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British Society for Rheumatology guideline on prescribing drugs in pregnancy and breastfeeding: comorbidity medications used in rheumatology practice

British Society for Rheumatology (BSR) · 2022 · United Kingdom

Source and licence

Authors
Karen Schreiber, Margreta Frishman, Mark D Russell et al.
Title
British Society for Rheumatology guideline on prescribing drugs in pregnancy and breastfeeding: comorbidity medications used in rheumatology practice
Journal
Rheumatology (Oxford, England), 2022
DOI
10.1093/rheumatology/keac552
Licence
CC BY 4.0
Changes
Verbatim excerpts; formatting adapted

Full text retrieved 2026-10-27 from Europe PMC · PMC10070063

Licence statement of the original publication

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.

This page reproduces excerpts of the original publication; the original is authoritative. It has not been reviewed by a physician, does not state a recommendation of Medelix and does not replace medical advice. The guideline may have been updated since.

Open the original publication →Full text on Europe PMC

Recommendations

Verbatim, with grade of recommendation or strength of consensus where given.

Recommendations for paracetamol in pregnancy and breastfeeding

  • Paracetamol is the analgesic of choice and compatible peri-conception and throughout pregnancyGRADE 1B, SOA 99
  • LactMed describes paracetamol as a good choice for analgesia and fever reduction in breastfeeding mothersGRADE 2C, SOA 99.5

Recommendations for codeine in pregnancy and breastfeeding

  • Codeine is compatible peri-conception and throughout pregnancy, although long-term use should be avoided. There is no consistent evidence to recommend a dose reduction pre-delivery but neonatologists should be aware of maternal useGRADE 1B, SOA 97.8
  • Caution is advised with use of codeine in breastfeeding, due to the risk of CNS depression resulting from unpredictable metabolism of codeine to morphineGRADE 1C, SOA 98

Recommendations for tramadol in pregnancy and breastfeeding

  • Avoid tramadol peri-conception and in first trimester and only consider in second/third trimester if no alternative analgesiaGRADE 2B, SOA 97.8
  • Based on limited data, tramadol may be compatible with short-term use in breastfeedingGRADE 2C, SOA 94.8

Recommendations for amitriptyline in pregnancy and breastfeeding

  • Amitriptyline is compatible with pregnancy. There is no evidence of adverse effect on IQ or developmental outcomesGRADE 1C, SOA 100
  • Because very little amitriptyline is found in breastmilk with antidepressant doses and it is used at lower doses for chronic pain, it is unlikely to cause adverse effects in breastfed infantsGRADE 1C, SOA 100

Recommendations for gabapentin and pregabalin in pregnancy and breastfeeding

  • Gabapentin at lowest effective dose may be considered in pregnancy with folic acid supplementation if no alternative analgesic is suitableGRADE 1B, SOA 95
  • Gabapentin may be considered in breastfeeding if no alternative analgesic is suitableGRADE 2C, SOA 96
  • Pregabalin may be considered in pregnancy (with folic acid supplementation) and during breastfeedingGRADE 2C, SOA 95.3

Recommendations for SNRIs in pregnancy and breastfeeding

  • Venlafaxine is compatible at conception and throughout pregnancy. There may be an increased risk of neonatal abstinence syndrome/short-term behavioural effects, but larger studies are needed to evaluate this findingGRADE 2C, SOA 95.8
  • Duloxetine may be considered in pregnancy and breastfeeding but there are fewer data than for venlafaxineGRADE 2C, SOA 95.3
  • Venlafaxine and duloxetine may be considered in breastfeeding if there is no alternative chronic pain medicationGRADE 2C, SOA 95.8

Recommendations for SSRIs in pregnancy and breastfeeding

  • Fluoxetine, paroxetine and sertraline are compatible with pregnancyGRADE 1B, SOA 98.8
  • Based on limited evidence, SSRIs are compatible with breastfeedingGRADE 2C, SOA 98.3

Recommendations for NSAIDs and COX-2 inhibitors in pregnancy and breastfeeding

  • Discordant findings from retrospective, large studies with population controls on the use of non-selective NSAIDs in the first trimester of pregnancy raise the possibility of a low risk of miscarriage and malformation. Therefore, these drugs should only be used intermittently in the first trimester of pregnancyGRADE 1B, SOA 97.3
  • Intermittent rather than regular use of all non-selective NSAIDs except LDA is recommended throughout pregnancy and weaned from end of second trimester (26 weeks) to stop by gestational week 30 to avoid premature closure of the ductus arteriosusGRADE 1B, SOA 98
  • At present there are limited data on selective cyclooxygenase-2 inhibitors; they should therefore be avoided during pregnancyGRADE 2C, SOA 98.5
  • Non-selective NSAIDs (especially ibuprofen) are compatible with breastfeedingGRADE 1C, SOA 98.8

Recommendations for LDA and clopidogrel in pregnancy and breastfeeding

  • LDA may be continued throughout pregnancy and NICE guidelines (2019) for hypertension in pregnancy advise treatment with LDA (for prophylaxis of pre-eclampsia) until deliveryGRADE 1B, SOA 99.0
  • LDA is compatible with breastfeedingGRADE 2C, SOA 99.8
  • There are limited data on clopidogrel but it may be considered where alternative drugs are not suitable in pregnancy and breastfeedingGRADE 2C, SOA 96.3

Recommendations for colchicine and dapsone in pregnancy and breastfeeding

  • Colchicine therapy may be considered during pregnancyGRADE 1B, SOA 99.5
  • Dapsone may be used in pregnancyGRADE 2C, SOA 95.0
  • Colchicine may be used in breastfeedingGRADE 2C, SOA 98.3
  • Dapsone may be used in breastfeeding and due to the risk of haemolytic anaemia it is advised to monitor the infant for signs of haemolysis, especially in newborn or premature breastfed infantsGRADE 2C, SOA 90.7

