Management of common medications for patients with SLE who are considering pregnancy or who are pregnant

Medication^*	Use during pregnancy	Additional considerations
Treatment of SLE
Hydroxychloroquine	Recommended during pregnancy	May reduce the risk of developing neonatal lupus in patients with anti-Ro/SSA and/or anti-La/SSB antibodies Dose adjustment is not needed Consider checking serum levels if available
NSAIDs	Selective use allowed during pregnancy	Used for analgesia only, not for disease control Risk of oligohydramnios when used after 20 weeks of gestation^¶ Avoid use of NSAIDs after 30 weeks of gestation given the risk of premature closure of the ductus arteriosus
Immunosuppressive medications
Glucocorticoids	Selective use allowed during pregnancy	Fluorinated glucocorticoids (eg, dexamethasone) are typically avoided as they are more likely to cross the placenta compared with nonfluorinated formulations (eg, prednisone) When used as maintenance therapy for SLE, glucocorticoids should be given at the lowest possible dose (ideally less than 10 mg/day of prednisone or the equivalent) When used for SLE flares during pregnancy, higher doses may be required^Δ If patients who are on chronic glucocorticoids require a cesarean section, stress dose steroids may be required^◊
Azathioprine	Selective use allowed during pregnancy	Azathioprine doses should not exceed 2 to 3 mg/kg/day^§ Dose adjustment is not needed
Sulfasalazine	Selective use allowed during pregnancy	Used for arthritis Sulfasalazine should be taken with folic acid (eg, 1 mg a day) Dose adjustment is not needed
Cyclosporine	Selective use allowed during pregnancy	Closely monitor maternal blood pressure and kidney function Use the lowest effective dose
Tacrolimus	Selective use allowed during pregnancy	Used for lupus nephritis
Mycophenolate mofetil	Contraindicated in pregnancy	Patients who are taking mycophenolate and who are interested in becoming pregnant should transition to alternative therapy 4 to 6 months prior to conception
Methotrexate	Contraindicated in pregnancy	Patients who are taking methotrexate and who are interested in becoming pregnant should transition to alternative therapy 1 to 3 full menstrual cycles prior to conception
Leflunomide	Contraindicated in pregnancy	Patients who are taking leflunomide or who have taken it in the previous 24 months and who are interested in becoming pregnant should have undetectable leflunomide blood levels or do a cholestyramine washout until blood levels are undetectable^¥
Selected biologics: Belimumab, rituximab^‡	Selective use with caution in pregnancy	May be continued through conception If there are no safe alternative therapies, continued use during pregnancy may be preferable to a flare of SLE
Cyclophosphamide	Contraindicated in pregnancy	Highest risk of teratogenicity when used during first trimester In life-threatening situations, may be used for severe SLE flares in late pregnancy
Treatment of hypertension
Labetalol, nifedipine, hydralazine, and methyldopa	Selective use allowed during pregnancy	Preferred antihypertensive choices in pregnancy based on established fetal safety profile
Thiazide diuretics	Selective use allowed during pregnancy	May be continued in patients who are using them prior to pregnancy During pregnancy, may be useful in hypertension due to volume overload (eg, related to chronic kidney disease); otherwise, are only used if other antihypertensives are insufficient
Nitroprusside	Selective use allowed during pregnancy	May be used as a last resort for urgent control of refractory severe hypertension in pregnant patients with SLE
ACE inhibitors and ARBs	Contraindicated in pregnancy	ACE inhibitors and ARBs should be discontinued in patients planning pregnancy and switched to another antihypertensive allowed during pregnancy
Treatment of APS
Warfarin	Contraindicated in pregnancy	Patients with SLE who are taking warfarin for comorbid antiphospholipid antibody syndrome are typically transitioned to therapeutically dosed low molecular weight heparin in the first trimester^†
Prevention of preeclampsia
Low-dose aspirin	Recommended during pregnancy	Typically given between 12 and 36 weeks of gestation^**

To be used with UpToDate content on pregnancy in women with systemic lupus erythematosus and safety of rheumatic disease medication use during pregnancy and lactation.

ACE: angiotensin-converting enzyme; APS: antiphospholipid antibody syndrome; ARB: angiotensin II receptor blocker; NSAIDs: nonsteroidal antiinflammatory drugs; SLE: systemic lupus erythematosus.

* For information on drug dosing and monitoring, refer to UpToDate content on the safety of rheumatic disease medication use during pregnancy and lactation.

¶ NSAIDs are typically avoided after 20 weeks gestation. If used between 20 to 30 weeks of gestation (eg, for a selected patient without an appropriate alternative), we use the lowest dose and shortest duration possible with monitoring of amniotic fluid levels.

Δ For more information on dosing glucocorticoids for flares of SLE during pregnancy, refer to UpToDate content on pregnancy in women with SLE.

◊ For more information on who may require stress-dose steroids, refer to UpToDate content on the management of the surgical patient taking glucocorticoids.

§ For information on screening for thiopurine S-methyltransferase (TPMT) deficiency prior to starting azathioprine, refer to UpToDate content on the use of azathioprine in rheumatic diseases.

¥ For more information on the leflunomide washout, refer to UpToDate content on the pharmacology, dosing, and adverse effects of leflunomide in the treatment of rheumatoid arthritis as well as the UpToDate Lexidrug leflunomide monograph.

‡ On a case-by-case basis, other biologics can sometimes be used during the first trimester after consultation with a specialist.

† For more information on management of anticoagulation, refer to UpToDate content on the obstetrical implications and management of antiphospholipid antibody syndrome during pregnancy.

** Low-dose aspirin is defined as 81 to 162 mg a day. For more information on the optimal duration of aspirin prophylaxis, refer to UpToDate content on pregnancy in women with SLE.

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Management of common medications for patients with SLE who are considering pregnancy or who are pregnant