The medical management of the rheumatology patient during pregnancy

Decisions regarding medication use during pregnancy are amongst the most challenging clinicians will face. The health of both the mother and the developing fetus must be taken into account when designing a treatment plan. Limited data on an individual drug's risk for use during pregnancy and conflicting recommendations regarding drug safety contribute to uncertainty in therapy choices. Clinicians and patients individually have their own risk tolerance for prescribing and taking medications. Finally, pregnancy itself can impact an individual patient's disease activity rendering typical treatment approaches invalid. This chapter will discuss the treatment of the pregnant and nursing woman with a rheumatic disease. It will review the literature on commonly used medications for rheumatic disease management including aspirin, the nonsteroidal anti-inflammatory medications and COX-2 inhibitors; the glucocorticoids; the antimalarials; sulfasalazine; the immunosuppressive agents azathioprine and 6-mercaptopurine, cyclosporine, mycophenolate mofetil, and tacrolimus; the anti-metabolite methotrexate; leflunomide; cylophosphamide; intravenous immunoglobulin; the biologics including tumor necrosis factor-α (TNF-α) blockers, rituximab, belimumab, actemra, anakinra, abatacept, and tocilizumab; the anti-coagulants warfarin and unfractionated and fractionated heparin and colchicine. Wherever possible, specific recommendations will be made.