monitoring of maternal blood pressure, renal function, blood glucose and drug levels.

Breastfeeding

*In the healthy, full-term infant only

Paternal exposure

*If conception is delayed by >12months, consider stopping sulfasalazine alongside investigation of other causes of infertility

Tacrolimus


Periconception
1st Trimester

*Suggested monitoring of maternal blood pressure, renal function, blood glucose and drug levels.

2nd/3rd Trimester

*Suggested monitoring of maternal blood pressure, renal function, blood glucose and drug levels.

Breastfeeding
Paternal exposure
Periconception
1st Trimester

*Suggested monitoring of maternal blood pressure, renal function, blood glucose and drug levels.

2nd/3rd Trimester

*Suggested monitoring of maternal blood pressure, renal function, blood glucose and drug levels.

Breastfeeding

*In the healthy, full-term infant only

Paternal exposure

*If conception is delayed by >12months, consider stopping sulfasalazine alongside investigation of other causes of infertility

Cyclophosphamide


Periconception

Only in cases of severe (life or organ-threatening) maternal disease.

1st Trimester

Only in cases of severe (life or organ-threatening) maternal disease.

2nd/3rd Trimester

Only in cases of severe (life or organ-threatening) maternal disease.

Breastfeeding
Paternal exposure
Periconception

Stop ≥1 month pre-conception

1st Trimester
2nd/3rd Trimester
Breastfeeding
Paternal exposure

Mycophenolate mofetil


Periconception

Stop ≥6 weeks pre-conception

1st Trimester
2nd/3rd Trimester
Breastfeeding
Paternal exposure
Periconception

Stop ≥6 weeks pre-conception

1st Trimester
2nd/3rd Trimester
Breastfeeding
Paternal exposure

Intravenous immunoglobulin


Periconception
1st Trimester
2nd/3rd Trimester
Breastfeeding
Paternal exposure
Periconception
1st Trimester
2nd/3rd Trimester
Breastfeeding
Paternal exposure

Infliximab


Periconception
1st Trimester
2nd/3rd Trimester

*If low risk of disease flare and stopped by 20 weeks, full-term infant can have a normal vaccination schedule.

Breastfeeding
Paternal exposure
Periconception
1st Trimester
2nd/3rd Trimester

*If low risk of disease flare and stopped by 20 weeks, full-term infant can have a normal vaccination schedule.

Breastfeeding
Paternal exposure

Etanercept


Periconception
1st Trimester
2nd/3rd Trimester

*If low risk of disease flare and stopped by 32 weeks, full-term infant can have a normal vaccination schedule.

Breastfeeding
Paternal exposure
Periconception
1st Trimester
2nd/3rd Trimester

*If low risk of disease flare and stopped by 32 weeks, full-term infant can have a normal vaccination schedule.

Breastfeeding
Paternal exposure

Adalimumab


Periconception
1st Trimester
2nd/3rd Trimester

*If low risk of disease flare and stopped by 28 weeks, full-term infant can have a normal vaccination schedule.

Breastfeeding
Paternal exposure
Periconception
1st Trimester
2nd/3rd Trimester

*If low risk of disease flare and stopped by 28 weeks, full-term infant can have a normal vaccination schedule.

Breastfeeding
Paternal exposure

Certolizumab


Periconception
1st Trimester
2nd/3rd Trimester
Breastfeeding
Paternal exposure
Periconception
1st Trimester
2nd/3rd Trimester
Breastfeeding
Paternal exposure

Golimumab


Periconception
1st Trimester
2nd/3rd Trimester

*If low risk of disease flare and stopped by 28 weeks, full-term infant can have a normal vaccination schedule.

Breastfeeding
Paternal exposure
Periconception
1st Trimester
2nd/3rd Trimester

*If low risk of disease flare and stopped by 28 weeks, full-term infant can have a normal vaccination schedule.

Breastfeeding
Paternal exposure

Rituximab


Periconception

Consider stopping at conception.

May be considered to manage severe maternal disease if no other pregnancy-compatible drugs are suitable.

1st Trimester

Severe disease if no alternatives.

