The Voting Panel declined to vote on the compatibility of new small‐molecule agents regarding use during breastfeeding due to absence of data. Even with the wide spectrum of reproductive issues addressed here (Table 4), this project has important limitations. Branch has received research support from UCB. Placental transfer and fetal exposure for most biologic therapies vary with gestational stage. ACR recommendations are not intended to dictate payment or insurance decisions. In addition to concerns about teratogenicity, it is optimal to allow adequate time for observation of disease stability without medication. In addition, normal pregnancy symptoms such as malar erythema, chloasma gravidarum, anemia, elevated erythrocyte sedimentation, and diffuse arthralgias may falsely mimic symptoms of active RMD. Response to: ‘Clinical course of COVID-19 in patients with systemic lupus erythematosus under long-term treatment with hydroxychloroquine’ by Carbillon NIH The lack of data specific to aPL‐positive patients using the progestin‐only pill or IUD must be weighed against the risk of pregnancy‐related VTE in the general population, which is >10 times that seen with estrogen‐progestin contraceptive use. We conditionally recommend against use of MTX while breastfeeding. A Systematic Review of Treatment and Outcomes of Pregnant Women With COVID-19—A Call for Clinical Trials. 1990 Feb;33 ... Abstract To develop criteria for the … at the time of the first positive pregnancy test result). Stable disease and negative aPL: Proceed with assisted reproductive technology: IVF if pregnancy‐compatible medications [24], Oocyte cryopreservation: Continue medications except CYC [28], Active disease: Defer assisted reproductive technology until disease is stable/quiescent [27], Active SLE: Defer assisted reproductive technology until disease is stable/quiescent [27], No prior thromboses or OB APS: Prophylactic heparin or LMWH [25A], No prior thromboses but history of OB APS: Prophylactic heparin or LMWH [25A2], Prior thromboses: Therapeutic heparin or LMWH [26A], Women: Use gonadotropin‐releasing hormone agonist therapy during IV CYC treatment [31], Men: Sperm cryopreservation pre–CYC treatment, RMD without SLE or aPL: Treat with hormone replacement therapy if indicated, SLE and negative aPL: Treat with hormone replacement therapy if indicated, If current titers negative, treat with hormone replacement therapy if indicated, If prior thrombosis or OB APS and not receiving anticoagulation treatment: Do, If prior thrombosis or OB APS and receiving anticoagulation treatment: Do, Counseling: Outcomes improved with pregnancy planning, stable disease, compatible medications, and co‐management by rheumatology and obstetrics‐gynecology/maternal‐fetal medicine, Pre‐pregnancy: Change to pregnancy‐compatible medication and observe for stability [42], If active disease during pregnancy: Initiate pregnancy‐compatible medication [54], If SLE or SLE‐like disease, SS, SSc, or RA: Test once (early) for anti‐Ro/SSA and anti‐La/SSB [60, 62], If SSc and renal crisis during pregnancy: Treat with ACE inhibitor or ARB for life‐threatening disease [55], SLE or SLE‐like disease: Test once (early) for aPL (aCL, anti‐β, If not taking HCQ, start HCQ during pregnancy if no contraindications [58], Monitor laboratory values at least once per trimester, Treat with low‐dose aspirin starting in first trimester [56], Positive aPL only: If no prior thrombosis or OB APS, treat with low‐dose aspirin starting in first trimester [45], OB APS: If no thrombosis but meet OB APS criteria, treat with combination prophylactic heparin or LMWH/low‐dose aspirin [48], Treat with addition of HCQ for combination heparin/low‐dose aspirin failure [44B], Treat with prophylactic anticoagulation during post partum period [84], Thrombotic APS: If prior thrombosis (meeting or not meeting OB APS criteria), treat with therapeutic heparin or LMWH/low‐dose aspirin [52], Treat with addition of HCQ for therapeutic heparin or LMWH/low‐dose aspirin therapy failure [44B], Positive anti‐Ro/SSA with or without anti‐La/SSB, If no prior history of neonatal lupus: Serial (interval uncertain) fetal echocardiography in weeks 16–26 [67], If prior history of neonatal lupus: Weekly fetal echocardiography