Changes in Rheumatoid Arthritis Pharmacotherapy During Pregnancy

Fertility and RA

Although most offspring of women with RA are of normal birth weight and gestational age, an increase in prematurity and a decrease in birth weight have been noted in children born of mothers with RA.8  Additionally, women with RA are more likely than normal controls to use assisted reproductive technology, like in vitro fertilization, suggesting a higher baseline rate of infertility.9

The true relationship between RA and fertility has yet to be clarified. Factors hypothesized to affect fertility in women with RA include disease activity, pharmacotherapies received, and immunologic influences.9  Higher rates of infertility are noted among patients with RA, resulting in longer times to pregnancy (TTP).10  One study from Denmark found that 25% of patients with RA were more likely to have taken longer than 12 months to conceive compared with 15.6% of controls.11 A national cohort study found that TTP in women with RA was longer if patients were older or nulliparous, had higher disease activity, used nonsteroidal anti-inflammatory drugs (NSAIDs), or used prednisone >7.5 mg/d.9  

Dr Kuriya further noted to Rheumatology Advisor that “many women want to know if RA affects their chances of conceiving and there is still no large-scale evidence to inform us about the risks of infertility with RA and what may be done to lower this risk if it is present.” 

RA Pharmacotherapies and Pregnancy

Methotrexate is the cornerstone of treatment in RA; however, it is a known teratogen and abortifacient with no definitive safe dosage in pregnant women.12  It should therefore be avoided during pregnancy. Sulfasalazine and hydroxychloroquine are the nonbiologic DMARDs of choice in pregnant patients with RA.12 The use of tumor necrosis factor (TNF) inhibitors and other biologic therapies in pregnant patients with RA is more controversial. 

A 2009 review of the US Food and Drug Administration (FDA) database found a higher-than-normal amount of congenital anomalies that are part of a constellation of abnormalities—vertebral, anal, cardiac, tracheoesophageal, renal, and limb (VACTERL)—seen in children born to mothers taking a TNF antagonist.13

However, analyses of other studies have not found the rate of congenital malformations in the offspring of TNF inhibitor-exposed mothers to be different from the general population.14

NSAIDs are generally not used after 32 weeks of gestation due to their potential for causing premature closure of the ductus arteriosus.1  These agents are associated with an increased risk of miscarriage in early pregnancy, possibly by causing abnormal implantation of the embryo.1 Glucocorticoids such as prednisone and prednisolone are frequently used to treat disease flares. They should be maintained at the lowest dose possible and gradually weaned.1