Inflammatory Bowel Disease (IBD): Choices during pregnancy and breastfeeding

IBD sufferers Therapeutic Choices during pregnancy and  breastfeeding

This short blog will help guide your pharmacological choices when treating Crohn’s or Colitis in pregnancy and lactation.

IBD (Crohn’s Disease, Colitis…) in pregnant women increases the risk of preterm birth, low birth weight and miscarriages however, the evidence is not as strong for an increased risk of congenital abnormalities.

Pregnant IBD (Crohn’s Disease, Colitis…) patients in remission at the time of conception are likely to remain in remission during pregnancy but up to one-third may relapse during the pregnancy. Women with IBD who are planning a pregnancy should try conceiving at a time when the disease is in remission.

Remember: female and male patient IBD (Crohn’s Disease, Colitis…) patients do not have reduced fertility because of the disease; the observed childlessness in IBD patients is due to voluntary’ choices often based on incorrect patient beliefs rather than physiologic or organic causes.

Most IBD medications, except methotrexate, should not be discontinued at conception or while breastfeeding since their cessation might lead to disease flare; the risk of the untreated disease (preterm birth, miscarriage) is often greater than the risk of most available medications.

Aminosalicylates are considered low risk for use in pregnancy or while breastfeeding. Due to potential antifolate effects, women taking sulfasalazine may be safely switched to 5-ASA (Lialda® or Mezavant® in Canada, Asacol®) or are generally advised to supplement with 2 mg of folic acid daily starting before conception and continuing throughout their pregnancy.

Corticosteroids are considered safe and may be continued in pregnancy if indicated; however, they should be used with caution in the 1st trimester since they have been associated with an increased, though still low, risk of oral clefts in the newborn.

Corticosteroids may be used at any stage of pregnancy (including 1st trimester) if benefits outweigh potential risks, e.g., during disease flares. Prednisone and prednisolone are considered compatible with breastfeeding.

Cyclosporine is not usually used for treatment of IBD but is considered to have an overall low risk during pregnancy.

Do not use cyclosporine during breastfeeding; anti-TNF-alpha agents are safer in this situation.

Azathioprine and 6-mercaptopurine (6-MP) are considered low risk during pregnancy despite the conflicting safety data. Azathioprine and 6-MP are generally considered compatible with breastfeeding but it is considered safest to separate breastfeeding by a few hours from dosing.

Methotrexate is contraindicated in pregnancy and breastfeeding owing to its teratogenic and cytotoxic effects. Consider effective contraception in patients receiving methotrexate. Discontinue the drug 3-6 months prior to attempted conception.

Use of adalimumab (Humira®), golimumab (Simponi®) and infliximab (Remicade®)in pregnant patients with IBD (Crohn’s Disease, Colitis…) is considered low risk during the 1st and 2nd trimesters; however, there are concerns about immunosuppression in the newborn if administered during the 3rd trimester.

In patients with active disease and those at high risk of relapse of active IBD (Crohn’s Disease, Colitis…) the risks of uncontrolled disease activity to mother and child (e.g., preterm birth, low birth weight and miscarriage) may outweigh the potential toxicity of anti- TNF-alpha medications, e.g., serious systemic infections.

Therefore, expert consensus statements recommend these therapies for inflammatory bowel disease be continued during the 3rd trimester, particularly in those with a history of difficult to control disease, but consideration can be made for discontinuing anti- TNF-alpha agents around the start of the 3rd trimester if the patient is in long-term remission.

Adalimumab, golimumab and infliximab are actively transported across the placenta in the 3rd trimester and may remain in the newborn’s blood for up to 6 months postdelivery. Therefore, unless serum anti-TNF-alpha levels in the newborn are proven negative, administration of any live vaccines (e.g., rotavirus vaccine) should be delayed until at least 6 months of age. Use of anti- TNF-alpha therapies is compatible with breastfeeding, as levels detected in breast milk are minimal to none.

The safety of using ustekinumab (Stelara®) or vedolizumab (entyvio®) during pregnancy and breastfeeding is currently unknown.

Metronidazole (Flagyl®) has a low teratogenic risk when used during pregnancy, but should not be used while patient is breastfeeding because it transfers to breast milk. Avoid prolonged metronidazole use in pregnant patients.

Alternatives to ciprofloxacin (Cipro®)should be considered for pregnant and breastfeeding women.

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References are available upon request!

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