*8.4.1 Cyclophosphamide (CYC)*

*Lupus - Need to Know*

*8.2.3 Azathioprine (AZA)*

exceed 2 mg/Kg/day.

*8.2.4 Intravenous immunoglobulin*

compatible with pregnancy [62].

*8.2.5 Cyclosporine and tacrolimus*

*8.2.6 Antihypertensive medications*

**8.3 Drugs to be used with caution during pregnancy**

However, it has not been shown to be teratogenic [60, 64].

minimum doses [63].

time [20].

*8.3.1 Biologic agents*

Methylprednisolone has similar rates of placental transfer to prednisone so it is

Azathioprine is especially used in SLE patients with hematological manifesta-

Intravenous immunoglobulin (IVIG) is an immunomodulator that regulates the inflammatory processes through anti-idiotype mechanisms. Although it crosses the placenta after the 2nd trimester and in a more significant way after the 3rd trimester, no fetal malformations have been reported. Hence, it is considered a drug

Both cyclosporine (CSA) and tacrolimus are calcineurin inhibitors used as maintenance drugs and steroid-sparing agents, in patients with moderate to severe SLE [60]. CSA is considered safe in pregnancy, but blood pressure and renal function should be closely monitored [20]. It is recommended that CSA and tacrolimus should only be used when maternal benefit outweighs fetal risk, and preferably at

Metildopa, labetalol and hydralazine are frequently used during pregnancy with efficacy and no harm. Nifedipine is also compatible at doses up to 60 mg/ day. By contrast, angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers are contraindicated throughout gestation and should be stopped as soon as possible, once pregnancy is confirmed. Diuretics can be used with caution and should be used as a last resource to control a severe and refractory hypertension, in an emergency setting and for a short period of

There is no sufficient data regarding biologic agents during pregnancy, so their use cannot be encouraged. Rituximab (RTX) is a B-cell depleting chimeric monoclonal antibody and is recommended to be stopped 6 months before conception.

Belimumab (BEL) is BAFF inhibitor human monoclonal antibody and there is no sufficient data to recommend it during pregnancy. Until 12th week, IgG does not across placenta in significant amounts; so, accidental exposure to RTX or BEL during the first trimester is unlikely to be harmful. On the other hand, second/third

trimester exposure will be associated with neonatal B-cell depletion [65].

tions, but it can also be used in LN, as a maintenance drug [60]. This drug is compatible with pregnancy, since fetal liver lacks the enzyme to convert AZA to its active form [61]. Therefore, AZA is considered a safe drug, but doses should not

expected to be safe and compatible with pregnancy [20].

**96**

Cyclophosphamide (CYC) is an alkylating drug used in SLE, to treat severe organ or life-threatening manifestations [60]. Due to its teratogenic effects, its use in pregnancy is contraindicated, especially during the first trimester, when the fetus is more susceptible to congenital malformations. Nevertheless, it can be considered in exceptional circumstances, when mother faces an organ- or life-threatening disease complication. Embryotoxicity varies according to the stage of gestation. The use of this drug in fertile women should always be carefully evaluated and counseling about fertility preservation strategies should be advised prior to its use [66].
