Is Methotrexate for RA Safe During Pregnancy?

The FDA does not recommend taking methotrexate while pregnant. We’ll cover its safety issues and some alternatives.

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Understanding methotrexate and rheumatoid arthritis (RA)

Rheumatoid arthritis (RA) is a chronic autoimmune condition that causes inflamed joints with pain, swelling, stiffness, and reduced range of motion. It most often affects women.

Symptoms may come and go and may be severe at times. Though there’s no cure for RA, medications and other treatments can help keep it under control.

If you’re thinking about pregnancy, you likely have many questions. A big one may be, “Is the methotrexate I take for RA still safe while I’m pregnant?”

Methotrexate is commonly prescribed for RA. It belongs to a class of medications called disease-modifying anti-rheumatic drugs (DMARDs).

It reduces inflammation caused by RA by dialing down the hyperimmune response. This action can help prevent further joint damage and ease the symptoms caused by RA.

Methotrexate can help manage your RA, but it can also have dangerous effects on your pregnancy.

Methotrexate isn’t safe during pregnancy

The Food and Drug Administration (FDA) states that methotrexate shouldn’t be used in pregnancy.

There are good reasons for the severe restrictions on taking methotrexate during pregnancy. Using methotrexate while pregnant could end your pregnancy or cause severe developmental issues for a fetus.

These irregularities could affect the way your child looks, develops, or functions for the rest of their life.

Fetus structural changes from methotrexate

Examples of the severe developmental issues that methotrexate can cause include:

• neural tube defects, such as:
  • anencephaly, when a child is missing a part of their brain or skull
  • myelomeningocele, a type of spina bifida that causes an incomplete closing of the spinal cord
  • meningocele, a type of spina bifida that causes a swollen cyst on the spine filled with cerebrospinal fluid
  • encephalocele, where saclike parts of the brain extend out through the skull
  • spina bifida cystica, or a bony defect in the spinal column
• cleidocranial dysostosis, which can cause:
  • missing or poorly developed collarbones
  • abnormal skull development
  • bulging of the forehead
• hypertelorism, or increased distance between two body parts (such as the eyes)
• other malformations such as misshapen ears, a flat nose, and an undersized jaw
• abnormal positioning of the hands at the wrist
• missing bones in the arm and feet

Safety issues for women

Women shouldn’t take this drug if they’re pregnant or trying to become pregnant.

If you’re trying to conceive and you have RA, you should take the following steps:

• Complete a pregnancy test before starting treatment with methotrexate. Your doctor will likely give you the test in their office.
• Use effective birth control during treatment with methotrexate and for 6 months after stopping treatment.
• Ask a doctor what type of birth control you can use during and after treatment.

Stop taking methotrexate and call your doctor right away if you become pregnant.

Safety issues for men

Men who take methotrexate shouldn’t get a partner pregnant during treatment with the medication. Men should take the following steps:

• Wait at least 3 months after stopping treatment before trying to get a partner pregnant.
• Use effective birth control during treatment with methotrexate and for 3 months after stopping treatment.

Methotrexate and breastfeeding

You also shouldn’t take methotrexate when you’re breastfeeding or chestfeeding. This is because methotrexate can cause serious side effects in a child who’s nursed.

These side effects can include blood disorders, such as low levels of blood cells.

If your child develops low white blood cell (WBC) levels, they’re at risk of increased infections. With low red blood cell (RBC) levels, your child could develop anemia.

If you need to take methotrexate after your baby is born, talk with your doctor about other ways to feed your child.

Safe alternatives to methotrexate

These methotrexate warnings don’t necessarily mean you have to stop treating your RA during pregnancy. There are other RA drug options that may be safer to take during pregnancy.

These medications include the following prescription drugs:

• azathioprine (Azasan, Imuran)
• cyclosporine (Neoral, Gengraf)
• hydroxychloroquine (Plaquenil)
• sulfasalazine (Azulfidine EN-Tabs)

Safe options also include low doses of certain corticosteroids. Your doctor can tell you if one of these drugs would be a good match for you.

Also, if your doctor says it’s safe for you, you can take over-the-counter (OTC) nonsteroidal anti-inflammatory drugs (NSAIDs) during your first and second trimesters. These NSAIDs include ibuprofen (Advil, Motrin) and naproxen (Aleve).

However, you shouldn’t take NSAIDs during your third trimester of pregnancy. During that time, NSAIDs can cause severe damage to your baby’s heart.

Talk with your doctor

If you have RA and are pregnant or planning to become pregnant, talk with your doctor. They can tell you more about the effects of methotrexate on pregnancy. They can also advise you about the best RA treatment for you during pregnancy.

At your appointment, you can discuss concerns and ask questions, such as:

• How might pregnancy affect my RA?
• What RA drug options are safe to use during pregnancy?
• Are there non-drug ways to reduce RA symptoms during pregnancy?

You and your doctor can create a treatment plan for your RA that’s safe for you and your pregnancy.