Is HCQ Safe For Pregnant Women With Rheumatoid Arthritis (RA)?

Last Editorial Review: 9/4/2020

Ask the Experts

I have rheumatoid arthritis and I have been on a maintenance dose of hydroxychloroquine (Plaquenil) for my RA, along with a dose of prednisone, for about five years now.

I never really thought about it much until two things happened; first, my boyfriend and I started talking about marriage and starting a family, and I know my RA will definitely cause some challenges in that area. I already expect trouble conceiving because of my disease and the fertility problems it’s known for.

Second, hydroxychloroquine has been in the news constantly because of the COVID-19 coronavirus pandemic, including claims about whether it does or doesn’t work on the pandemic virus. I don’t really worry about that because I have been strictly isolating and social distancing because of my condition, and I’ll be taking HCQ no matter what.

But I never thought about all the side effects that I read about online all the time, now. It makes me worried I may have to sacrifice my relatively flare-free life if I want to keep my baby safe from drug side effects in-utero.

Is hydroxychloroquine safe to take during pregnancy? What about for nursing mothers?

Doctor’s Response

Assuming you get the OK from your own doctor, you may be able to safely take hydroxychloroquine (Plaquenil) throughout your pregnancy.

The scientific literature on hydroxychloroquine or HCQ shows no increase in the rate of birth defects or embryonic deaths, according to the U.S. Food and Drug Administration.

Don’t breastfeed while taking hydroxychloroquine, though. HCQ is excreted in human milk and infants are extremely sensitive to the toxic effects of 4-aminoquinolines, the chemical class to which HCQ belongs, according to the FDA.

The action of hydroxychloroquine in rheumatoid arthritis is cumulative, and may require weeks to months to achieve the maximum therapeutic effect, according to the FDA. Here are the FDA’s directions for dosing hydroxychloroquine in rheumatoid arthritis patients (your doctor may want to adjust doses during your pregnancy):

  • Initial adult dosage: 400 mg to 600 mg (310 to 465 mg base) daily, administered as a single daily dose or in two divided doses. In a small percentage of patients, side effects may require temporary reduction of the initial dosage.
  • Maintenance adult dosage: When a good response is obtained, the dosage may be reduced by 50 percent and continued at a maintenance level of 200 mg to 400 mg (155 to 310 mg base) daily, administered as a single daily dose or in two divided doses.
  • Do not exceed 600 mg or 6.5 mg/kg (5 mg/kg base) per day, whichever is lower, as the incidence of retinopathy has been reported to be higher when this maintenance dose is exceeded.
  • Corticosteroids and salicylates may be used in conjunction with Plaquenil, and they can generally be decreased gradually in dosage or eliminated after a maintenance dose of Plaquenil has been achieved.

Corticosteroids like the prednisone you take in conjunction with your hydroxychloroquine are generally safe during pregnancy, as well, when used in low doses. 

They are designated as category B medications. Category B drugs are those which are safe in pregnant animals but lack adequate studies in pregnant women. 

Corticosteroids have potent anti-inflammatory action. Potential side effects include: 

  • Increase the maternal risk of high blood pressure
  • Swelling, 
  • Increased blood sugar during pregnancy (gestational diabetes), 
  • Poor bone health in pregnancy, 
  • Premature delivery, 
  • Low birth weight babies, and 
  • Birth defects such as cleft palate in the newborn
  • Certain corticosteroids such as prednisone and hydrocortisone are safer for use without adverse events in the fetus.

Once again, do not make any changes to your medication regimen until you’ve spoken with your doctor. It’s important to involve your rheumatologist and OB/GYN in your family planning when you have RA.

Medscape Medical Reference