May be considered to manage severe maternal disease if no other pregnancy-compatible drugs are suitable.

2nd/3rd Trimester

Severe disease if no alternatives.

If used in third trimester, avoid live vaccinations in infant vaccination schedule until 6 months of age.

Breastfeeding

Limited evidence.

Paternal exposure

Limited evidence.

Periconception

Consider stopping at conception.

May be considered to manage severe maternal disease if no other pregnancy-compatible drugs are suitable.

1st Trimester

Severe disease if no alternatives.

May be considered to manage severe maternal disease if no other pregnancy-compatible drugs are suitable.

2nd/3rd Trimester

Severe disease if no alternatives.

If used in third trimester, avoid live vaccinations in infant vaccination schedule until 6 months of age.

Breastfeeding

Limited evidence.

Paternal exposure

Limited evidence.

IL-6 inhibitors


Periconception

Consider stopping at conception.

May be considered to manage severe maternal disease if no other pregnancy-compatible drugs are suitable.

1st Trimester

Severe disease if no alternatives.

May be considered to manage severe maternal disease if no other pregnancy-compatible drugs are suitable.

2nd/3rd Trimester

Severe disease if no alternatives.

If used in third trimester, avoid live vaccinations in infant vaccination schedule until 6 months of age.

Breastfeeding

Limited evidence.

Paternal exposure

Limited evidence.

Periconception

Consider stopping at conception.

May be considered to manage severe maternal disease if no other pregnancy-compatible drugs are suitable.

1st Trimester

Severe disease if no alternatives.

May be considered to manage severe maternal disease if no other pregnancy-compatible drugs are suitable.

2nd/3rd Trimester

Severe disease if no alternatives.

If used in third trimester, avoid live vaccinations in infant vaccination schedule until 6 months of age.

Breastfeeding

Limited evidence.

Paternal exposure

Limited evidence.

IL-1 inhibitors


Periconception

Consider stopping at conception.

May be considered to manage severe maternal disease if no other pregnancy-compatible drugs are suitable.

1st Trimester

Severe disease if no alternatives.

May be considered to manage severe maternal disease if no other pregnancy-compatible drugs are suitable.

2nd/3rd Trimester

Severe disease if no alternatives.

If used in third trimester, avoid live vaccinations in infant vaccination schedule until 6 months of age.

Breastfeeding

Limited evidence.

Paternal exposure

Limited evidence.

Periconception

Consider stopping at conception.

May be considered to manage severe maternal disease if no other pregnancy-compatible drugs are suitable.

1st Trimester

Severe disease if no alternatives.

May be considered to manage severe maternal disease if no other pregnancy-compatible drugs are suitable.

2nd/3rd Trimester

Severe disease if no alternatives.

If used in third trimester, avoid live vaccinations in infant vaccination schedule until 6 months of age.

Breastfeeding

Limited evidence.

Paternal exposure

Limited evidence.

Abatacept


Periconception

Consider stopping at conception.

May be considered to manage severe maternal disease if no other pregnancy-compatible drugs are suitable.

1st Trimester

Severe disease if no alternatives.

May be considered to manage severe maternal disease if no other pregnancy-compatible drugs are suitable.

2nd/3rd Trimester

Severe disease if no alternatives.

If used in third trimester, avoid live vaccinations in infant vaccination schedule until 6 months of age.

Breastfeeding

Limited evidence.

Paternal exposure

Limited evidence.

Periconception

Consider stopping at conception.

May be considered to manage severe maternal disease if no other pregnancy-compatible drugs are suitable.

1st Trimester

Severe disease if no alternatives.

May be considered to manage severe maternal disease if no other pregnancy-compatible drugs are suitable.

2nd/3rd Trimester

Severe disease if no alternatives.

If used in third trimester, avoid live vaccinations in infant vaccination schedule until 6 months of age.

Breastfeeding

Limited evidence.

Paternal exposure

Limited evidence.

Belimumab


Periconception

Consider stopping at conception.

May be considered to manage severe maternal disease if no other pregnancy-compatible drugs are suitable.

1st Trimester

Severe disease if no alternatives.

May be considered to manage severe maternal disease if no other pregnancy-compatible drugs are suitable.

