Optimum use of disease-modifying and immunosuppressive antirheumatic agents during pregnancy and lactation

Women with rheumatic diseases frequently need treatment throughout pregnancy and lactation. Physicians must confront the dual challenge of monitoring the possible effects of the underlying maternal disease and the medications on both mother and child. It is essential that the maternal disease is well controlled before, during and after pregnancy to ensure the best possible outcome for the mother and child. Glucocorticoids have been used extensively in pregnant patients with systemic lupus erythematosus and rheumatoid arthritis; there have been no reports of congenital malformations in the exposed infants. There is limited information on the safety of disease-modifying antirheumatic drugs, including hydroxychloroquine, cyclosporin, oral and parenteral gold and sulfasalazine, during pregnancy. However, penicillamine, another disease-modifying antirheumatic drug, is contraindicated during pregnancy. There is considerable experience with the use of azathioprine during pregnancy if the maternal condition requires a cytotoxic drug. There has been no increased risk of congenital malformations in the exposed infants. The other cytotoxic drugs frequently used in the treatment of rheumatic diseases, chlorambucil, cyclophosphamide and methotrexate, are contraindicated during pregnancy. Glucocorticoids (such as prednisone and methylprednisolone) and hydroxychloroquine are considered to be safe during lactation. Oral and parenteral gold and sulfasalazine can be used with caution during lactation. Penicillamine, cyclosporin and all cytotoxic drugs are contraindicated during lactation.