Tips for Managing Autoimmune Disease During Pregnancy

Drug Topics JournalDrug Topics February 2022
Volume 166
Issue 02

Managing autoimmune conditions like type 1 diabetes, rheumatoid arthritis, and lupus during pregnancy can present challenges for patients and physicians.

The most valuable advice pharmacists can give to women with autoimmune conditions who want to get pregnant is simple: Participate in preconception planning.

Beyond that general advice, understanding a woman’s “head-to-toe” health is important, explained Susan Lanni, MD, a professor in the Division of Maternal-Fetal medicine at Virginia Commonwealth University (VCU) School of Medicine’s Department of Obstetrics and Gynecology. Women with type 1 diabetes (T1D), for example, might have another autoimmune condition present, she explained.

Conditions such as a history of heart attack; underlying vascular disease, nephropathy, or retinopathy; or other autoimmune disorders can make the care of a woman with T1D more complex, said Lanni, who is also a women’s health provider at VCU Health in Richmond, Virginia.

It makes a big difference if a woman’s T1D is well managed, and the general rule with such patients is “no alteration whatsoever,” Lanni said. The only reason to change the woman’s insulin is to get her blood sugar level under control, she added, noting that surveillance for vascular disease is also important if the woman’s condition isn’t well managed.

For other autoimmune diseases, study results have shown that hydroxychloroquine, sulfasalazine, and azathioprine are safe for pregnant women, said Mary Temple-Cooper, PharmD, MS, BCPS, a clinical coordinator at Cleveland Clinic’s Hillcrest Hospital in Ohio who specializes in obstetrics. It is safe to use azathioprine in pregnant women who have rheumatoid arthritis (RA) or lupus, she said, but dosage is important: Try to maintain it at 2 mg/kg per day or less.

Hydroxychloroquine can be prescribed safely in pregnancy to treat RA, lupus, and other autoimmune diseases.1 Sulfasalazine, a disease-modifying antirheumatic drug, is used to treat RA, inflammatory bowel disease, and other autoimmune conditions.2

OTC treatments like nonsteroidal anti-inflammatory drugs may cause the fetus to experience kidney problems, which can result in low levels of the amniotic fluid that supports the development of their lungs, digestive system, and muscles.3 According to Temple-Cooper, other treatments to steer clear of include methotrexate, which can take 4 months to clear from the body, and mycophenolate mofetil, which a woman should stop taking a minimum of 4 weeks before conception.

Methotrexate can result in miscarriage or birth defects affecting the brain and bones,4 while mycophenolate mofetil can cause miscarriage and have teratogenic effects.5 During the first 3 to 5 weeks of pregnancy, teratogens can lead to neural tube defects, such as spina bifida.6

For those prescribed steroids, appropriate use of those treatments is another consideration. “Many women [with autoimmune disease] will have major flares during pregnancy. The goal is to get them treated,” said Temple-Cooper. “You may have to use a high-dose steroid for the shortest possible [time] and then get them on the lowest dose possible to control them. What [we] find is that if you don’t keep [women] controlled, the outcomes are usually a lot worse if you pull them off the steroids.”


  1. Hydroxychloroquine (Plaquenil). American College of Rheumatology. Updated April 2020. Accessed January 14, 2022.
  2. Sulfasalazine (Azulfidine). American College of Rheumatology. Updated December 2020. Accessed January 14, 2022.
  3. FDA recommends avoiding use of NSAIDs in pregnancy at 20 weeks or later because they can result in low amniotic fluid. FDA. Reviewed November 3, 2020. Accessed January 14, 2022.
  4. Rheumatoid arthritis medications: dangerous during pregnancy? Mayo Clinic. April 4, 2020. Accessed January 14, 2022.
  5. Coscia LA, Armenti DP, King RW, Sifontis NM, Constantinescu S, Moritz MJ. Update on the teratogenicity of maternal mycophenolate mofetil. J Pediatr Genet. 2015;4(2):42-55. doi:10.1055/s-0035-1556743
  6. Medical genetics: teratogens. Stanford Children’s Health. Accessed January 14, 2022.
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