If lupus pregnancy planning and management is a test, here are the answers! Remembering the details can be hard, so pull the information below into your Electronic Medical Record so you can quickly access the facts that you need. Communicating this information to your patient and other providers is also essential for good care. Use the text below in your notes so you can be clear and confident in the information you provide.
***The text is set up to work in EPIC: just make a new dotphrase for each text, give it a name you will remember, and you are ready to get started.
Lupus Pregnancy Planning for Clinic Notes
1. The best way to have the safest pregnancy possible is to maintain good control of lupus with pregnancy compatible medications. ***
2. Current assessment of her lupus activity: ***
· Proteinuria: ***
3. Medications: ***
· Hydroxychloroquine: ***
· Azathioprine: ***
· Prednisone: ***
· Rheumatic Teratogens: ***
4. Physicians to Involve: ***
· See rheumatology at least once per trimester ***
· Maternal-fetal Medicine: ***
· Others: ***
5. Other pregnancy risks:
· Antiphospholipid antibodies: ***
· Ro antibodies: ***
· Blood Pressure: ***
· Pain: ***
Azathioprine use in pregnancy:
I strongly suggest taking azathioprine during pregnancy. Azathioprine does not increase birth defects and can control or prevent lupus activity during pregnancy. Both EULAR and the British Society of Rheumatology consider azathioprine compatible with pregnancy. If azathioprine works to control lupus activity, then women on azathioprine have the same level of pregnancy success as women with lupus not on the drug. On the other hand, if lupus flares on or off azathioprine, the risk of pregnancy loss and preterm birth is high. For this reason, I strongly suggest continuing azathioprine with the goal of minimizing lupus activity and allowing the pregnancy the best chance of success.
Switching Medications prior to Pregnancy:
You are currently taking *** which is a medication that is not considered safe during pregnancy. We will switch to ***, which is considered safe during pregnancy.
Please follow the plan outlined below to safely switch medications:
Month 1 - *** mg of *** and *** mg of ***
Month 2 - *** mg of *** and *** mg of ***
Month 3 - *** mg of *** and *** mg of ***
Please do not get pregnant until we have confirmed that your lupus is stable on the new medications for several months.
Benlysta and Pregnancy Planning:
There is insufficient data to assess the risk of Benlysta to pregnancy success or fetal development. It likely doesn't cross the placenta until week 16, like other antibodies, but likely does cross easily following that point. I don't currently recommend dosing Benlysta intentionally during pregnancy.
We will be switching to ***, which is considered safe during pregnancy.
Medications in Breastfeeding:
Medications considered compatible with breastfeeding:
· Azathioprine (Imuran)
· Cyclosporine (Neoral, Restasis)
· Hydroxychloroquine (Plaquenil)
· Prednisone (if >20mg, delay feeding until 4hrs after dose)
· Tacrolimus (Prograf)
· NSAIDs (ibuprofen is the preferred NSAID)
· Other biologics are likely safe, but with no measured cases.
Medications not considered compatible with breastfeeding:
· Methotrexate (may have limited transfer in the 6 days of the week that it isn’t dosed)
Conception while taking Methotrexate:
When methotrexate is taken during pregnancy the risk of pregnancy loss increases to around 40%. Of the surviving pregnancies, about 7% of babies will have an abnormality. Most, but not all, of these abnormalities can be seen on ultrasound during pregnancy.
Now that you are pregnant:
· Stop methotrexate
· Increase folic acid to 5mg per day and continue through pregnancy
· To control your lupus, start azathioprine ***mg/day. Azathioprine is considered safe in pregnancy and does not increase the risks for birth defects or pregnancy loss.
· Referral to Maternal-Fetal Medicine
This patient needs contraception:
· Her thrombotic risk is *** (high/low). Therefore, she ***(should/should not) use estrogen containing contraceptive options.
· Her lupus activity ***(does/doesn’t) increase her risk for pregnancy complications.
· Her medications ***(may/would not) cause birth defects.
· Lupus is not a contraindication to any IUD, Nexplanon, or other progesterone only contraceptives.
The GO List:
These medications can be used to manage lupus during pregnancy. Both EULAR and the British Society of Rheumatology consider each of these medications compatible with pregnancy
- Azathioprine (Imuran)
- Cyclosporine (Neoral, Restasis)
- Hydroxychloroquine (Plaquenil)
- Prednisone (use sparingly)
- Tacrolimus (Prograf)
The CAUTION List:
These medications are generally stopped before pregnancy as the risk is unknown. They don’t appear to be a major risk but there is limited human data.
The STOP List:
These medications are known to cause birth defects and increase the risk for pregnancy loss. Do not take these medications during pregnancy.
- Leflunomide (remove with cholestyramine)
- Lenalidomide (Revlimid)
- Mycophenolic acid (Myfortic)
- Mycophenolate (CellCept)
- Thalidomide (Thalomid)