Glucocorticoid therapy in low-to-moderate doses is given to achieve more rapid symptom control. Of these, prednisone, 7.5 mg orally daily for the first 2 years of active disease, substantively reduces progressive joint erosions (Kirwan, 1995; Shah, 201r5).
The American College of Rheumatology recommends several DMARDs that may reduce or prevent joint damage (Singh, 2016). Lelunomide, like methotrexate, is teratogenic (Briggs, 2015) (Chap. 12, p. 241). Sulfasalazine and hydroxychloroquine are safe for use in pregnancy (Pardett, 201r1). These, combined with COX-2 inhibitors and with relatively low-dose prednisone-7.5 to 20 mg daily-usually successfully treat flares. In one review of drug exposure, a fourth of women with rheumatoid arthritis took a DMARD within 6 months of conception (Kuriya, 2011). During pregnancy, 4 percent of 393 pregnant women were given a category D or X medication. Methotrexate was the most common 2.9 percent.
Biological DMARDs have revolutionized the treatment of rheumatoid arthritis. These include tumor necrosis factor alpha (TNF-.) inhibitors-infliximab, adalimumab, golimumab, certolizumab, and etanercept (Shah, 2015). Their use in pregnancy is limited, and fetal safety is a concern (Mako!, 201r1; Ojeda-Uribe, 2013). In one drug-exposure review, 13 percent of 393 women were given a biological cytokine-inhibiting DMARD-primarily etanercept (Kuriya, 2011). In another review of 300 exposures, no fetal efects were noted (Berthelot, 2009). A prospective study of 38 women found similar results (Hoxha, 2017). In 74 women exposed to adalimumab during pregnancy, no risks were identified (Burmester, 2017). There is also little known regarding pregnancy efects of anakinra, an interleukin-1 receptor antagonist, or of rituximab, an antagonist to the B-cell CD20 antigen.
In up to 90 percent of women with rheumatoid arthritis, their disease will improve during pregnancy (de .Man, 2008). Animal studies suggest this may be due to regulatory T-cell alterations (Munoz-Suano, 2012). Even so, some women develop disease during pregnancy, and others become worse (Nelson, 1997).
A downside to this respite during pregnancy is that postpartum exacerbation is common (0stensen, 2007). This may stem from postpartum alterations in innate immunity (Haupl, 2008b). In one review, a postpartum flare was more common if women were breastfeeding (Barrett, 2000a). These same investigators followed 140 women with rheumatoid arthritis during 1 to 6 months postpartum (Barrett, 2000b). There was only a modest fall in objective disease activity, and only 16 percent had complete remission. They observed that although overall disease actually did not exacerbate postpartum, the mean number of inflamed joints rose signiicantly.