Rheumatoid, psoriatic arthritis & pregnancy : All queries answered

Posted on November 11, 2019By Nilesh Nolkha

Rheumatoid (RA) and psoriatic arthritis (PsA) frequently involves women in child-bearing age. RA affects 1 in 100-300 people, with women affected more than men. One of the big concerns of females in this age group (also the men with RA) is planning pregnancy with the disease. We have tried to address all major issues in brief. We have clubbed rheumatoid and psoriatic arthritis here because their initial therapies are quite same. Yes, certain biologic therapies are entirely different in the two. But, the basic pregnancy planning factors and how to tackle those issues remain the same. Individual points might be addressed in the article and should be discussed with your rheumatologist and obstetrician. For the ease, I will just mention RA in most cases. Unless specified, please assume that same thing implies for PsA.

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Rheumatoid Arthritis – Basics for Patient
What is Rheumatology & arthritis ? Who is a Rheumatologist?

Can I conceive (become pregnant) normally if I have Rheumatoid or Psoriatic arthritis ? Are my chances of being pregnant (conceiving) affected by me having these diseases ?

There is no major effect of these diseases or drugs used in these diseases on male or female fertility. This basically means that even if you have these diseases, your chances of getting pregnant are not less than average normal population.Most people with RA or PsA unable to conceive (despite a healthy sexual life) have some other factor unrelated to these disease or drugs.

What will be the effect of Rheumatoid arthritis (RA) on foetus (baby in womb) or child after delivery ?

RA or PsA do not increase abortion chances or cause any deformity or genetic abnormalities to your child. Also though genes increase risk of these diseases, they are not hereditary. Basically, these diseases are not transferred from parent to child.

If I have no pregnancy plans, should I still be taking some advice on RA and pregnancy ? What method of contraception can be used ?

Even if you don’t want to get pregnant now, start thinking about future. A good rheumatologist will bring contraception and pregnancy into discussion in anybody with child-bearing age (from first visit itself). If you are having a sexual relationship and do no want pregnancy, you obviously need to think of contraception. Your choice of contraception is usually not affected by having these diseases. Once cannot be careless about this. It is very important for a rheumatologist to know your future pregnancy plans and treat accordingly. Some drugs like methotrexate can cause issues if you become pregnant on them.

When to plan pregnancy in Rheumatoid arthritis ? Why do I need to discuss pregnancy plans with Rheumatologist ?

In most rheumatic diseases, it is best to plan pregnancy when disease is controlled or stable. Since RA and PsA have very good treatments now, it is always best to plan when disease is well controlled or in a very low activity state. As mentioned above, your rheumatologist should be made aware of the plans well in advance. He/she can accordingly plan therapy in you. Certain drugs need to be stopped or changed, followed by waiting period, before planning pregnancy. Eg : Methotrexate needs to be completely stopped at least for 6-12 weeks before you plan to get pregnant. Eat healthy, stop smoking (will help your arthritis too), stay relaxed, be active and try to maintain healthy sexual life to conceive. Its better to take 500 ug (0.5mg) or even more (upto 5mg) of folic acid daily if you are planning pregnancy.

How will my rheumatoid or psoriatic arthritis behave during and after pregnancy ? Will I have a flare or more pain ?

In pregnancy, about 30-70 percent RA and possibly more than 80% of PsA patients will have decrease or stabilisation in their arthritis activity. Many patients even go into complete remission or total control. If a patient is in remission or control even before pregnancy, they tend to maintain their good status in pregnancy. However some patients (10-30%) will have flare of arthritis during their pregnancy. We don’t know if this is a coincidence or pregnancy causes it. In any case, we can manage it easily in most cases. In most patients, after pregnancy the disease tends to come back to same intensity as to that of pre-pregnancy stage or even lead to a flare. No need to fear in any case. Now a days rheumatologists are well equipped to handle these ups and downs.

Even a fairly normal pregnancy can have many body changes and symptoms which can be confused with arthritis. For example, it might cause slightly increased joint or lower back pain, may cause swelling in hands and feet, may lead to numbness in hands or feet etc. Your rheumatologist and obstetrician together should be able to differentiate what is arthritis and what is pregnancy effect.

Drugs for Rheumatoid or psoriatic arthritis during pregnancy – are these drugs safe for pregnancy and breast feeding ?

The following table should solve basic queries. For rest, talk to your rheumatologist. Generally, none of the drugs make you less fertile or decreases your chances of getting pregnant. However, some drugs need to be stopped, because if they remain in blood while you conceive, they can potentially harm foetus.

Please do not check on pregnancy categories of drugs or read product characteristics note (Spc) given by pharma company. They do not give information as suggested by experts. Eg : Azathioprine is FDA pregnancy category D drug which is category given to drugs with possible risk to foetus. However, all experts in the world recommend to continue and have used it in pregnant patients with autoimmune diseases without issues.

