August 11, 2022

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Drugs for systemic lupus erythematosus during pregnancy

 

Drugs for systemic lupus erythematosus during pregnancy.

Pay attention to disease control during pregnancy in SLE patients, and it is extremely important to clarify the safety of anti-SLE drugs during pregnancy.

 

 

Drugs for systemic lupus erythematosus during pregnancy

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The diagnosis and treatment of patients with systemic lupuserythematosus (SLE) during pregnancy has always been a challenge for clinicians, and the diagnosis and treatment are complicated.

Pregnancy can increase the disease activity of systemic lupus erythematosus (SLE) and the recurrence of mild to moderate disease, mainly manifested by the involvement of the skin, joints and blood system.

 

Lupus nephritis (LN) and antiphospholipid antibodies (APL) are risk factors for pregnancy-induced hypertension and preeclampsia, which may lead to adverse pregnancy outcomes such as miscarriage, stillbirth, and preterm delivery.

APL and LN are also associated with low birth weight and fetal intrauterine dysplasia. Fetal congenital heart block (CHB) is another complication of SLE pregnancy, the incidence is about 2%-4.5%, and it is related to anti-SSA/SSB antibodies.

 

Active SLE is associated with poor pregnancy outcomes. It is very important to pay attention to disease control in SLE patients during pregnancy and to clarify the safety of anti-SLE drugs during pregnancy.

The 2016 British Society for Rheu matology (BSR)/British Health Professionals in Rheumatology (BHPR) guidelines recommend medication:

 

 

1. Hydroxychloroquine (HCQ):

Hydroxychloroquine is one of the therapeutic drugs of choice for pregnant women with rheumatism who plan to become pregnant.

Hydroxychloroquine has been proven to improve pregnancy outcomes, and may play a role in preventing preeclampsia and cardiac neonatal SLE.

It is absolutely safe to use during pregnancy. If the patient with SLE is already taking hydroxychloroquine, it is recommended to continue taking it during pregnancy.

If it is not taking hydroxychloroquine, it is recommended to start taking it if there are no contraindications. Fundus examinations are performed before and after the medication, and the fundus should be reviewed every 6-12 months thereafter.

 

 

2. Glucocorticoids:

Glucocorticoid is currently the main drug for the treatment of pregnancy complicated with systemic lupus erythematosus.

Prednisone is a commonly used clinical glucocorticoid. The drug has anti-inflammatory, anti-allergic, non-specific immune suppression, anti-shock and other effects, and can improve immune abnormalities.

And the condition of systemic lupus erythematosus, thereby improving pregnancy outcome.

At present, related studies have proposed that prednisone can be inactivated by the placenta when the dose is less than 15 mg/d, and the drug is safe, and the adverse reaction is small when the short-term dose is less than 30 mg/d.

Fluoride-containing glucocorticoids such as dexamethasone and betamethasone can penetrate the placenta and affect the growth and development of the fetus.

It is not recommended to use it, but dexamethasone can be used in late pregnancy to promote fetal lung maturity.

When there is moderate or severe disease activity, on the basis of using hydroxychloroquine, the dose of hormone can be increased, usually prednisone 0.5~1mg (kg.d) or combined immunosuppressant.

Hormones can increase the risk of gestational diabetes, high blood pressure and infection, so long-term high-dose use is not recommended, and the dose should be reduced to prednisone ≤ 15 mg/d as soon as possible.

 

 

3. Other anti-rheumatic drugs:

According to the 2016 BSR/BHPR guidelines, anti-rheumatic drugs that can be used during pregnancy to improve the condition include azathioprine, cyclosporine, and tacrolimus.

The dose of azathioprine that can be used throughout pregnancy should not exceed 2 mg/ (kgd), cyclosporine and tacrolimus should be used at the lowest effective dose, while other antirheumatic drugs such as cyclophosphamide, mycophenolate mofetil, leflunomide, and methotrexate are prohibited during pregnancy of.

When the kidneys are involved, especially type V LN, cyclosporine can be used at a dose of 3~5mg/(kg.d), orally in 2 doses.

During the medication, the liver and kidney function and blood pressure are checked regularly. It can be used throughout pregnancy. Rheumatology and immunology doctor consultation to confirm.

For severe SLE, high-dose methylprednisolone shock therapy and intravenous injection of high-dose human immunoglobulin can be used.

If the condition is critical and endangers the mother’s safety, the pregnancy should be terminated as soon as possible.

 

 

4. Biological agents:

The biological agent approved for the treatment of SLE is belimus monoclonal antibody, but there are currently few data on its safety during pregnancy.

Unless the benefit is greater than the potential risk, it is recommended to stop using it before pregnancy [11].

For anti-CD20 monoclonal antibodies such as rituximab, it is best to stop using them 6 months before conception. Rituxan monoclonal antibody is still an off-indication application in SLE.

For severe lupus nephritis, blood system involvement and neuropsychiatric lupus, Rituxan monoclonal antibody can be used as a second-line drug.

Only in severe hemolytic anemia and immune thrombocytopenia, rituximab monoclonal antibody can be considered as a first-line treatment.

 

 

 

5. Breastfeeding treatment

In 2016, EULAR recommended low-dose prednisone, hydroxychloroquine, non-steroidal anti-inflammatory drugs, azathioprine, cyclosporine, and tacrolimus for SLE patients who can breastfeed, while using methotrexate, cyclosporine Breastfeeding is not recommended for patients with phosphoramide, mycophenolate mofetil, and leflunomide.

 

 

6. Other treatments:

SLE patients are a high-risk population with preeclampsia during pregnancy. Aspirin (75-100mg/d) and calcium supplementation (at least 1g/d) in the middle and early stages can reduce the risk of preeclampsia.

The use of cyclosporine and high-dose cortisol drugs during pregnancy can increase the risk of preeclampsia. For patients with positive serum aPL or lupus anticoagulant, aspirin can be started in the early pregnancy.

For those with a history of miscarriage in early pregnancy and intrauterine death in the second and third trimesters, combined use of heparin is recommended to reduce the risk of placental thrombosis.

 

 

 

 

Drugs for systemic lupus erythematosus during pregnancy

(source:internet, reference only)


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