2nd/3rd Trimester

Severe disease if no alternatives.

If used in third trimester, avoid live vaccinations in infant vaccination schedule until 6 months of age.

Breastfeeding

Limited evidence.

Paternal exposure

Limited evidence.

Periconception

Consider stopping at conception.

May be considered to manage severe maternal disease if no other pregnancy-compatible drugs are suitable.

1st Trimester

Severe disease if no alternatives.

May be considered to manage severe maternal disease if no other pregnancy-compatible drugs are suitable.

2nd/3rd Trimester

Severe disease if no alternatives.

If used in third trimester, avoid live vaccinations in infant vaccination schedule until 6 months of age.

Breastfeeding

Limited evidence.

Paternal exposure

Limited evidence.

IL-17 inhibitors


Periconception

Consider stopping at conception.

May be considered to manage severe maternal disease if no other pregnancy-compatible drugs are suitable.

1st Trimester

Severe disease if no alternatives.

May be considered to manage severe maternal disease if no other pregnancy-compatible drugs are suitable.

2nd/3rd Trimester

Severe disease if no alternatives.

If used in third trimester, avoid live vaccinations in infant vaccination schedule until 6 months of age.

Breastfeeding

Limited evidence.

Paternal exposure

Limited evidence.

Periconception

Consider stopping at conception.

May be considered to manage severe maternal disease if no other pregnancy-compatible drugs are suitable.

1st Trimester

Severe disease if no alternatives.

May be considered to manage severe maternal disease if no other pregnancy-compatible drugs are suitable.

2nd/3rd Trimester

Severe disease if no alternatives.

If used in third trimester, avoid live vaccinations in infant vaccination schedule until 6 months of age.

Breastfeeding

Limited evidence.

Paternal exposure

Limited evidence.

IL-12/23 inhibitors


Periconception

Consider stopping at conception.

May be considered to manage severe maternal disease if no other pregnancy-compatible drugs are suitable.

1st Trimester

Severe disease if no alternatives.

May be considered to manage severe maternal disease if no other pregnancy-compatible drugs are suitable.

2nd/3rd Trimester

Severe disease if no alternatives.

If used in third trimester, avoid live vaccinations in infant vaccination schedule until 6 months of age.

Breastfeeding

Limited evidence.

Paternal exposure

Limited evidence.

Periconception

Consider stopping at conception.

May be considered to manage severe maternal disease if no other pregnancy-compatible drugs are suitable.

1st Trimester

Severe disease if no alternatives.

May be considered to manage severe maternal disease if no other pregnancy-compatible drugs are suitable.

2nd/3rd Trimester

Severe disease if no alternatives.

If used in third trimester, avoid live vaccinations in infant vaccination schedule until 6 months of age.

Breastfeeding

Limited evidence.

Paternal exposure

Limited evidence.

JAK-inhibitors


Periconception

Stop ≥2 weeks pre-conception

1st Trimester
2nd/3rd Trimester
Breastfeeding
Paternal exposure

Limited evidence.

Periconception

Stop ≥2 weeks pre-conception

1st Trimester
2nd/3rd Trimester
Breastfeeding
Paternal exposure

Limited evidence.

Considerations

The tool is for educational use only, is not meant to be a substitute for professional advice and should not be used for medical diagnosis and/or medical treatment.

References

Russell MD, Dey M, Flint J, Davie P, Allen A, Crossley A, Frishman M, Gayed M, Hodson K, Khamashta M, Moore L, Panchal S, Piper M, Reid C, Saxby K, Schreiber K, Senvar N, Tosounidou S, van de Venne M, Warburton L, Williams D, Yee CS, Gordon C, Giles I; BSR Standards, Audit and Guidelines Working Group. British Society for Rheumatology guideline on prescribing drugs in pregnancy and breastfeeding: immunomodulatory anti-rheumatic drugs and corticosteroids. Rheumatology (Oxford). 2022 Nov 2:keac551. doi: 10.1093/rheumatology/keac551. Epub ahead of print. Erratum in: Rheumatology (Oxford). 2022 Dec 13;: PMID: 36318966

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