I am a 35-year old female that has had RA for 17 years. I am currently taking Humira, Methotrexate, Predisone, & Naproxen. I would like to get pregnant in the near future. What are the risks for both during and after pregnancy?

I am glad to see that you are planning ahead! I'll go through each drug one by one. Keep in mind, however, that there isn't great data to tell us all of the risks and benefits of these medications in pregnancy. All pregnancies have risks and our goal is to minimize the risks that we can.

For RA in general - about 65-75% of women improve during pregnancy, even with stopping medications. In my experience, however, women who are doing very well on the number of medications that you are currently taking will not do as well during pregnancy if you stop all of them. Often, women will need to continue some medications during pregnancy to maintain a basic level of comfort. Many older studies show a significant RA flare after delivery. More recent studies, and my own experience in clinic, show that restarting medications very soon after delivery (i.e. within 2-3 weeks) can decrease this flare rate.

1. Humira -- This is an FDA Class B drug - this means that the animal data did not show any pregnancy problems but there is limited human data. It is an antibody against tumor necrosis factor. We think that antibodies do not cross the placenta in the 1st half of pregnancy, but around 16 weeks all antibodies (probably including Humira) will cross the placenta. The amount of antibodies that cross is pretty low at the start, but increases closer to your due date. The majority of the human data available shows no problems with Humira and pregnancy, but this is limited data. I often allow women to continue Humira until conception (it can take a while to conceive, particularly with RA, and without any medications you may suffer both pain and joint damage). Once you conceive, I generally recommend holding the Humira and seeing how you do. Some women do fine (RA tends to improve in pregnancy), other women flare and we restart the Humira.

2. Methotrexate: this is an FDA Class X drug, meaning there is no circumstance in which the benefits of the drug would justify using it in pregnancy. There is about a 1/10 chance of having a fetal anomaly if you take methotrexate in pregnancy (compared to a 1/30 chance without it). There is also a high chance for miscarriage (1/4 at least) if you conceive on it. I recommend stopping the methotrexate at least 3 months prior to conception. IMPORTANT: Stay on the folic acid even when you stop the methotrexate. Folic acid prevents birth defects.

3. Prednisone: a modest dose of prednisone (15mg or less) is probably the best treatment option for RA during pregnancy. There is a 3/1000 chance of cleft lip/palate with 1st trimester exposure (compared to a 1/1000 chance of this without prednisone). It might increase the chances for diabetes, high blood pressure, preeclampsia, and preterm delivery, particularly at doses of 20mg or higher per day.

4. Naproxen: there is some data suggesting that naproxen (and all other NSAIDs, including celecoxib, ibuprofen, etc) may impair ovulation and may increase the risk for miscarriage. I generally recommend that women use this drug sparingly when trying to conceive (particularly avoiding it between the time of ovulation and menstruation). During pregnancy, I also recommend restricting use to really bad days. In the 2nd and 3rd trimesters it can decrease the amount of amniotic fluid that surrounds the baby. In the 3rd trimester it can alter the dynamics of the fetus's heart, so you shouldn't take it then at all.