The guideline working group considered the evidence supporting the use of corticosteroids, disease modifying drugs, biologics and other drugs alongside their own experience. The prescribing of many drugs in pregnancy is complicated by a lack of knowledge regarding their compatibility leading to patient misinformation and withdrawal/denial of disease-ameliorating therapies. LactMed describes paracetamol as a good choice for analgesia and fever reduction in breastfeeding mothers (LOE 4, GOR D, SOA 100%). All non-selective NSAIDs except LDA should be withdrawn at gestational week 32 to avoid premature closure of the ductus arteriosus (LOE 4, GOR D, SOA 100%). Khamashta I.G. Funding : No specific funding was received from any funding bodies in the public, commercial or not-for-profit sectors to carry out the work described in this article. Recommendations for corticosteroids in pregnancy and breastfeeding. d Insufficient evidence regarding use for treatment of chronic pain in pregnancy. et al.  has received individual support to attend a meeting from Roche. Implementing guidelines Pregnancy and rheumatic diseases: best practice and prescribing considerations. Mothers on CSA should not be discouraged from breastfeeding (LOE 3, GOR D, SOA 100%). Guideline on prescribing drugs in pregnancy and breastfeeding Part 1: standard and biologic disease modifying anti-rheumatic drugs and corticosteroids. Prednisolone is compatible with paternal exposure (LOE 2+, GOR D, SOA 98.9%). For further information and caveats, see relevant recommendations and main text in executive summary and full guideline. Rivaroxaban and dabigatran cannot be recommended in pregnancy or breastfeeding due to a lack of human data and concerns from animal studies (LOE 4, GOR D, SOA 100%). Therefore, unintentional RTX exposure early in the first trimester is unlikely to be harmful (LOE 2−, GOR D, SOA 97.9%). These findings are summarized in Table 1 . Updated 16 December You can find our COVID-19 guidance below. e Only consider in severe or life-/organ-threatening maternal disease. et al. Based on limited evidence IFX, ETA and ADA are compatible with paternal exposure (LOE 2−, GOR D, SOA 98.9%). S Biologic therapies are not without potential risk, and hence it is imp… has received educational support from Daiichi Sankyo. Based on limited evidence, LEF may not be a human teratogen but it is still not recommended in women planning pregnancy (LOE 2+, GOR C, SOA 100%). MTX at any dose should be avoided in pregnancy and stopped 3 months in advance of conception (LOE 2−, GOR D, SOA 100%). Caution is advised with the use of codeine in breastfeeding due to the risk of CNS depression resulting from unpredictable metabolism of codeine to morphine (LOE 2+, GOR D, SOA 98.4%). There are no data relating to paternal exposure to amitriptyline, but due to maternal compatibility, it is unlikely to be harmful (LOE 4, GOR D, SOA 98.4%). has received individual support to attend meetings from GlaxoSmithKline, UCB and Astra-Zeneca, chairing fees from Bristol-Myers Squibb and honoraria from GlaxoSmithKline/Human Genome Sciences, Medimmune, INOVA Diagnostics and Merck. M.N. The human breast may selectively restrict the passage of captopril and/or enalapril from blood into breast milk, so it is unlikely to cause adverse effects in breastfed infants (LOE 3, GOR D, SOA 98.9%). To provide evidence-based recommendations, which do not imply a legal obligation, for clinicians to follow when prescribing drugs commonly used in the management of multisystem rheumatic conditions before/during pregnancy and breastfeeding, updating previous recommendations [ 2 , 3 ]. Target audience Health professionals directly involved in managing patients with rheumatic disease in the UK who are or are planning to become pregnant and/or breastfeeding, men … British Association of Dermatologists guidelines for biologic therapy for psoriasis 2017 5 et al. There are no data relating to paternal exposure to codeine, but due to maternal compatibility, it is unlikely to be harmful (LOE 4, GOR D, SOA 98.9%). Lockshin All others have declared no conflicts of interest. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide, This PDF is available to Subscribers Only. A description of evidence and full recommendations are given in the full guideline provided as supplementary data , available at Rheumatology Online. Lockshin has received unit and individual support to attend meetings from UCB and Jansen UK and participated on an expert panel for UCB. Flint Hurrell M.G. "BSR and BHPR guideline on prescribing drugs in pregnancy and breastfeeding-Part I: standard and biologic disease modifying anti-rheumatic drugs and corticosteroids". This situation should be avoided because active rheumatic disease is associated with adverse pregnancy outcomes [ 1 ] and there is growing evidence of drug safety in pregnancy. Hurrell Therapy: A fine conception -- BSR/BHPR guidelines on drugs in pregnancy. Limited evidence supports the use of prostacyclines to treat PHT during pregnancy (LOE 3, GOR D, SOA 99.5%). • The 2012 BSR and BHPR guideline for the treatment of psoriatic arthritis with biologics20 • The 2016 BSR and BHPR guideline in prescribing drugs in pregnancy and breastfeeding21. Østensen They should be essential in everyday clinical decision making. There are no data relating to paternal exposure to anakinra, but it is unlikely to be harmful (LOE 4, GOR D, SOA 98.9%). M et al. There are no data relating to breastfeeding or paternal exposure to pulmonary vasodilators on which to base a recommendation (SOA 100%). Certolizumab pegol is compatible with all three trimesters of pregnancy and has reduced placental transfer compared with other TNF inhibitors (TNFis) (LOE 2−, GOR D, SOA 97.9%). The British Society of Rheumatology (BSR) has released guidelines … 2017 Jun 1;56(6):865-868. doi: 10.1093/rheumatology/kew479. Julia Flint, Sonia Panchal, Alice Hurrell, Maud van de Venne, Mary Gayed, Karen Schreiber, Subha Arthanari, Joel Cunningham, Lucy Flanders, Louise Moore, Amy Crossley, Neetha Purushotham, Amisha Desai, Madeleine Piper, Mohamed Nisar, Munther Khamashta, David Williams, Caroline Gordon, Ian Giles, on behalf of the BSR and BHPR Standards, Guidelines and Audit Working Group, BSR and BHPR guideline on prescribing drugs in pregnancy and breastfeeding—Part II: analgesics and other drugs used in rheumatology practice, Rheumatology, Volume 55, Issue 9, September 2016, Pages 1698–1702, https://doi.org/10.1093/rheumatology/kev405. on behalf of the BSR and BHPR Standards, Guidelines and Audit Working Group (2016). This guideline does not cover the management of infertility; acute pain relief during labour, hence morphine was excluded; or the indications for these drugs in specific rheumatic diseases in pregnancy. L.M. BSR and BHPR guideline for the prescription and monitoring of non-biologic disease-modifying anti-rheumatic drugs Rheumatology (Oxford). Men taking SSZ may have reduced fertility. Warfarin is compatible with breastfeeding (LOE 1−, GOR B, SOA 100%). BSR and BHPR guideline on prescribing drugs in pregnancy and breastfeeding-Part II: analgesics and other drugs used in rheumatology practice Read time: 1 mins Last updated: 2nd Mar 2016 Paracetamol is compatible peri-conception and throughout pregnancy [level of evidence (LOE) 2+, grade of recommendation (GOR) C, strength of agreement (SOA) 100%]. Panchal Therefore, these drugs should be used with caution in the first trimester of pregnancy (LOE 1−, GOR B, SOA 99.5%). For recommendations on prescribing anti-rheumatic drugs in pregnancy and breastfeeding, see the BSR and BHPR guideline part I [ 4 ]. For full access to this pdf, sign in to an existing account, or purchase an annual subscription. Part 2 of this guideline considers pain manage-BSR and BHPR guideline on prescribing drugs in pregnancy … Nifedipine is compatible with breastfeeding (LOE 3, GOR D, SOA 100%). There are no data relating to paternal exposure to ABA, but it is unlikely to be harmful (LOE 4, GOR D, SOA 98.9%). guideline, part 1, considers antimalarials, corticosteroids, DMARDs and immunosuppressive therapies and bio-logics. Dose increases should be monitored by FBC, creatinine/calculated GFR, ALT and/or AST and albumin every 2 weeks until on stable dose for 6 weeks then revert to previous schedule (GRADE 2B, 97%). BSR and BHPR guideline on prescribing drugs in pregnancy and breastfeeding-Part I: standard and biologic disease modifying anti-rheumatic drugs and corticosteroids. HCQ remains the antimalarial of choice in women planning a pregnancy with rheumatic disease in need of treatment and should be continued during pregnancy (LOE 1 ++, GOR A, SOA 100%). et al.  c Limited evidence, but unlikely to be harmful. has received unit and individual support to attend meetings from UCB and Jansen UK and participated on an expert panel for UCB. Should it be stopped pre-conception? Methylprednisolone has rates of placental transfer similar to prednisolone with equivalent anti-inflammatory effects at 80% of prednisolone dose and would therefore be expected to be compatible with pregnancy, breastfeeding and paternal exposure (LOE 4, GOR D, SOA 93.7%). Limited evidence supports the use of sildenafil to treat PHT during pregnancy (LOE 3, GOR D, SOA 99.5%). . There is no consensus on best practices for drug management during pregnancy by rheumatologists. Based on limited evidence, low-dose MTX may be compatible with paternal exposure (LOE 2+, GOR D, SOA 95.8%). Summary of drug compatibility in pregnancy and breastfeeding. has received unit support from AbbVie, MSD, Roche, Bristol-Myers Squibb and Sobi, participated on advisory boards for Pfizer and received fees for participation in an educational meeting by UCB. Low-dose amitriptyline for chronic pain is unlikely to cause adverse effects in breastfed infants (LOE 4, GOR D, SOA 98.4%). Andreoli has received individual support to attend meetings from GlaxoSmithKline, UCB and Astra-Zeneca, chairing fees from Bristol-Myers Squibb and honoraria from GlaxoSmithKline/Human Genome