Autoimmune diseases often affect women of childbearing age. There are over 100 recognized conditions, including rheumatoid arthritis, lupus, inflammatory bowel disease, type 1 diabetes, and multiple sclerosis. Advances in treatment have improved women's quality of life and ability to raise children. But are the drugs safe during pregnancy and lactation? A recent article in the medical literature reviews the possibilities.
Worst Drugs: methotrexate, leflunomide, and mycophenolate mofetil. These drugs must be discontinued far in advance of conception to make sure they have cleared out of the woman's body. The recommendations are as follows:
1. Methotrexate: discontinue at least three months before conception.
2. Leflunomide: it may take up to two years for the active metabolite to fall to 0.03 mg/l or less, which is considered to be the safe level. Treatment with cholestyramine can reduce the levels faster. Any patient who has taken leflunomide within the last two years should be tested before conception.
3. Mycophenolate mofetil: discontinue at least six weeks before conception.
Best Drugs: hydroxycloroquine, corticosteroids, sulfasalazine, and azathioprine. These appear to be safe during pregnancy. However, the authors caution that available data are based on animal studies, individual case reports, and observational cohorts. The gold standard of randomized, placebo-controlled clinical trials are unusual for drugs during pregnancy.
Other Drugs: NSAIDs, anti-TNF agents, cyclophosphamide.
1. Non-steroidal anti-inflammatory drugs (NSAIDs) should be used sparingly while trying to conceive, and during the first and second trimesters. They should be stopped completely during the third trimester.
2. Anti-TNF agents have very limited data on use during pregnancy. Doctors and patients should carefully consider the risks of using these drugs without knowing the effects on the fetus.
3. Cyclophosphamide should never be used in the first trimester of pregnancy, but has been used safely in the later half of pregnancy. The medical literature reports three women who delivered healthy infants after cyclophosphamide treatment for breast cancer in late pregnancy. Four patients with lupus experienced spontaneous abortions or miscarriages after treatment with cyclophosphamide, but this may have been caused by the disease.
Recommendations for medication during lactation are similar. Ibuprofen is recommended as the best NSAID while breast feeding. Corticosteroids reach their highest level in breast milk approximately two hours after a dose is taken, so three to four hours after a dose is considered the optimum time for breast feeding.
Be sure to discuss all your medications with your doctor before trying to get pregnant.
Reference:
Elliott AB et al, “Immunosuppressive medications during pregnancy and lactation in women with autoimmune diseases”, Womens Health (Lond Engl). 2010 May; 6(3): 431-40.
Linda Fugate is a scientist and writer in Austin, Texas. She has a Ph.D. in Physics and an M.S. in Macromolecular Science and Engineering. Her background includes academic and industrial research in materials science. She currently writes song lyrics and health articles.