Rheumatoid Arthritis Drugs & Pregnancy

Here’s a topic I’ve been able to find precious little about. So, I've decided to do some research since we do want to have kids someday, and it doesn't look like my RA is going anywhere. While research shows that a lot of women experience a decrease of symptoms during pregnancy, there’s no guarantee that will happen and no guarantee that even symptoms at a decreased level will be tolerable. My preference would be to not be on any drugs while I’m pregnant, and that will be my first attempted course of action. But I need a contingency plan. If I can’t be completely off medications, I wanted to know the risks involved with various medications before making a decision on what my contingency treatment plan would entail. I’ve had numerous discussions with my rheumatologist and my primary care physician (and we are all in agreement on what my plan will be at this point), but I wanted to pull together a list so that I could organize my thoughts and make sure I examined all (or at least many) of the options and understood the risks.

I have had a hard time finding a simple, comprehensive list detailing the pregnancy risk of rheumatoid arthritis drugs, so I decided to create one for myself – and for anyone else who might be looking for this information (*note: I did also re-discover this great resource from OTIS, which does contain a drug list with pregnancy categories AND the best pregnancy safety information I’ve been able to find on RA treatments: click here todownload the PDF – it’s very valuable, detailed information!) I’ve outlined some of the main drugs used in the treatment of rheumatoid arthritis and listed the pregnancy category as set by the U.S. Food and Drug Administration. For a description of what the pregnancy categories mean, click here. Clicking on a drug name below will either bring you to the manufacturer’s website or an informational webpage from the American College of Rheumatology. Clicking on the pregnancy category within the table will pull up additional information about the drug as relates to pregnancy either from SafeFetus.com or Drugs.com.

RA Drugs
Brand Name	Generic Name	Administration	Pregnancy Category
Biologics
Enbrel®	Etanercept	Injection	B
Humira®	Adalimumab	Injection	B
Simponi®	Golimumab	Injection	B
Rituxan®	Rituximab	Infusion	C
Remicade®	Infliximab	Infusion	B
Actemra®	Tocilizumab	Infusion	C
Orencia®	Atabacept	Injection/Infusion	C
Cimzia®	Certolizumab	Injection	B
Kineret®	Anakinra	Injection	B
Synthetic DMARDs
Plaquenil®	Hydroxychloroquine	Oral	C
Arava®	Leflunomide	Oral	X
Rheumatrex®, Trexall®	Methotrexate	Oral	X
Azulfidine®, Sulfazine®	Sulfasalazine	Oral	B
NSAIDs
Naprosyn®, Aleve®	Naproxen	Oral	C
Celebrex®	Celecoxib	Oral	C
Mobic®	Meloxicam	Oral	C
Corticosteroids
	Prednisone	Oral	C

From here, it seems that by and large anti-TNF drugs have the safest reputation among biologics. Unfortunately, there is so little data currently available that it’s hard to say for sure (hence the category B classification). If you are considering continuing on a biologic treatment during pregnancy or want more information on it, I highly encourage you to check out the database maintained by OTIS of pregnant women who have been exposed to these drugs. They also have great Fact Sheets on drugs and other substances expectant mothers may be exposed to.

Note also that some DMARDs are considered category X drugs, and must be discontinued several months prior to trying to conceive.

There are a couple other important and interesting side notes:

1. Despite being pregnancy category C, according to my doctor (and information from OTIS), prednisone has been shown to be safe at low doses (I think my doctor said he'd do a maximum of 5mg/day) and demonstrated risks seem to be associated with higher doses. My doctor would actually prefer me to be on low-dose prednisone before anything else if I need something to control symptoms while I’m pregnant because he says the safety outcomes are better documented.

2. I’m currently taking hydroxycholoroquine, so my doctor discussed the pregnancy risk of this drug with me last time I was in his office. It’s still classified as a Category C drug, but he said that there is more recent data that suggests safety during pregnancy – what he referenced was actually a study done on lupus patients. Click here to read more about the outcome of that study.

3. I’m also currently taking Naproxen, which apparently is category C, but the main risk seems to be in the last trimester. My doctor and most of the RA resources I’ve found have simply said to discontinue use in the third trimester, leaving me to wonder what risks are involved earlier in the pregnancy. I've not investigated this much, so it's still on my to-do list. Tylenol (acetaminophen) is considered safe during pregnancy, but I've never found it to be effective for me.

Obviously, talk to your doctor if you are on any medications and plan to become pregnant, and come up with a treatment plan that both you and your doctor are on board with. My rheumatologist has been great to work with in this regard, and I'm very thankful for that!

For more information, check out these resources:

OTIS -- "dedicated to providing accurate evidence-based, clinical information...about exposures during pregnancy and lactation"

LactMed – Drug and lactation reference database from the U.S. National Library of Medicine

SafeFetus.com – Searchable Drug Database with Information on Pregnancy & Breastfeeding

Drugs.com -- Searchable Informational Drug Database

EmbryoTox.de -- Many thanks to Dr. Kirsch for showing me this great resource -- search a drug and it pulls up all sorts of information regarding the drug and pregnancy/lactation. The site is in German, so if you're like me and don't speak German you'll just need to translate it :)

Rheumatoid Arthritis (RA) Pregnancy & Enbrel -- Stephanie's blog is one of the first resources I stumbled upon with information on pregnancy and Enbrel (when I was on Enbrel...). She shares her experiences and MANY others do in the comments, too!

Choosing Medications for Adults with RA -- Good list of available treatment options for RA.

**Please note that I am NOT a health care professional, and nothing on this blog should be taken as medical advice. The information provided here is based on my personal experiences. Please speak with your doctor for medical advice or before making any medical decisions.

at the Water's Edge