Drug	Can it be given in females trying to conceive / get pregnant ?	Can it be given during pregnancy	Can it given with breastfeeding (after pregnancy) ?	Can it be given in male trying to conceive ?
Corticosteroids / Steroids / Prednisolone	Yes – lowest possible doses	Yes – lowest possible doses	Yes – lowest possible doses	Yes
Methotrexate and pregnancy (Folitrax / Rasuvo / Rheumatrex)	No. Stop at least 6-12 weeks (best to stop 12 weeks) before trying to conceive – take folic acid 5mg (Also read -some other points below)	No (Also read some other points below)	No	Yes
Leflunomide and pregnancy (Arava / Lefno)	Usually not given in women wanting to plan pregnancy within 2-3 years. If given need to give a washout with drug called cholestyramine – take folic acid 5mg (Also read -some other points below)	No (Also read some other points below)	No	Yes
Sulfasalazine (Saaz / Azulfidine / Sulfazine )	Yes – take folic acid 5mg	Yes – take folic acid	Yes – take folic acid	Yes (Also read -some other points below)
Hydroxychloroquine (Plaquenil / HCQS)	Yes	Yes	Yes	Yes
Pain-killers (NSAIDS) – Ibuprofen, Diclofenac, Naproxen, etc (Combiflam, Brufen, Aleve, Mortin, Voltaren, Voveran, Neurofen) (Newer Cox 2 inhibitor NSAIDS like etoricoxib and celecoxib – Arcoxia, celebrex, Nucoxia, etody etc are not recommended in pregnancy and breastfeeding as no data)	Yes – but lesser is better	First 3 months (trimester) of pregnancy Use with caution – some increased risk og miscarriage, occasional doses should be fine Second Trimester – safe Should not be given after 32 weeks in any case	Yes	Yes
Aspirin in lower doses (< 100 mg /day)	Yes	Yes – in low dose its considered safe throughout pregnancy despite being in class of NSAIDS as above	Yes	Yes
Paracetamol and Codeine	Yes	Yes	Yes	Yes
Amitriptyline, other antidepressants (or fibromyalgia drugs)	Amitriptyline safe in all the above scenarios. Most other anti-depressants though safe in these scenarios, data about breastfeeding is limited. Please take suitable advice.
	Biologic drugs in Rheumatoid and Psoriatic arthritis – Pregnancy safety There is no evidence that any biologic drug decreases chances of conceiving or getting pregnant
Anti – TNF drugs Etanercept (Enbrel, Intacept, Etacept, Erelzi), Infliximab – (Remicade, Remsima, Infimab). Adalimumab- (Humira,Exemptia). Simponi(Golimumab). Certlolizumab (Cimzia)	All TNF drugs are usually safe to continue when planning pregnancy. Some anti TNFs cross placenta and are recommended to be stopped at 16-30 weeks of pregnancy. If they are continued beyond their recommended period, the infants are usually not recommended to given as a live vaccine for 6-9 months. Cimzia (certolizumab) has shown to not cross placenta significantly and hence can be technically given throughout pregnancy. Your rheumatologist may prefer this biologic if you are planning pregnancy. But it doesn’t mean you need to change what you are taking. Again discuss with your rheumatologist. Most anti TNF’s are safe in breastfeeding Data on Golimumab in all phases in limited to recommend anything with authority, but appears to be safe.
Mabthera (Rituximab )	Pregnancy is not advised until six months have elapsed since last rituximab dose. However if by chance if you have had pregnancy within 6 months of last rituximab, it usually causes no harm. It is not recommended in patients who are breastfeeding as it is secreted in milk.
Tocilizumab (Actemra)	Pregnancy is not advised until three months have elapsed since last tocilizumab dose. However if by chance if you have had pregnancy within 3 months of last tocilizumab, it usually causes no harm (as it doesn’t cross placenta until 16th week). It is not recommended in patients who are breastfeeding.
Abatacept (Orencia), Tofacitinib (Xeljanz), Baracitinib (Olumiant), Secukinumab (Cosentyx, Scapho), Ustekinumab (Stelara), Apremilast (Otezla), Ixekizumab (Taltz)	There is not much data about these drugs and pregnancy.Unintentional exposure during first three months of pregnancy is likely to be safe with most drugs. They are usually avoided unless necessary.

What if I don’t take my rheumatoid drugs during pregnancy ?

There is good evidence that RA or PsA treatment can be continued without major issues during pregnancy. If you don’t continue these medicines there is chance that patient’s disease might flare up. This might become problematic both for patient and baby. The increased disease and higher doses of these medications that may be required for controlling arthritis might cause complications in pregnancy and baby. Hence, it is advised to continue at least some medications in pregnancy (on advice of rheumatologist).

