Immune Modulating Therapies in Pregnancy and Lactation

Because autoimmune conditions occur more often among women of childbearing age, continuation of these medications during pregnancy is often considered to optimize disease management in the woman and pregnancy outcomes, without placing the fetus at undue risk. Many commonly prescribed drugs can be used safely during pregnancy, without risk of teratogenicity or pregnancy complications, whereas a few are strictly contraindicated. The decision to use any agent during pregnancy should be based on the clinical context, risks associated with individual medications, and gestational age. For immunomodulators considered appropriate to use during pregnancy, the common clinical practice of stopping use at approximately 32 weeks of gestation because of theoretic concerns regarding the immune system of the fetus is not supported by currently available data. Low-risk medications typically are continued in pregnancy, or initiated during pregnancy as needed, because the benefits of therapy and disease control far outweigh any theoretic risks associated with the medication. Use or initiation of medications with intermediate risk or little or no data during pregnancy or lactation (or both) should be individualized. High-risk medications are typically not continued or initiated in pregnancy. However, it is critical that counseling occur, ideally in the prepregnancy and interpregnancy periods, to review the individual risks and benefits as they relate to disease management and pregnancy-associated risks with high-risk medication. There may be select circumstances when continued treatment is the safest option. In general, immunomodulating drugs that are not contraindicated in pregnancy are compatible with breastfeeding.