Prescribing anti-rheumatic drugs in pregnancy and breastfeeding - the BSR guideline scope

Ian Giles, Alexander Allen, Amy Crossley, Julia Flint, Margreta Frishman, Mary Gayed, Munther Kamashta, Louise Moore, Sonia Panchal, Madeline Piper, Clare Reid, Katherine Saxby, Karen Schreiber, Naz Senvar, Sofia Tosounidou, Maud Van De Venne, Louise Warburton, David Wiliams, Chee-seng Yee, Caroline Gordon

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Abstract

The BSR guidelines on prescribing anti-rheumatic drugs in pregnancy and breastfeeding (parts I and II) were published in 2016 (2, 3). The literature search for these guidelines was run in December 2013. Subsequently, there has been an appreciable increase in the number of published pregnancy exposures to biologic disease modifying anti-rheumatic drugs (bDMARDs) and two of these drugs are now licenced for use in pregnancy. In addition, therapeutic advances in management of various inflammatory rheumatic diseases (IRDs) have led to an expansion of bDMARDs and biosimilars with different modes of action as well as a new class of targeted synthetic DMARDs (tsDMARDs).

Additional evidence-based guidelines from the European League Against Rheumatism (EULAR) (4, 5), BSR (6) and the American College of Rheumatology (ACR) (7) have now been published. These guidelines advise on the management of various rheumatic diseases in women of childbearing age and discuss drug usage during pregnancy. In addition, recent EULAR recommendations have been produced following a consensus review detailing a core data set for pregnancy registries in rheumatology (8). This data-set is important because it could allow us, in the future, to gather better quality evidence from registries and has already been shown to be feasible in daily clinical practice (9). Although, these publications have greatly increased awareness amongst healthcare professionals of how to collect data and which anti-rheumatic drugs may be compatible with pregnancy the continuing expansion of existing and novel DMARDs means that uncertainty remains around use of many of these drugs in pregnancy. This uncertainty may still lead to withdrawal of treatment from pregnant women unnecessarily (10). Discontinuation of treatment in preparation for or during early pregnancy can increase the risk of disease activity and flares during pregnancy, and are reported following discontinuation of biologics in patients with inflammatory rheumatic disease (IRD), such as rheumatoid arthritis (RA) and axial spondyloarthritis (AxSpA) (11).

Therefore, an update of the guidelines is now required to address the use of various drugs, particularly bDMARDs and other novel therapies, in patients planning pregnancy, during pregnancy and breastfeeding. This updated information will provide advice for healthcare professionals and patients to ensure more confident prescribing in these scenarios and will highlight any medications that should be stopped and/or avoided in the reproductive age group unless contraception is used.
Original languageEnglish
JournalRheumatology
Early online date12 Apr 2021
DOIs
Publication statusE-pub ahead of print - 12 Apr 2021

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