What after pregnancy in Rheumatoid or Psoriatic arthritis ? Can breastfeeding be an issue if I have RA or psoriatic arthritis ?

As mentioned above, patient’s arthritis may flare after pregnancy and can be controlled easily by rheumatologists. Breastfeeding is not an issue, as most patients will be able to breastfeed without issues. Also, most pregnancy safe drugs are breastfeeding safe too. At least 2 years of spacing is recommended between two pregnancies, more so when you have a chronic disease. So, do no forget discussing contraception after pregnancy with your obstetrician (have discussion during pregnancy).

Can Rheumatoid or psoriatic arthritis start after pregnancy ?

Many autoimmune diseases, especially rheumatoid arthritis, are known to affect (start) patients immediately after pregnancy. We don’t know the exact reason for same. Possibly pregnancy leads to immune over activation and that might be a reason. In any case, most such people have a factor which predisposes them to that disease. Pregnancy probably hastens it or is just a coincidence. This occurrence is rare in real-life pregnancies. One should not fear pregnancies just for this, even if they have a family history of autoimmune disease. Also, such patient should not fear future pregnancies just because their disease started after last pregnancy.

Some other points

In every pregnancy, there is some inherent background risk of miscarriage or defect in the baby. We can say that a particular drug is safe in pregnancy, basically studies haven’t found any increased background risk. One might still take this drugs and have some problems in pregnancy or baby, that doesn’t mean the drug caused it.
Very rarely, pregnancy might be very risky in RA patients with very severe lung or other organ disease. This is uncommon in child-bearing age group and todays era of rheumatoid treatment. Your rheumatologist will guide you accordingly.
Planning should help one avoid unwanted / unplanned pregnancies. Some patients still get pregnant while taking drugs like methotrexate and leflunomide, which have potential harms to pregnancy and baby. Your rheumatologist and obstetrician should be able to discuss all ifs and buts in that scenario and help you to make a decision. In worst scenario, abortion is a safe option in RA patients.
A male rheumatoid or psoriatic arthritis patient trying to conceive should also have a word with rheumatologist before starting. Mostly, it is not required for them to stop any drugs. There is no data that rheumatoid drugs lead to any genetic abnormalities in sperm and hence harm conceiving chances or damage to foetus. However, data on some newer drugs is limited and hence one should have a discussion with their doctor. Sulfasalazine can rarely decrease the sperm count in male patients (oligospermia). This usually doesn’t decrease libido or pregnancy chances and is totally reversible when you stop sulfasalazine. In most male patients on sulfalsalazine and not able to conceive, one should look for other causes before blaming the drug.
Pain and depressed mood in RA patients can decrease sexual desire and may make sexual act too painful. Again the best way to handle this is get adequate treatment from your rheumatologist. Help of a psychologist or a counsellor might be required in some cases.

Summary – Rheumatoid arthritis, psoriatic arthritis and pregnancy

To summarise, most patients of RA and PsA have absolutely healthy pregnancies in real life. They need close discussion with treating rheumatologist and obstetrician. There is some planning required beforehand. There is good information on most drugs and something can be given during pregnancy to manage your arthritis well.

References

Pottinger E, Woolf RT, Exton LS, Burden AD, Nelson-Piercy C, et al. Exposure to biological therapies during conception and pregnancy: a systematic review. Br J Dermatol. 2018 Jan;178(1):95-102. PubMed PMID: 28718898.
Flint J, Panchal S, Hurrell A, van de Venne M, Gayed M, et al. BSR and BHPR guideline on prescribing drugs in pregnancy and breastfeeding-Part I: standard and biologic disease modifying anti-rheumatic drugs and corticosteroids. Rheumatology (Oxford). 2016 Sep;55(9):1693-7. PubMed PMID: 26750124.
Flint J, Panchal S, Hurrell A, van de Venne M, Gayed M, et al. BSR and BHPR guideline on prescribing drugs in pregnancy and breastfeeding-Part II: analgesics and other drugs used in rheumatology practice. Rheumatology (Oxford). 2016 Sep;55(9):1698-702. PubMed PMID: 26750125.
Nelson JL, Ostensen M. Pregnancy and rheumatoid arthritis. Rheum Dis Clin North Am. 1997 Feb;23(1):195-212. PubMed PMID: 9031383.

Author: Dr Nilesh Nolkha, Rheumatologist
Dr Nilesh Nolkha is a rheumatologist who strongly believes in patient education and empowering patients to make rational treatment decisions. He is a practicing rheumatology consultant in Wockhardt hospital, Mumbai.