From Contraception to Breastfeeding: Experts Address Reproductive Health & Medication Management

Non-TNF biologics (e.g., anakinra, belimumab, abatacept, tocilizumab, secukinumab, ustekinumab) should be discontinued during pregnancy due to limited safety data. However, due to their large molecular size, these medications result in minimal transfer to breastmilk and are compatible with breastfeeding.

“Because IgG placental transfer only begins at 16 weeks of gestation, TNF inhibitors can be used safely through the end of the second trimester,” Dr. Sammaritano explained. “These are often discontinued at 30 weeks, when transfer significantly increases—except certolizumab.”

If needed, these medications can be continued throughout the pregnancy, with consideration of the risk of neonatal immunosuppression. 

In another example, she emphasized that the most effective form of contraception for all rheumatic disease patients is long-acting reversible contraception, such as an IUD or progestin implant. Estrogen-containing contraception must be avoided in patients with aPL positivity and/or very active lupus. Additionally, depot-medroxyprogesterone acetate (DPMA or depo) should be avoided in patients who are aPL positive given limited data suggesting an increased risk of thrombosis. Because DMPA also reduces bone mineral density, its use may not be ideal in patients who have risk factors for osteoporosis.

Question & Answer

During the question-and-answer session, clinical dilemmas were discussed that often have absence of rigorous evidence to guide practice. For instance, the precise dosing of hydroxychloroquine in pregnant patients who are SSA/SSB positive and necessary frequency of fetal echocardiogram monitoring in these patients is unknown.

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Mithu Maheswaranathan, MD, completed his fellowship in rheumatology at Duke University in Durham, N.C., where he is currently a clinical instructor in the Division of Rheumatology and Immunology. He can be contacted on Twitter (@MithuRheum).

Reference

1. Sammaritano LR, Bermas BL, Chakravarty EE, et al. 2020 American College of Rheumatology Guideline for the Management of Reproductive Health in Rheumatic and Musculoskeletal Diseases. Arthritis Rheumatol. 2020 Apr;72(4):529–556. Epub 2020 Feb 23.