Recommendations for anticoagulants in pregnancy and breastfeeding

  • LMWH heparin is compatible throughout pregnancyGRADE 1A, SOA 100
  • LMWH is compatible with breastfeedingGRADE 1C, SOA 100
  • The use of warfarin in pregnancy is associated with increased foetal risk throughout pregnancy and has limited indications, therefore should only be considered in exceptional circumstancesGRADE 1B, SOA 98.8
  • Warfarin is compatible with breastfeedingGRADE 1A, SOA 100
  • Direct oral anticoagulants (DOACs) cannot be recommended in pregnancyGRADE 1C, SOA 97.9
  • Rivaroxaban may be considered in breastfeedingGRADE 2C, SOA 95.3
  • Other DOACs are not recommended in breastfeeding due to lack of human data and concerns from animal studiesGRADE 1C, SOA 97.4
  • Fondaparinux may be considered in pregnancy and breastfeeding if there is an allergy or adverse response to LMWHGRADE 2C, SOA 95.5

Recommendations for bisphosphonates in pregnancy and breastfeeding

  • There is insufficient data upon which to recommend bisphosphonates in pregnancy or to advise a specific time for them to be stopped pre-conception. Given their biological half-life in bone of up to 10 years and no evidence of harm from limited reports of their use in pregnancy, a pragmatic recommendation is that they should be stopped 3 months in advance of pregnancyGRADE 2C, SOA 96.8
  • There are no data on which to base a recommendation for the use of bisphosphonates during breastfeedingGRADE 2C, SOA 98.5

Recommendations for ACEis/ARBs in pregnancy and breastfeeding

  • ACEis and ARBs should be stopped as soon as possible when pregnancy is confirmed in the first trimester and if necessary an alternative antihypertensive compatible with pregnancy givenGRADE 1A, SOA 100
  • ACEis/ARBs should be avoided in the second and third trimester but may be considered under specialist advice in certain circumstancesGRADE 1C, SOA 98.5
  • Based on limited evidence, enalapril is compatible with breastfeedingGRADE 2C, SOA 98.5

Recommendations for CCBs in pregnancy and breastfeeding

  • Nifedipine is compatible with pregnancy with no direct evidence of harm at doses up to 90 mg/dayGRADE 1A, SOA 99.0
  • Nifedipine is compatible with breastfeedingGRADE 1B, SOA 100
  • Amlodipine can be considered in pregnancy and breastfeeding as there is no evidence of harmGRADE 1C, SOA 97.9

Recommendations for pulmonary vasodilators in pregnancy and breastfeeding

  • Established moderate to severe PHT remains a contraindication to pregnancy. If pregnancy occurs, the use of these pulmonary vasodilator drugs in pregnancy should be considered only as part of a multidisciplinary team assessmentGRADE 1C, SOA 99.5
  • Limited evidence supports the use of prostacyclines to treat PHT during pregnancyGRADE 2C, SOA 98.0
  • Limited evidence supports the use of sildenafil to treat PHT during pregnancyGRADE 2C, SOA 98.0
  • Bosentan is teratogenic in animals and although there is no evidence of harm from human pregnancy, the evidence is insufficient to recommend in pregnancyGRADE 1C, SOA 98.8
  • There are no data relating to breastfeeding exposure to pulmonary vasodilators on which to base a recommendationGRADE 2C, SOA 98.8

Recommendations for paternal exposure

  • Paracetamol is compatible with paternal exposureGRADE 1B, SOA 98.5
  • Amitriptyline, SNRIs and SSRIs are compatible with paternal exposureGRADE 1B, SOA 98.5
  • Non-selective NSAIDs are compatible with paternal exposureGRADE 1C, SOA 98.4
  • Based on limited or no data and no association with adverse foetal development or pregnancy outcome, paternal exposure to all other drugs described in this guideline are unlikely to be harmfulGRADE 2C, SOA 97.3

Contents of the original publication

The section headings of the original.

  • Scope and purpose
  • Background
  • Need for guideline
  • Objectives of guideline
  • Target audience
  • The areas the guideline does not cover
  • Stakeholder involvement
  • Involvement and affiliations of stakeholder groups involved in guideline development
  • Rigour of development
  • Statement of scope of literature search and strategy employed
  • Statement of methods used to formulate the recommendations (levels of evidence)
  • Strength of recommendation
  • Quality of evidence
  • Strength of agreement
  • Statement of any limits of search and when guideline will be updated
  • The guideline
  • Generic recommendations on prescribing in rheumatic disease in pregnancy
  • Pain management: conventional analgesics
  • Codeine
  • Tramadol
  • Other treatments for chronic pain
  • Gabapentin and pregabalin
  • Serotonin–norepinephrine reuptake inhibitors (SNRIs)
  • Selective serotonin reuptake inhibitors (SSRIs)
  • NSAIDs and anti-platelet drugs
  • NSAIDs and COX-2 inhibitors
  • Low-dose aspirin
  • Clopidogrel
  • Colchicine and dapsone
  • Anticoagulants in rheumatic disease
  • Heparin
  • Warfarin
  • New anticoagulants
  • Fondaparinux
  • Bisphosphonates
  • Antihypertensive medication in rheumatic disease
  • Angiotensin blockade
  • Calcium channel blockers
  • Pulmonary vasodilators
  • Sildenafil
  • Bosentan
  • Prostacyclines
  • Paternal exposures
  • Applicability and utility
  • Implementation
  • Key standards of care
  • Future research agenda
  • Mechanism for audit of the guideline
  • Supplementary data
  • Contributor Information

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