Antirheumatic Medications in Pregnancy and Breastfeeding

Mehret Birru Talabi; Megan E.B. Clowse


Curr Opin Rheumatol. 2020;32(3):238-246. 

In This Article

Abstract and Introduction


Purpose of review: As active rheumatic and musculoskeletal disease during pregnancy increases the risk for pregnancy loss, preterm birth, and maternal illness, ongoing management with pregnancy-compatible medications can improve these outcomes. Selecting and taking these medications can be challenging for rheumatologists and patients due to limited knowledge about potential risks and benefits.

Recent findings: Fortunately, the American College of Rheumatology, American College of Obstetrics and Gynecology, British Rheumatology Society, and the European League Against Rheumatism have each published recommendations to guide the use of antirheumatic medications in pregnancy and lactation. Each of these groups endorsed the use of hydroxychloroquine, azathioprine, sulfasalazine, corticosteroids, NSAIDs, and tumor necrosis factor inhibitors in pregnancy. They also agreed that methotrexate, mycophenolate, cyclophosphamide, and leflunomide should be avoided in pregnancy. New medications, including small-molecules and biologics, have limited data to support safety in pregnancy and are not currently recommended during this period. Most antirheumatic medications are compatible with lactation.

Summary: Because many patients are hesitant to use antirheumatic medications during pregnancy, honest and accurate discussions about pregnancy planning and management are important to help women make decisions that are in their and their offspring's best interest.


Rheumatic and musculoskeletal disorders (RMD) disproportionately affect women, many of whom are diagnosed while they are of reproductive age.[1] Advances in the treatment of RMDs have enabled women to live longer and healthier lives, and therefore to consider the potential for pregnancy and childrearing.[2] Treatment decisions between patients and providers may thus require consideration of women's plans for pregnancy, current pregnancy, or desire to breastfeed. Fortunately, several sets of guidelines and recommendations have been published by national and international organizations that provide needed guidance for the use of medications to manage RMDs.[3–6] In this review, we summarize the current data and these guidelines to facilitated the safe use of medications during pregnancy and lactation.