Pregnancy and Breast feeding: What medicines are safe?

Pregnancy & Breastfeeding Advice

Pregnancy and breast feeding in those with rheumatological conditions.

What medications are safe?

These are very important questions which we are asked in clinic frequently and the answers are not always clear, there is often limited data from research trials available on patients who are planning a family, pregnant and breast feeding.

Recently the BSR (British Society for Rheumatology) has published guidelines for the use of DMARD’s (Disease Modifying Ant -rheumatic Drugs) and other medicines such as pain killers and anti- inflammatory medication.

This has helped to make things clearer, in particular advice on the use of anti-TNF agents in pregnancy which will allow more women to have effective treatment if necessary.

The most important advice for women and men planning a family is to discuss with your rheumatologist as soon as possible to allow time to review medication and disease activity. Sometimes a referral to a pre pregnancy clinic is necessary and occasionally the advice may be that would not be safe to plan a pregnancy at that time

Below is a summary of the key messages from these guidelines. The full guidance can be found at: http://rheumatology.oxfordjournals.org/content/suppl/2016/01/09/kev404.DC1/kev404-Full_Guidelines.pdf

 

Medications for pain relief and anti inflammatories

 

Pre pregnancy During pregnancy Breast feeding
Paracetamol Safe Safe – but only use as low as dose as possible. Safe – but only use as low a dose as possible.
Codeine Safe Safe With caution only
Tramadol Safe Safe Probably safe but limited info available
Amitriptyline Safe Safe Safe
Gabapentin/Pregabilin Not recommended Not recommended due to limited data Not recommended due to limited data
NSAID e.g. ibuprofen, diclofenac, naproxen Safe 1st trimester – not recommended –may increase risk of miscarriage.

2nd trimester –safe but need to stop by 32 weeks.

Safe
COX 2 inhibitors e.g. Celecoxib Not recommended Not recommended Not recommended

DMARDS – standard agents

 

        Pre-pregnancy During pregnancy Breast feeding
Corticosteroids (prednisolone) Safe Safe Safe
Hydroxychloroquine safe safe safe
Methotrexate Stop 3 months in advance Not safe Not safe
Sulphasalazine (with 5mg folic acid  i.e. higher than the standard 400µg Safe Safe Safe in full term healthy infants
Leflunomide Not recommended – may need cholestyramine washout pre pregnancy Not recommended Not recommended
Azathioprine Safe Safe sSafe
Mycophenolate Stop 6 weeks in advance Not recommended Not recommended

 

 

Anti-TNF agent and other biologics

 

  Pre pregnancy During pregnancy Breast feeding
Infliximab          Safe Stop at 16 weeks – if not risk of increase infection risk in baby Probably safe but limited data
Etanercept           Safe Only in 1st and 2nd trimester Probably safe but limited data
 Adalimumab          Safe Only in 1st and 2nd     trimester Probably safe but limited data
Certolizumab          Safe Thought to be safe through all trimesters as doesn’t cross placenta but data limited Probably safe but limited data
Golimumab No data

(but likely to be the same as other drugs in this class)

No data No data
Rituximab Stop 6 months in advance Not recommended No data
Tocilizumab Stop 3 months in advance Not recommended No data

Men planning a family

Do male patients planning a family need to alter medication?

Usually not but there are some important considerations:

Sulphasalazine may cause reduced fertility but altering sperm movement. However it is thought reasonable to continue this unless their partner hasn’t become pregnant after 12 months and then other causes of infertility should also be considered.

There is limited data on the use of methotrexate and anti TNF and other biologic drugs such as rituximab but generally considered that it is safe to continue.

Conclusions

 

Good preparation and early discussion with your GP are really important to ensure the treatment plan is correct for planning a pregnancy.

These guidelines give rheumatologists clearer options and a lot the medicines we use can be continued during at least some of the pregnancy.

As some medication are thought to increase risk of fetal malformations (Methotrexate, mycophenolate, leflunomide and others) it is vitally important that contraception is used while on this treatment and for 6 weeks to 3 months afterwards

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