Sciences, MedImmune, INOVA Diagnostics and Merck. IVIG is compatible with pregnancy (LOE 1 ++, GOR A, SOA 100%). Read all of BSR's resources on rheumatology and COVID-19. There is limited evidence on the use of ACEIs in breastfeeding. supplementary data C.G. Staging pregnancy-related acute kidney injury according to Kidney Disease: Improving Global Outcomes guidelines: what are the barriers? There are insufficient data on which to base a recommendation regarding paternal exposure to ACEIs, but there are no theoretical concerns (LOE 4, GOR D, SOA 100%). Based on limited data, tramadol may be compatible with short-term use in breastfeeding (LOE 2−, GOR D, SOA 97.9%). Østensen There is insufficient evidence to recommend venlafaxine for the treatment of chronic pain in breastfeeding women (LOE 4, GOR D, SOA 98.9%). e Possible association with miscarriage and malformation. There may be an increased risk of neonatal abstinence syndrome/short-term behavioural effects, but larger studies are needed to evaluate this finding (LOE 2+, GOR C, SOA 98.9%). d Suggested monitoring of maternal blood pressure, renal function, blood glucose and drug levels. Oxford University Press is a department of the University of Oxford. Low molecular weight heparin is compatible throughout pregnancy (LOE 1 ++, GOR A, SOA 100%). L Østensen Codeine is compatible peri-conception and throughout pregnancy. MTX cannot be recommended in breastfeeding because of theoretical risks and insufficient outcome data (LOE 4, GOR D, SOA 100%). Actual Guidelines You must be logged in to access this page Click here to login has undertaken consultancies and received honoraria from Bristol-Myers Squibb, GlaxoSmithKline, MedImmune, Merck Serono and UCB, has been a member of the speakers’ bureau for GlaxoSmithKline, UCB and Lilly and has received research grant support from UCB, but none of these activities have been related to the use of any specific drug in pregnancy. Pulmonary hypertension (PHT) remains a contraindication for pregnancy. There are no data relating to the use of LDA during breastfeeding or paternal exposure to LDA, but there are no theoretical concerns (LOE 4, GOR D, SOA 98.9%). BSR and BHPR guideline on prescribing drugs in pregnancy and breastfeeding-Part II: analgesics and other drugs used in rheumatology practice. Fortunately, the British Society for Rheumatology (BSR) guidelines and European League Against Rheumatism (EULAR) recommendations concerning prescribing anti-rheumatic drugs in pregnancy were published in 2016. L.M. C.G. At present, there are limited data on selective COX-2 inhibitors; they should therefore be avoided during pregnancy (LOE 2+, GOR D, SOA 98.9%). M Publikation: Bidrag til tidsskrift › Tidsskriftartikel › Forskning › peer review There are no data on paternal exposure to paracetamol, but due to maternal compatibility, it is unlikely to be harmful (LOE 4, GOR D, SOA 99.5%). Discordant findings from retrospective, large studies with population controls on the use of non-selective NSAIDs in the first trimester of pregnancy raise the possibility of a low risk of miscarriage and malformation. In contrast to conventional systemic DMARDs (csDMARDs) traditionally used to treat inflammatory disease, these agents offer a targeted approach, and their widespread use has resulted in disease remission becoming an increasingly achievable goal. M M a Intermittent use advised, see main text for details. There are no data relating to paternal exposure to serotonin and norepinephrine reuptake inhibitors, but due to maternal compatibility, they are unlikely to be harmful (LOE 4, GOR D, SOA 98.9%). There are no data relating to paternal exposure to BEL, but it is unlikely to be harmful (LOE 4, GOR D, SOA 98.9%). There are no data relating to paternal exposure to calcium channel blockers, but they are unlikely to cause harm (LOE4, GOR D, SOA 98.9%). f Unintentional first trimester exposure is unlikely to be harmful. For Permissions, please email: journals.permissions@oup.com. The BSR issued guidelines for the treatment of adult psoriatic arthritis with biologic agents (particularly anti-TNF therapy). S ACEI: angiotensin-converting enzyme inhibitor; COX: cyclooxygenase; LMWH: low molecular weight heparin; MDT: multidisciplinary team. Julia Flint, Sonia Panchal, Alice Hurrell, Maud van de Venne, Mary Gayed, Karen Schreiber, Subha Arthanari, Joel Cunningham, Lucy Flanders, Louise Moore, Amy Crossley, Neetha Purushotham, Amisha Desai, Madeleine Piper, Mohamed Nisar, Munther Khamashta, David Williams, Caroline Gordon, Ian Giles, on behalf of the BSR and BHPR Standards, Guidelines and Audit Working Group, BSR and BHPR guideline on prescribing drugs in pregnancy and breastfeeding—Part I: standard and biologic disease modifying anti-rheumatic drugs and corticosteroids, Rheumatology, Volume 55, Issue 9, September 2016, Pages 1693–1697, https://doi.org/10.1093/rheumatology/kev404. Paternal exposure to CYC is not recommended (LOE 4, GOR D, SOA 98.4%). 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