Risk-benefit considerations for antirheumatic drug use in pregnancy, breastfeeding, and male preconception: expert perspectives

<h2>ABSTRACT</h2><h3>Objectives</h3> Managing antirheumatic drug therapy during family planning, pregnancy, and breastfeeding remains challenging in rheumatology. Since inactive rheumatic disease is an important prerequisite for favourable fertility and pregnancy outcomes, clinicians must weigh the risk of drug exposure against the risk of uncontrolled disease. This study explored how considerations of disease activity influence prescribing decisions. <h3>Methods</h3> We surveyed 20 experts from the EULAR (European Alliance of Associations for Rheumatology) task force on their use of antirheumatic drugs in reproduction, pregnancy, and lactation. <h3>Results</h3> In pregnant women, antimalarials, sulfasalazine, azathioprine, calcineurin inhibitors, colchicine, and the tumour necrosis factor inhibitor certolizumab would mostly be prescribed as if the patient were not pregnant. Decisions to use other biologics during gestation were based on knowledge of relative drug safety and the risk of active disease without treatment. Nonsteroidal anti-inflammatory drugs and glucocorticoids during pregnancy were largely restricted to the control of active disease. In breastfeeding women, experts would use most antirheumatic drugs as if the patient were not breastfeeding, including many biologics. In male patients planning a family, experts would use many drugs as if the patient did not plan to father a child, including colchicine, methotrexate, leflunomide, sildenafil, and biologics, while Janus kinase inhibitors and other drugs with limited data would be avoided or used only to treat severe disease. <h3>Conclusions</h3> These findings highlight a progressive shift towards individualised, disease activity-guided prescribing, alongside growing confidence in the relative safety of several antirheumatic drugs. Expert surveys help define consensus, identify uncertainties, and guide future practice.