Rheumatism patients want to prepare for pregnancy, pregnancy, these 6 drugs must be stopped!

*It is only for medical professionals to read for reference.
The use of peri-pregnancy drugs must take into account the two aspects of maintaining the mother's condition and ensuring the safety of the fetus, and adjust the treatment plan in time
.

Rheumatic diseases (hereinafter referred to as rheumatism) are a large group of systemic diseases that mainly affect joints and surrounding tissues, including systemic lupus erythematosus (SLE), antiphospholipid syndrome (APS), rheumatoid arthritis (RA), Sjogren's syndrome (the SS), systemic sclerosis (SSc), idiopathic inflammatory myopathies (the IIM), systemic vasculitis, spinal arthritis
.

Part of the peak incidence of rheumatism is the childbearing age, and long-term medication is often required to maintain stable disease.
It is often difficult to avoid the use of related drugs during pregnancy
.

In addition, female patients with rheumatism may face the risk of fluctuating or worsening of the condition during pregnancy.
The use of peri-pregnancy drugs must take into account the two aspects of maintaining the stability of the mother’s condition and ensuring the safety of the fetus.
According to the different stages of pregnancy, the mother’s condition, the safety of drugs and the drugs Whether to pass the placental barrier and other factors, adjust the treatment plan in time
.

So how do patients with rheumatism use commonly used drugs during pregnancy, pregnancy and lactation? Let's see it together
.

Remember to stop these 6 drugs before pregnancy! During the peri-pregnancy period, drugs that may cause fetal malformations should be avoided.
Rheumatologists need to reasonably plan the medication according to the patient's condition and pregnancy plan
.

The following drugs to be avoided during pregnancy and pregnancy should be discontinued in time before the planned pregnancy (Table 1) [1]
.

Table 1: Drugs to avoid for female patients with rheumatism during pregnancy and pregnancy, and when to stop the drugs.
Is it difficult to take drugs during peri-pregnancy? List of key points of 11 types of drugs! 1.
Glucocorticoids (hereinafter referred to as hormones): Hormone is one of the main drugs for the treatment of rheumatism, and its correlation with adverse pregnancy events has been reported differently [2]
.

Table 2: Anti-inflammatory equivalent doses of commonly used glucocorticoids 2.
Hydroxychloroquine: A number of studies support the benefits of hydroxychloroquine for pregnancy in patients with rheumatism, including the possibility of reducing the preterm birth rate of pregnant women with SLE, reducing lupus recurrence, and reducing adverse fetal outcomes Occurrence of risks, etc.
[3-4]
.

3.
Calcineurin inhibitors: The main calcineurin inhibitors used by patients with rheumatism include cyclosporine and tacrolimus
.

4.
Azathioprine: It is a relatively safe immunosuppressant in patients with rheumatism during the peri-pregnancy period.
The usual dose is 1.
5~2.
0 mg·kg-¹d-¹
.

Avoid taking azathioprine as much as possible during lactation, but the content of its metabolite 6-mercaptopurine in breast milk is less than 1% of the mother’s medication dose.
Therefore, if the medication cannot be stopped due to illness, you can continue to use it as appropriate.
It is recommended to discard the medication.
Milk produced within 4 hours
.

Patients need to monitor blood routine closely after using azathioprine to detect possible bone marrow suppression at an early stage
.

5.
Sulfasalazine: Mainly used to treat RA and spondyloarthritis with peripheral arthritis
.

Sulfasalazine can pass the placental barrier, but it may not increase the risk of miscarriage, low birth weight, or congenital malformations
.

6.
Colchicine: It is an alkaloid drug that inhibits mitosis.
It has anti-inflammatory and anti-fibrotic effects.
It is often used to treat gout, familial Mediterranean fever, Behçet’s syndrome, SSc, etc.
in rheumatism
.

7.
Non-steroidal anti-inflammatory drugs (NSAIDs): NSAIDs are widely used in rheumatism, such as RA, spondyloarthritis, etc.
, and their main effects are antipyretic, analgesic and anti-inflammatory
.

8.
Tumor necrosis factor (TNF) inhibitor: often used to treat RA and spondyloarthritis
.

9.
Aspirin: The commonly used dose of aspirin in patients with rheumatism during pregnancy is a small dose (50-100 mg/d), used alone or in combination with low-molecular-weight heparin.
The specific dose depends on the patient’s drug tolerance and availability.
No vaginal bleeding or weight adjustment
.

10.
Heparin/low-molecular-weight heparin: Primary and secondary APS patients: low-molecular-weight heparin/heparin or combination with low-dose aspirin is often required during pregnancy.
Choose a preventive dose (once a day) or a therapeutic dose according to the condition ( 2 times a day) low molecular weight heparin
.