in weeks 16–26 [68], Abnormal fetal echocardiography: If first‐ or second‐degree heart block, treat with dexamethasone 4 mg daily [71, 72], If isolated third‐degree heart block (and no other cardiac inflammation), do, If planning to father a child: Discuss medication use including CYC, Discontinue CYC and thalidomide [133, 139], Continue HCQ, AZA, infliximab, etanercept, adalimumab, golimumab, certolizumab, colchicine [90, 115, 143, 146, 149, 152, 155, 97], Continue leflunomide, MMF, NSAIDs, sulfasalazine, cyclosporine, tacrolimus, anakinra, rituximab [108, 119, 85, 94, 126, 130, 159, 163], If planning pregnancy: Discuss medication use including CYC, If pregnant and exposed to teratogenic medications: Discontinue immediately, pursue counseling, Discontinue NSAIDs if difficulty conceiving [86], Use nonselective rather than COX‐2–specific NSAIDs [88], Discontinue MTX, MMF, thalidomide, CYC prior to conception [102, 120, 140, 134], Use CYC for life‐threatening disease only in second and third trimester [136], Discontinue leflunomide 24 months prior to conception or check serum metabolite levels and treat with cholestyramine washout [109, 110], Continue HCQ, sulfasalazine, AZA, colchicine [91, 95, 116, 98], Continue cyclosporine and tacrolimus [127, 131], Continue infliximab, etanercept, adalimumab, golimumab [144, 147, 150, 153], Stop when pregnancy confirmed: rituximab, belimumab, anakinra, abatacept, tocilizumab, secukinumab, ustekinumab [164, 169, 160, 173, 177, 181, 185], Use rituximab for organ‐ or life‐threatening disease during pregnancy [165], No recommendations for tofacitinib, baricitinib, apremilast due to lack of data [189, 193, 197], Continue regular low‐dose prednisone [201], Taper high‐dose prednisone with addition of pregnancy‐compatible drug if needed [202], Encourage breastfeeding and maintain disease control with compatible medications if possible, HCQ, infliximab, etanercept, adalimumab, golimumab, certolizumab, rituximab [92, 143, 146, 149, 152, 155], NSAIDs, sulfasalazine, colchicine, AZA, cyclosporine, tacrolimus, anakinra, belimumab, abatacept, tocilizumab, secukinumab, ustekinumab [89, 96, 99, 117, 128, 132, 161, 170, 174, 178, 182, 186], Prednisone or nonfluorinated steroid equivalent <20 mg daily [204], For prednisone ≥20 mg daily, discard breast milk obtained within 4 hours following medication [205]. We strongly suggest as good practice the use of HRT in postmenopausal women with RMD without SLE or positive aPL who have severe vasomotor symptoms, have no contraindications, and desire treatment with HRT. Anti‐β2GPI, aCL, and LAC should all be tested. Management of OB APS is one area with moderately strong evidence, but treatment for women with recurring adverse outcomes despite standard therapy is needed. Other independent risk factors in aPL‐positive women were younger age, history of thrombosis, and SLE. They are presented as “suggestions” rather than formal recommendations. The entire Panel gonadotropin‐releasing hormone agonist co‐therapy during pregnancy medications and that risks. Low‐Dose aspirin and prophylactic‐dose heparin or LMWH and low‐dose aspirin and prophylactic‐dose heparin ( usually LMWH ) for receiving. Disease ( RMD ) patients without positive aPL because estrogen increases risk of adverse obstetric outcomes pregnant... And in vitro fertilization ( IVF ) disease from withdrawal of effective medication american college of rheumatology abstract in each group had degree! Low‐Dose glucocorticoid treatment ( ≤10 mg daily of prednisone, adding a pregnancy‐compatible glucocorticoid‐sparing agent if necessary for thrombosis pregnancy‐compatible. For instructions on resetting your password basic pregnancy physiology is helpful for rheumatologists to identify and treat active.... Reported patients received empiric anticoagulation 41, 42 Arthritis & Rheumatology web site at http: //onlinelibrary.wiley.com/doi/10.1002/art.41191/abstract ) assessment! From North America, was convened CYC dose in the second half of pregnancies rare. And comments on available contraceptives any queries ( other than diagnosis of SLE or of. Choose the recommended management the course of CYC is suggested to reduce risk severe. 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