Rheumatoid Arthritis and its Treatment During Pregnancy

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Rheumatoid Arthritis pregnancy

Rheumatoid arthritis (RA) is an autoimmune disease which affects three times as many women as men, and is often diagnosed in the 20s and 30s, when many women start to think about having kids. However, even though the RA-associated symptoms of fatigue and pain as well as the type of medication you are taking for RA should be considered when planning a pregnancy, having RA doesn’t have to disrupt your dreams of having a family. Although RA is associated with a slight risk of miscarriage or babies with a low birth weight, the vast majority of pregnancies in women with RA are normal.1 In addition, around 20% to 40% of pregnant women with RA achieve remission by the third trimester and 50% have low disease activity; however, 20% will have moderate-to-high disease activity throughout the pregnancy and may need further treatment.2 Moreover, disease activity, and consequently RA-associated pain often worsens in the postpartum period.2

Effect of RA on fertility

The jury is out as to whether RA has a definitive effect on fertility; however, women with RA do appear to take longer to get pregnant compared to women without RA. This may be due to women with RA tending to have irregular ovulation, decreased sex drive, or less sex due to fatigue and/or pain. In a study from The Netherlands, disease activity was higher in women with RA who did not conceive or who took a longer time to become pregnant. Other factors which were associated with a longer time to conceive were preconception use of nonsteroidal anti-inflammatory drugs (NSAIDs) or prednisone (>7.5 mg/day).3

Men with RA can experience temporary decreases in sperm count and function as well as erectile and libido problems during an acute flare of RA.1

However, all of these issues can be resolved to a large degree with use of appropriate and effective treatment.

Medication for RA during pregnancy – what is safe to take?

Unfortunately, many drugs for RA, such as leflunomide (Arava) and methotrexate (Otrexup, Rheumatrex, Trexall) can cause birth defects when taken by both men and women. As soon as you decide to start trying to conceive, make an appointment with your rheumatologist as some drugs need a long time to get out of your system. In fact, leflunomide needs to be stopped two years before attempting to get pregnant! However, there are ways to “wash” it out of your system quicker.

The evidence is mixed concerning NSAIDs during pregnancy; however, a large meta-analysis found that NSAIDs significantly increased the risk of premature closure of the ductus arterious and therefore NSAID use is advised against in the third trimester; however they are considered to be a category B drug* in the first and second trimester.4,5

Glucocorticosteroids (low-dose prednisone) are commonly used during pregnancy and are considered to be a category B drug. However, they are associated with some pregnancy risks, such as shorter gestation and consequently lower birth weights. In addition, glucocorticosteroid use during the second and third trimester is associated with a marginally significant increased risk of major malformations as well as a significantly increased risk of oral cleft.5 However, this risk is still small and in general prednisone is considered to be safe during pregnancy. Hydroxychloroquine (Plaqueril) and sulfalazine are also considered to be safe during pregnancy.

Tumor necrosis factor (TNF) inhibitors, such as etanercept (Enbrel), etanercept-szzs (Erelzi), infliximab (Remicade), infliximab-dyyb (Inflectra) and adalimumab (Humira), do not appear to be associated with either congenital abnormalities or miscarriage according to recent studies. Consequently, many rheumatologists are confident that they are safe during pregnancy.1,2

Abatacept is considered to be a category C pregnancy drug** and, based on expert opinion, attempts to conceive should occur at least 14 weeks after the last dose. Rituximab is also a category C pregnancy drug and it is recommended to wait at least 12 months after exposure to rituximab before trying to fall pregnant.2

* Animal reproduction studies have failed to demonstrate a risk to the fetus and there are no adequate and well-controlled studies in pregnant women.4

** Animal reproduction studies have shown an adverse effect on the fetus and there are no adequate and well-controlled studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks.4

References:

  1. http://www.webmd.com/rheumatoid-arthritis/family-planning-and-rheumatoid-arthritis#1
  2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5098768/
  3. https://www.ncbi.nlm.nih.gov/pubmed/24833784
  4. https://chemm.nlm.nih.gov/pregnancycategories.htm
  5. https://www.ncbi.nlm.nih.gov/pubmed/16638921
  6. https://www.ncbi.nlm.nih.gov/pubmed/11091360
Melody Watson
Melody Watson holds Bachelors degrees in Biochemistry and Microbiology. She works as a medical writer for a medical communications agency in Berlin, Germany, where her work ranges from medical translation to writing publications for medical journals. Melody is passionate about promoting science, including evidence-based medicine, and debunking pseudoscience.

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