It is determined that the drug should be started as soon as possible after pregnancy.
Some APS patients with recurrent miscarriage can be given a preventive dose after the end of the menstrual month of the planned conception, and used throughout the pregnancy.
The drug should be stopped 24 to 48 hours before delivery and continue to be given 12 to 24 hours after delivery.
Medicine
.

Obstetric APS patients: use a combination of low-dose aspirin and preventive doses of low molecular weight heparin during the whole pregnancy, and continue to use preventive doses of low molecular weight heparin for 2-12 weeks after delivery
.

Pregnant women with thrombotic APS: use low-dose aspirin and therapeutic dose low-molecular-weight heparin during the whole pregnancy and 6-12 weeks postpartum.
Those who use anticoagulant drugs before pregnancy will resume the original long-term anticoagulation regimen after 6-12 weeks postpartum
.

Only aPL-positive patients who do not meet the obstetric APS criteria: there is no need to use prophylactic low-molecular-weight heparin
.

11.
Intravenous immunoglobulin (IVIG): IVIG can be safely used during peri-pregnancy in patients with rheumatism
.

IVIG can be used in patients with rheumatism during pregnancy or refractory APS.
There is no uniform plan for dosage and treatment.
Most of them use 0.
4g·kg-¹·d-¹, lasting 3~5 days, with an interval of 3~4 weeks.
1 time
.

Do you want to stop a drug whose safety is not clear? 1.
Biological agents: ■ Interleukin (IL)-6 receptor antagonist: Tocilizumab is mainly used to treat RA and systemic juvenile idiopathic arthritis
.

Tocilizumab is not recommended for patients during pregnancy
.

It is recommended to stop tocilizumab for 3 months before pregnancy
.

It is recommended to discontinue tocilizumab for unexpected pregnancy who are using tocilizumab
.

■ IL-17 inhibitors: 2.
Small molecule targeted drugs: Small molecule targeted drugs represented by Janus kinase (Janus kinase, JAK) inhibitors (tofacitib, baritinib) have been approved to treat RA , But it is not recommended to use such drugs during pregnancy
.

Women of childbearing age should use effective contraceptive methods when receiving JAK inhibitor treatment and for at least 4 weeks after the end of treatment, and should not use such drugs during breastfeeding
.

For male patients with rheumatism, how to take medicine during the fertility preparation period? The drugs that male rheumatism patients can continue to use during the fertility preparation period include azathioprine, colchicine, hydroxychloroquine and various TNF inhibitors
.

Sulfasalazine may cause reversible sperm deficiency in men.
If pregnancy difficulties occur, the drug should be discontinued 3 months before pregnancy
.

Cyclophosphamide should be discontinued for at least 12 weeks before pregnancy, and thalidomide should be discontinued for at least 4 weeks before pregnancy
.

The safety data of drugs such as methotrexate, leflunomide, mycophenolate mofetil, and a variety of biologically targeted drugs other than TNF inhibitors are limited, and their use is not currently recommended
.

Summary: 1.
Patients with rheumatism need to plan pregnancy under the premise of stable disease, and fully communicate with specialists to jointly decide the treatment plan
.

2.
Female patients with rheumatism need to stop using thalidomide, methotrexate, mycophenolate mofetil, tripterygium wilfordii, cyclophosphamide and leflunomide during pregnancy.
Hormones, hydroxychloroquine, hydroxychloroquine, etc.
Calcineurin inhibitors, azathioprine, sulfasalazine, colchicine, NSAIDs, TNF inhibitors, aspirin, heparin and IVIG
.

3.
Male patients with rheumatism cannot use cyclophosphamide and thalidomide during the fertility preparation period.
Drugs that can continue to be used include azathioprine, colchicine, hydroxychloroquine and TNF inhibitors
.

References: [1] Zhang Wen, Li Yisha, Liu Dongzhou, et al.
Peri-pregnancy drug usage guidelines for patients with rheumatic diseases[J].
Chinese Journal of Internal Medicine,2021,60(11):946-953.
DOI:10.
3760/cma.
j.
cn112138-20210527-00372.
[2]Bandoli G,Palmsten K,Forbess Smith CJ,et al.
A review of systemic corticosteroid use in pregnancy and the risk of select pregnancy and birth outcomes[J].
Rheum Dis Clin North Am ,2017,43(3):489 502.
DOI:10.
1016/j.
rdc.
2017.
04.
013[3]Kroese SJ,de Hair MJH,Limper M,et al.
Hydroxychloroquine use in lupus patients during pregnancy is associated with longer pregnancy duration in preterm births[J].
J Immunol Res,2017,2017:2810202.
DOI:10.
1155/2017/2810202.
[4]Liu E,Liu Z,Zhou Y.
Feasibility of hydroxychloroquine adjuvant therapy in pregnant women with systemic lupus erythematosus[ J].
Biomedical Research,2018,29(5):980 983.
DOI:10.
4066/biomedicalresearch.
29 17 3539.
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