Treatment for rheumatoid arthritis during pregnancy and lactation

―Balancing women’s life events and treatment―

Abstract

Rheumatoid arthritis （RA） is an autoimmune disease characterized by polyarthritis, which is prevalent in women of childbearing age. Recent advances in therapeutic agents have made it possible to achieve early remission of the disease and the treatment aims to maintain remission while preserving the patient’s quality of life. Thus, if a young female patient desires to become pregnant, it is essential to continue treatment with drugs that allow pregnancy and lactation. First, the mutual effects of rheumatoid arthritis and pregnancy must be identified. The high disease activity decreases fertility and increases the risk of obstetric complications. While it was believed that RA generally improves with pregnancy, it has been demonstrated that improvement during pregnancy is inhibited if the patient becomes pregnant while in a state of high disease activity. Thus, to prevent joint destruction and enable a good pregnancy outcome, it is important to conceive while RA is stable and to stabilize the RA activity during pregnancy. The use of MTX （methotrexate）, the anchor drug for RA, is contraindicated during pregnancy and lactation, requiring the withdrawal of at least one menstrual cycle before pregnancy. If arthritis flares up or is predicted to flare up after discontinuation of MTX, suitable intervention with medications that are known to have a high safety profile is recommended. Therefore, use of medications during pregnancy and lactation can be very uncomfortable for the patient; hence, it is essential to offer an adequate explanation and obtain consent for treatment. To achieve the best result in complicated pregnancies, it is crucial to provide preconception care and planned pregnancy prior to conception, in addition to intensive care with other departments and multidisciplinary care during the pregnancy and the postpartum period.