Fast Five Quiz: Rheumatoid Arthritis Management

Herbert S. Diamond, MD; Abhishek Nandan, MD


February 22, 2023

Low-risk treatment options for pregnant patients with RA include SSZ, antimalarial agents, and azathioprine. Low-dose glucocorticoids may be used on an as-needed basis for flares or if there is a lack of control of underlying disease activity with other options.

Due to teratogenic effects and increased risk of miscarriage, LEF and MTX are contraindicated during pregnancy. Moreover, MTX should be discontinued at least 3 months before a patient attempts to conceive, and drug level measurements should be performed. In the case of leflunomide, owing to its very long half-life and persistence of drug metabolites, an even longer washout period of > 6 months prior to planned conception should be considered. The addition of cholestyramine treatment (to accelerate the washout) should be considered if there is insufficient time for a natural washout.

Recommendations on TNF inhibitors and pregnancy have varied historically. In the first study on a modern treatment approach in pregnant patients with RA, low disease activity (LDA) and remission were determined to be an attainable goal during pregnancy. In the cohort studied, nearly half of the patients used a TNF inhibitor at any time during pregnancy, and 90.4% of patients achieved LDA and remission in the third trimester. The use of TNF inhibitors during pregnancy in women with RA has also been associated with increased birth weight and fewer children small for gestational age.

Learn more about managing RA in pregnant patients.


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