The European Alliance of Associations for Rheumatology (EULAR) has released updated recommendations for the use of antirheumatic drugs during reproduction, pregnancy, and breastfeeding. These updated guidelines, published in the April 2025 issue of Annals of the Rheumatic Diseases, reflect new evidence and advancements in treatment approaches since the initial 2016 points-to-consider guidelines. The new recommendations focus on how treatment can be tailored for individuals with rheumatic and musculoskeletal diseases (RMDs) who are planning a family, pregnant, or breastfeeding.
Rheumatic diseases, which commonly affect individuals during their reproductive years, can significantly impact fertility and increase the risk of poor pregnancy outcomes, such as premature or small-for-gestational-age babies. Many antirheumatic drugs also influence fertility and may not be safe during pregnancy. As a result, treatment strategies must be carefully considered and adjusted around the time of conception, during pregnancy, and while breastfeeding.
Rationale for Updated Recommendations
Since 2016, treatment approaches for RMDs have evolved toward a treat-to-target concept, which aims to reduce disease activity and prevent the negative impacts of active disease on fertility and pregnancy outcomes. Additionally, new data on the safety and efficacy of antirheumatic drugs in pregnancy, breastfeeding, and male reproductive health has led to the necessity of updating the original guidance.
The updated recommendations now consist of 12 specific recommendations and five overarching principles. These principles emphasize the importance of early and ongoing counseling for both men and women with RMDs regarding their reproductive health and the need to adjust their therapies accordingly.
Key Recommendations and Principles
Early and Regular Counseling: The new guidelines stress the importance of offering both men and women with RMDs regular counseling about their reproductive health. This includes discussions on the risks and benefits of antirheumatic drugs during pregnancy and breastfeeding.
Aim for Remission or Low Disease Activity: Treatment for RMDs before conception, during pregnancy, and after childbirth should aim for remission or low disease activity to reduce the risk of disease complications.
Risk Assessment: Healthcare providers must weigh the potential risk to the child against the risks of untreated disease for the mother. The updated guidelines make it clear that untreated disease can pose significant risks to both the mother and the baby.
Breastfeeding Considerations: Importantly, women with RMDs are not discouraged from breastfeeding, as the known benefits outweigh potential risks. The recommendations identify antirheumatic medications that are compatible with breastfeeding.
Shared Decision-Making: Treatment decisions regarding the use of antirheumatic drugs should be made collaboratively between healthcare providers and patients, considering both medical needs and personal preferences.
Three Key Areas of Focus
The 12 specific recommendations outlined in the updated guidelines focus on three key areas:
Medications Before and During Pregnancy: The guidelines provide detailed information on which antirheumatic drugs are safe to use before and during pregnancy. Some drugs should be discontinued before conception, while others are considered compatible during pregnancy. The recommendations also highlight which vaccines are appropriate for infants exposed to antirheumatic drugs in the womb.
Breastfeeding Compatibility: The guidelines also address which antirheumatic drugs are safe for use during breastfeeding, ensuring that mothers can continue their treatment without jeopardizing the health of their newborns.
Male Reproductive Health: EULAR’s recommendations also provide guidance on which drugs are compatible with male fertility, considering the impact of certain medications on sperm quality and reproductive health.
Implications for Healthcare Providers and Future Care
The updated guidelines from EULAR will help improve the care of individuals with RMDs during their reproductive years. The recommendations are designed to be shared across a wide range of healthcare disciplines, including rheumatology, obstetrics, gynecology, family medicine, and pediatrics. The updated knowledge will aid healthcare professionals in making informed decisions about treatment during pregnancy, lactation, and reproductive planning.
By incorporating these updated guidelines, healthcare providers can enhance the well-being of both mothers and their children, optimizing treatment strategies and improving long-term outcomes for patients with rheumatic and musculoskeletal diseases.
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