Lupus

ARTHRITIS & RHEUMATISM Vol. 54, No. 11, November 2006, pp 3640–3647 DOI 10.1002/art.22159 © 2006, American College of Rheumatology

Hydroxychloroquine in Lupus Pregnancy
Megan E. B. Clowse,1 Laurence Magder,2 Frank Witter,3 and Michelle Petri3
Objective. Hydroxychloroquine (HCQ) is often needed to manage disease activity in systemic lupus erythematosus (SLE) during pregnancy. The purpose ofthis study was to examine lupus activity and pregnancy outcomes in women with SLE treated or not treated with HCQ during pregnancy. Methods. This was a prospective study of pregnancies in women with SLE who were evaluated between 1987 and 2002. The pregnancies were divided into 3 groups: no HCQ exposure during pregnancy (163 pregnancies), continuous use of HCQ during pregnancy (56 pregnancies), orcessation of HCQ treatment either in the 3 months prior to or during the first trimester of pregnancy (38 pregnancies). The pregnancy outcomes, fetal outcomes, and lupus activity during pregnancy were compared among these groups. Results. The rates of miscarriage, stillbirth, pregnancy loss, and congenital abnormality were not statistically different among the 3 groups. The degree of lupusactivity during pregnancy, however, was significantly higher in women who stopped taking HCQ. These women had a higher degree of lupus activity, as measured by the physician’s estimate of lupus activity and the SLE Disease Activity Index, as well as an increased rate of flare, during pregnancy. More serious lupus complications, such as proteinuria and thrombocytopenia, were not significantly higher inwomen who stopped
Presented in part at the 68th Annual Scientific Meeting of the American College of Rheumatology, San Antonio, TX, October 2004. The Hopkins Lupus Cohort and the Hopkins General Clinical Research Center are supported by the NIH (grant R01-AR-43737 from the National Institute of Arthritis and Musculoskeletal and Skin Diseases and grant M01-RR-00052, respectively). Dr. Clowse’s workwas supported by the NIH (grant 5K12-HD-043446). 1 Megan E. B. Clowse, MD, MPH: Duke University Medical Center, Durham, North Carolina; 2Laurence Magder, PhD: University of Maryland School of Medicine, Baltimore; 3Frank Witter, MD, Michelle Petri, MD, MPH: Johns Hopkins University School of Medicine, Baltimore, Maryland. Address correspondence and reprint requests to Megan E. B. Clowse, MD, MPH,Duke University Medical Center, Box 3535, Trent Drive, Durham, NC 27710. E-mail: megan.clowse@duke.edu. Submitted for publication January 25, 2006; accepted in revised form July 11, 2006. 3640

taking HCQ. Women who continued taking HCQ were maintained on a lower average dose of prednisone during pregnancy. Conclusion. We recommend the continuation of HCQ treatment during pregnancy. Our findingsare consistent with prior reports of the absence of fetal toxicity. Similar to studies of nonpregnant women, the cessation of HCQ treatment during pregnancy increases the degree of lupus activity. Many women with systemic lupus erythematosus (SLE) take hydroxychloroquine (HCQ) to control disease activity. Studies have shown that HCQ can prevent renal and central nervous system lupus and lessen theeffects of SLE (1,2). It has also been demonstrated that cessation of HCQ treatment places a woman at more than twice the risk of a lupus flare in the subsequent 6 months (3,4). Women with SLE maintain fertility, and most can have a successful pregnancy (5–7). Experts in the care of SLE during pregnancy generally recommend continuing HCQ treatment during pregnancy (8). At the Fourth InternationalConference on Sex Hormones, Pregnancy, and the Rheumatic Diseases in 2004, the working group on medications during pregnancy recommended continuing HCQ treatment (9). The data to support this recommendation are limited to reports of 300 pregnancies, however. A significant minority of rheumatologists, particularly those who see few lupus pregnancies per year, do not routinely continue HCQ...