Recommendations for the use of DMARDs in pregnancy and reproductive health for patients with rheumatic disease: A scoping review.

Objective: Autoimmune rheumatic diseases commonly affect individuals of childbearing age, with historically increased adverse pregnancy outcomes in this group. The advent of disease-modifying anti-rheumatic drugs (DMARDs) has fostered more suitable conditions for pregnancy; however, this is accompanied by challenges in ensuring safe use in reproductive health. The aim of this review is to compare existing guideline recommendations for the use of DMARDs in pregnancy and reproductive health for patients with rheumatic disease.

Methods: A scoping review was performed with Medline and EMBASE, in addition to a hand search, to identify guidelines published since 2014 by academic societies in rheumatology that addressed management of DMARDs in pregnancy in any of rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis and systemic lupus erythematosus. Conventional synthetic DMARDs (csDMARDS; methotrexate, sulfasalazine, leflunomide, hydroxychloroquine), biologic DMARDs (bDMARDs; adalimumab, etanercept, infliximab, golimumab, certolizumab, abatacept, tocilizumab, rituximab, anakinra) and targeted synthetic DMARDs (tsDMARDs; tofacitinib, baricitinib, upadacitinib) were targeted. Two authors performed data extraction in duplicate.

Results: 18 guidelines were included. Recommendations for DMARD use in pre-conception were present in 10 (56%), lactation in 12 (67%) and male fertility in 6 (33%). 13 (72%) guidelines included recommendations for csDMARDs, 13 (72%) bDMARDs and 5 (28%) tsDMARDs. There was moderate evidence supporting relatively uniform csDMARD recommendations, compared to minimal evidence for b/tsDMARD use with variable recommendations.

Conclusions: There is heterogeneity in formulation of guidelines on the use of DMARDs in pregnancy. Recommendations for csDMARDs were similar between guidelines. There was significant variability in recommendations for b/tsDMARD use, reflecting current minimal literature in this area.