Can You Take Enbrel, Humira, or Cimzia During Pregnancy? A Rheumatologist Answers Common Questions
Disclaimer: This article is for general educational purposes only and is not intended to provide personal medical advice. Every pregnancy and every rheumatic disease is different. Always consult your personal physician, rheumatologist, and obstetrician for recommendations specific to your individual medical situation.
Why is it important to control inflammatory arthritis during pregnancy?
One of the most common misconceptions I hear is that women should simply stop all arthritis medications once they become pregnant.
In reality, the goal is not to stop treatment at all costs. The goal is to keep both mother and baby as healthy as possible.
Studies consistently show that pregnancy outcomes are generally best when inflammatory diseases such as ankylosing spondylitis, rheumatoid arthritis, psoriatic arthritis, and lupus are well controlled. Active inflammation can lead to significant pain, fatigue, disability, difficulty sleeping, decreased mobility, and increased stress on the mother’s body. Maintaining disease control allows women to stay healthier throughout pregnancy and better care for themselves and their growing baby.
Can arthritis flare during pregnancy?
Yes.
Although some women experience improvement in symptoms during pregnancy, others continue to have active disease or develop significant flares. In some cases, medications that previously worked very well may become less effective.
When inflammation becomes severe, patients may experience intense back pain, hip pain, joint swelling, stiffness, difficulty walking, and substantial impairment in daily activities.
Why can’t I just stop my arthritis medications during pregnancy?
Because uncontrolled inflammation can be harmful.
The decision is rarely “medication versus no medication.”
Instead, rheumatologists carefully balance:
The risks of uncontrolled disease
The risks of medication exposure
The health of both mother and baby
For many women with aggressive inflammatory arthritis, continuing treatment is safer than allowing severe disease activity to persist.
Which biologic medications are considered safest during pregnancy?
The most studied biologic medications in pregnancy are the TNF-alpha inhibitors, including:
Etanercept (Enbrel)
Adalimumab (Humira)
Infliximab (Remicade)
Certolizumab pegol (Cimzia)
Golimumab (Simponi)
The American College of Rheumatology recommends that TNF inhibitors can be continued during pregnancy when clinically necessary.
Is Cimzia different from the other TNF inhibitors?
Yes.
Cimzia (certolizumab pegol) is unique because it lacks the Fc portion of the antibody that facilitates placental transfer.
As a result, studies have demonstrated minimal transfer of Cimzia across the placenta, making it an especially attractive option for women who require biologic therapy during pregnancy.
This is one reason why many rheumatologists consider Cimzia when treating women who are pregnant or planning future pregnancies.
Why do some rheumatologists try to stop TNF inhibitors during the third trimester?
This is a nuanced discussion.
For TNF inhibitors such as Humira, Enbrel, Remicade, and Simponi, placental transfer increases significantly during the third trimester. As a result, measurable amounts of medication may be present in the newborn at delivery.
If a patient’s arthritis is in excellent control, some rheumatologists may choose to stop these medications during late pregnancy to reduce fetal exposure.
However, if the mother’s disease remains active, many experts recommend continuing treatment because uncontrolled inflammation may pose a greater risk than medication exposure. The American College of Rheumatology specifically notes that continuing TNF inhibitors through delivery can be appropriate when disease activity remains high.
Are TNF inhibitors safe during breastfeeding?
Yes.
The American College of Rheumatology considers TNF inhibitors compatible with breastfeeding. Available data suggest very low infant exposure through breast milk, and these medications are commonly used during lactation when clinically needed.
Is there an increased risk of infections in babies exposed to TNF inhibitors during pregnancy?
This is one of the most common concerns among expectant mothers.
Fortunately, current evidence has not demonstrated a clear increase in serious infections among infants exposed to TNF inhibitors during pregnancy. While ongoing research continues, available data have generally been reassuring.
What is the biggest concern about continuing TNF inhibitors late in pregnancy?
The primary concern involves live vaccines.
Because some biologic medications can cross the placenta during the third trimester, there has historically been concern regarding administration of live vaccines during early infancy.
In the United States, rotavirus is the only routine live vaccine administered during the first six months of life.
The American College of Rheumatology does not recommend routinely delaying rotavirus vaccination in infants exposed to TNF inhibitors during pregnancy. Families should still discuss vaccine timing with their pediatrician and rheumatologist.
What about prednisone during pregnancy?
Prednisone can be an important tool when inflammation becomes severe.
However, most rheumatologists try to use the lowest effective dose for the shortest possible duration. Higher doses and prolonged exposure may increase the risk of complications such as gestational diabetes, hypertension, excessive maternal weight gain, osteoporosis, and other steroid-related side effects.
When possible, we often add pregnancy-compatible medications to reduce reliance on prednisone.
What are some safer non-biologic medications during pregnancy?
Two commonly used medications include:
Sulfasalazine
Hydroxychloroquine (Plaquenil)
Both have extensive pregnancy safety data and are commonly used during pregnancy and breastfeeding when appropriate. The American College of Rheumatology recommends continuing these medications throughout pregnancy.
A Real-World Example of Shared Decision Making
Recently, I met a young woman with ankylosing spondylitis who was in the final weeks of pregnancy and experiencing a severe flare despite treatment with Enbrel. Her pain and stiffness had become debilitating, requiring substantial prednisone to remain functional.
In situations like this, the goal is not simply to stop medication. The goal is to reduce inflammation while minimizing risk to both mother and baby.
After discussing the available evidence, we decided to continue Enbrel through the remainder of her pregnancy while adding sulfasalazine to provide additional disease control and hopefully reduce her steroid requirements. Following delivery, we plan to transition her to infliximab because her current biologic appears to be losing effectiveness (she plans to have more children after this pregnancy).
Every treatment decision in pregnancy involves weighing risks and benefits, but one principle remains consistent:
Healthy pregnancies are supported by healthy mothers.
Key Takeaways
Active inflammatory arthritis should not be ignored during pregnancy.
Disease control is often safer than allowing severe inflammation to continue.
TNF inhibitors are the best-studied biologic medications in pregnancy.
Cimzia has minimal placental transfer and is often an attractive option.
Some TNF inhibitors are discontinued during the third trimester when disease is quiet, but may be continued when disease remains active.
TNF inhibitors are generally considered compatible with breastfeeding.
Prednisone can be used when necessary but should be minimized whenever possible.
Sulfasalazine and hydroxychloroquine are important pregnancy-compatible treatment options.
Treatment decisions should always be individualized through collaboration between the patient, rheumatologist, and obstetric team.