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.

7 responses to “Rheumatoid Arthritis Drugs & Pregnancy”

Anonymous

May 18, 2012 at 5:28 pm

Can I pin this on my Pinterest board, “Living With Illness?” This is such a great resource! My RA started after my second child was born, and we still want to have another baby sometime in the future. I've thought long and hard about it and I would definitely like to stay unmedicated during the pregnancy. My rheumy said that while some women experience a temporary remission during pregnancy, the flare usually resumes about two weeks postpartum. After having two kids, I can honestly say that I cannot thing of a WORSE time to have a flare than when you're recovering from birth and caring for a newborn. I guess the one good thing about being on meds during would be to forestall that backlash. Great info! Thank you for putting this together!

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Anonymous

May 18, 2012 at 5:37 pm

Yes – please do share this! My doctor has also warned that the symptoms tend to come back full force after delivery. He told me he'd put me back on biologics (assuming I was off) immediately after delivery to hopefully avoid any issues. What you describe is my worst fear: bad flare after delivery & struggling to take care of a newborn. Hope you're able to have another baby & a smooth pregnancy w/ RA!

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Anonymous

May 18, 2012 at 8:57 pm

EXCELLENT post and breakdown! Thank you for sharing the tremendous amount of research you've done 🙂

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Anonymous

May 18, 2012 at 10:10 pm

Thanks, Lauren 🙂

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Anonymous

May 19, 2012 at 11:53 pm

Great post- thank you for sharing this information! I share my experience in hopes that it will provide you some hope. My RA was controlled by plaquenil and enbrel. I found out I was pregnant (planned, but happened very fast) early Jan. I went cold turkey off everything at RA and OB suggestion I could still take plaquenil but it was too hard on my stomach without my good heartburn drugs plus I had morning sickness really bad. I got the prednisone and my OB and RA agreed it would be safe in 10mg max/day but I suffered with tylenol. Then, about 2.5 months in, I experienced a turning point. My joints stopped hurting as much as they had and it was fine with no meds. My doc said it is common for this to happen as your immune system slows down as to not attack baby. While I haven't felt “back to normal”, I feel pretty dang good without the meds. I still take tylenol here and there and would take a plaquenil if I had to. I am 5 1/2 months along and feeling good overall. I've heard the relapse can come after pregnancy, so I am waiting to decide about breastfeeding to see how I feel. I hope this helps to hear a real persons experience.

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Anonymous

May 20, 2012 at 12:40 am

Thank you SO much for sharing your experience — it is incredibly helpful and encouraging! I'm glad that you feel well enough to be off meds right now. I pray that your pregnancy continues to go well and for a safe delivery. Hope you continue to feel well after the baby is born. Yes, the breastfeeding issue is a whole other consideration; be sure to check out the OTIS resources and that LactMed database — there is some good info there if you find you do need to get back on meds.

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Anonymous

May 25, 2012 at 11:58 pm

Hi Dana, I thought i would share my story with you since I've had 3 kids during the course of RA. I have had RA for 10 years, I was first diagnosed after the birth of my first son. The pain started when he was about 6 weeks old but I didn't get diagnosed finally until he was 7 months. After trying different meds, I was finally on Enbrel. When we decided to try for baby #2, I went off Enbrel and stayed on plaquenil. It took 2.5 years of trying and we had given up getting pregnant. I went back on Enbrel but then it gave me an allergic reaction so i switched to remicade. I took one infusion, and bam! got pregnant the next week. I still took plaquenil as my rheumy said it was safe but i was in full remission from the pain and stiffness and felt sooo wonderful (besides the usual morning sickness). Six weeks after delivery of baby boy #2, again my RA flared as my rheumy said it would. I took it as long as I could because I wanted to keep nursing him. I made it 3 months and then had to get back on Remicade again. Well the magic of Remicade right around my ovulation time resulted in surprise!… baby boy #3 2 years later. Again went off Remicade as soon as i found out and stayed on plaquenil. Again felt wonderful during pregnancy and again flared 6 weeks after delivery. Again tolerated minimal meds while nursing until i just couldn't take the pain anymore. That was the hardest part for me, I loved nursing my boys, and I hated to give it up before either of us were ready to, but I had to listen to my body. My pain got so bad with my first son before i was diagnosed that i would cry trying to unbuckle him from his car seat. It's a helpless feeling.They told me plaquenil was safe during breastfeeding so thats the one I stayed on the longest. One of the meds turned my breastmilk blue (luckily I had pumped first before feeding it to baby #1) so quickly got off of that one. I felt so good during pregnancy, if I could stay pregnant and afford to raise more kids (and keep up with their energy levels), I certainly would. My 3 boys are wonderfully active and thankfully healthy, despite my having to take plaquenil (and I am awful at remembering to take my medicine so I only took it when I needed it, not regularly). Now we are done with having babies and I just pray they don't inherit this disease from me….fingers crossed they won't. Good luck to you in your endeavor to start a family. Hopefully you won't need anything too strong when you become pregnant and i hope you are as pain-free as I was for those few months. I felt “normal” again! I am impressed with all the research you've done before even getting pregnant. I wish you the best of luck. Take care, I am a new fan of your blog, although been following you on Twitter for awhile. Have a good weekend!

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