Lupus and Pregnancy: Medications

Part of a series of posts dealing with lupus and pregnancy. 
ETA: (No, I am not pregnant)

===============

Medications during pregnancy is such a confusing topic.  A search on the Internet will bring up tons of contradictory information, and doctors will have differing opinions over whether or not a medication is safe.  Part of this confusion is because there are very few studies done on lupus medications and pregnancy.

In 1979, the FDA introduced a classification of fetal risks due to pharmaceuticals.  These categories are:

CATEGORY	INTERPRETATION
A	Adequate, well-controlled studies in pregnant women have not shown an increased risk of fetal abnormalities to the fetus in any trimester of pregnancy.
B	Animal studies have revealed no evidence of harm to the fetus, however, there are no adequate and well-controlled studies in pregnant women. OR Animal studies have shown an adverse effect, but adequate and well-controlled studies in pregnant women have failed to demonstrate a risk to the fetus in any trimester.
C	Animal studies have shown an adverse effect and there are no adequate and well-controlled studies in pregnant women. OR No animal studies have been conducted and there are no adequate and well-controlled studies in pregnant women.
D	Adequate well-controlled or observational studies in pregnant women have demonstrated a risk to the fetus. However, the benefits of therapy may outweigh the potential risk. For example, the drug may be acceptable if needed in a life-threatening situation or serious disease for which safer drugs cannot be used or are ineffective.
X	Adequate well-controlled or observational studies in animals or pregnant women have demonstrated positive evidence of fetal abnormalities or risks. The use of the product is contraindicated in women who are or may become pregnant.

The medications I am currently taking fall into the following categories:

CATEGORY	MEDICATION
A	Levothyroxine (Synthroid)
C	Hydroxychloroquine (Plaquenil) Prednisone Erythropoietin (Procrit)
D	Azathioprine (Imuran)

I think everyone agrees that you need to weigh the risks of a medication against the benefits, but the difficulty is that this can be subjective.  In addition, each patient is different, so each situation must be looked at individually...there is no one-size-fits-all solution.

For my personal situation, the maternal fetal specialist (MFM) I consulted with recommends that I stay on Levothyroxine.  This is the drug that manages my hypothyroidsm.  Not only has the drug been shown to be safe to use during pregnancy, but not taking it could have adverse effects.  Hypothyroidism in the mother has been shown to affect brain development in the fetus and has been linked with developmental delays and lower IQs after a child is born.

MFM also recommends that I stay on Plaquenil.  In her opinion, it is safe for use during pregnancy, and some studies have indicated that it may even have a benefit to the fetus.  Most importantly, it will help to manage the lupus and lessen the chance of a flare, which could lead to further complications and put both baby and mother's health at risk.

I did some additional research online and found a study by Pediatric Rheumatology that concluded "HCQ [hydroxychloroquine] is not associated with any increased risk of congenital defect, spontaneous abortion, fetal death, pre-maturity or decreased numbers of live births in pregnant patients with auto-immune diseases.  Our data demonstrate that HCQ is safe for use during pregnancy."  However, there are still some concerns that there may be some drawbacks if you are considering cord blood blanking since the medication is passed to the fetus through the bloodstream.

MFM said that a low dose (<10 mg) of Prednisone would also be okay for me to stay on if it prevented me from flaring.

The Azathioprine has a risk of causing birth defects, but having a flare would put me and the baby at much higher risk.  Because of that, MFM would be okay with me staying on Azathioprine if it prevented me from flaring.  If I did have to stay on it, we would try to lower the dosage in the last trimester to lower the risk of it affecting the fetus.  Rheumy had originally put me on the Azathioprine to get me off of the Prednisone (which would have negative side effects for me if I relied on it long term), but MFM said that between Prednisone and Azathioprine, she would much rather have me on a low dose of Prednisone while pregnant.

At my appointment with Rheumy this past weekend, we discussed what MFM recommended.  We decided to try to lower my dose of Azathioprine and increase my Prednisone a little to see how my body reacts (We also increased the Prednisone because my WBC count is still low -- 1.5).  I would really like to get off the Azathioprine if possible...not only because I don't like putting drugs into my body, but because I really hate swallowing those pills!  I have a follow-up appointment in 4 weeks...wish me luck!

- a little lupie -

P.S. While doing a Google search for Plaquenil effects on pregnancy, I came across RA (maybe) Mamma's blog.  She has Rheumatoid Arthritis and was dealing with many of the same questions and concerns as I am.  I could relate with a lot of the things she said, so if you're interested in reading more, go check her out!