To describe the practices of rheumatologists when prescribing the disease modifying antirheumatic drugs (DMARD) methotrexate (MTX), leflunomide (LF), etanercept (ET), and infliximab (IN) to women of childbearing age with rheumatoid arthritis (RA) and the pregnancy outcomes of patients who become pregnant while taking these medications.
A questionnaire was mailed to 600 members of the American College of Rheumatology inquiring about their perception of fetal risk, their recommendations regarding the use of birth control in women of childbearing age taking DMARD, and the pregnancy outcomes of women with DMARD exposure.
One hundred seventy-five rheumatologists (29%) returned completed surveys. Respondents were more likely to agree that pregnancy is contraindicated in women taking MTX (95%) or LF (92.7%) than for women taking ET (38.6%) or IN (46.5%). Accordingly, most required birth control for women taking MTX (95.7%) and LF (97.3%), and fewer for women taking ET (75.4%) or IN (73.4%). A total of 65 pregnancies exposed to these DMARD were reported (MTX 38, LF 10, ET 14, IN 2, MTX and ET 1). Only 3 congenital malformations, all in the MTX group, were reported among the 52 pregnancies with known outcomes.
Rheumatologists agree that there is a risk of teratogenicity with MTX and LF and usually require the use of reliable methods of birth control in women taking these medications. There is no consensus about ET and IN; however, physicians still tend to discuss reliable birth control methods with their female patients. We have confirmed there is a risk of congenital malformations with in utero exposure to MTX. No malformations were reported in infants exposed to LF, ET, or IN, but the number of reported pregnancy outcomes was small.