Posted 11/20/2008 8:33 AM (GMT -7)
The AAP is not up-to-date. There have been clinical studies and years and years of clinical experience by top lupus pregnancy specialists, most notabley at major lupus pregnancy centers at Johns Hopkins and St Thomas' Hospital London. There has been no record of deformiity or any other problems. If these doctors were not perfectly sure they would advise against. The best advice is to be off all meds or on the lowest possible doses of the permitted ones. Lupus pregnancies should be planned along with the treating doctors.
Another reason for wrongly stopping the drug is pregnancy. Hydroxychloroquine is safe in pregnancy and is in routine use in our own lupus pregnancy clinic at St. Thomas' Hospital.
It is our
policy to change preconceptual maternal treatment as
little as possible. We do not add prophylactic prednisolone
to the treatment, since there is no evidence that this lowers
the frequency of flares, and its side effects during
pregnancy are substantial . On the other hand, hydroxychloroquine
has been shown to be safe for the fetus
, and its withdrawal can result in an SLE flare ;
accordingly, we maintain this drug during the whole pregnancy
as required. SLE flares are treated according to
their severity. Rash and arthritis can be managed with
non-steroidal anti-inflammatories, which should be
stopped in late pregnancy due to their interference with
delivery and the risk of premature closure of ductus arteriosus
, as well as with low dose prednisolone (up to
10 mg/day) or hydroxychloroquine.
More serious manifestations, like vasculitis, nephritis
or neuropsychiatric involvement, require higher doses of
prednisolone, pulses of methyl-prednisolone – which we
do not use very often – and the early introduction of
azathioprine to allow a rapid reduction of steroid dosage.
Should this not control disease activity, pregnancy termination
and more aggressive immunosuppressive
treatment is the next step. Cyclophosphamide and methotrexate
are absolutely contraindicated during pregnancy.
Cyclosporine, which is safe during pregnancy, is recommended
by some authors for treating nephritis when
azathioprine has failed. This can be considered in individual
cases with severe but non-life-threatening disease.
Treatment of pregnant women who have APS is directed
towards prevention of miscarriage and thromboprophylaxis.
However, not all patients with APS are at risk of
both complications . Therefore, decisions regarding
treatment mostly depend on previous clinical manifestations.
The two main drugs used during pregnancy in
women with APS are low dose aspirin (75–100 mg/day)
and heparin, since prednisone does not seem to play a
major role in APS [48,49]. Indeed, women treated with
corticosteroids for pregnancy losses experience higher
rates of prematurity, hypertension and diabetes .
Researchers from Johns Hopkins in Baltimore reported that Plaquenil can be safe for pregnant women with lupus.
Dr. Shiel's Perspective: Rheumatologists have been using Plaquenil during pregnancy to sustain remission in patients with lupus for some time now because previous work suggested its safety. In this study, Plaquenil did not impact the rate of live births or preterm births. The author of the study, Dr. Michelle Petri, a world's expert in lupus recommends continuing Plaquenil therapy throughout pregnancy to improve control of lupus activity.
"Certain medicines shouldn't be taken at the time of conception or during pregnancy because they cause birth defects," says Michelle Petri, M.D., M.P.H., professor of medicine at Johns Hopkins University School of Medicine and director of the Hopkins Lupus Center in Baltimore, MD. "These include thalidomide, methotrexate, leflunomide, cyclophosphamide, and mycophenolate mofetil (CellCept). Other medications, such as ACE inhibitors and NSAIDs, are stopped when the pregnancy is confirmed."
Once a woman becomes pregnant, she can continue on certain medications to maintain her own health with minimal risk to the baby. "I usually maintain Plaquenil during pregnancy," says Buyon. "I explain to my patients that Plaquenil passes through the placenta, but the risk of eye or ear toxicity in the baby is quite low, and the risk of flaring up if you stop Plaquenil may be greater. It's a long conversation.
You and your doctor should have the "long conversation" about medications as soon as you decide to conceive. Managing a pregnancy and a chronic illness is a balancing act-and keeping the lines of communication open with your healthcare team is important to maintain your and your baby's health.
Treatment in Pregnancy
High doses of aspirin and non-steroidal anti-inflammatory drugs (NSAIDs) should be avoided during the last few weeks of pregnancy. Hydroxychloroquine (Plaquenil) can be used safely during pregnancy and should not be discontinued since this could lead to disease flares. During pregnancy, prednisone, prednisolone, and methylprednisolone are the corticosteroids of choice because they are only minimally transferred to the placental circulation.