Rheumatic Diseases and Pregnancy: Should HCQ Dose Change in Pregnancy?

Tuesday, April 9, 2019

Megan Clowse, MD, MPH, associate professor of medicine (Rheumatology and Immunology), has been collecting data about disease activity and pregnancy outcomes from pregnant women with rheumatoid disease since 2007. The registry includes patient questionnaires, blood samples, and medical records. Originally called Duke Autoimmunity in Pregnancy (DAP), the registry has been renamed Maternal Autoimmune Disease Research Alliance (MADRA) and expanded to include patients from other institutions.

For women who take hydroxychloroquine (HCQ) to control rheumatic disease, research has shown that it’s best for mother and baby to continue the medicine during pregnancy. But should the dose be maintained, decreased, or increased? After all, pregnancy brings many metabolic and physiologic changes including weight gain, an increase in blood volume, and changes in kidney and liver function.

Stephen Balevic, MD, assistant professor of pediatrics and medicine (Rheumatology and Immunology), set out to investigate this question using data from the DAP registry. He looked at 145 blood samples collected from 50 women at different times during pregnancy. About half of the women had lupus. The other half had other rheumatic diseases for which they had been prescribed HCQ.

Balevic found that the level of HCQ per volume of blood decreases as the pregnancy progresses. However, the total amount in the body stays relatively stable, indicating there’s probably no need to adjust the dose. Clowse adds, “We are doing additional work to understand the best dose of hydroxychloroquine to give to improve pregnancy outcomes.”

Balevic also made the unexpected finding that about a quarter of the women at some point had low or non-existent HCQ levels, indicating that they probably weren’t taking their prescribed HCQ.

Most of these blood samples came from first prenatal visits. After that visit, blood levels among those women indicated that they resumed taking the drug. It may be they were reassured by Clowse after that first visit about the benefits to the baby of continuing HCQ. Even this limited amount of time off HCQ had the potential to cause problems.

“Women with lupus who had a period of time they weren’t taking HCQ had more pregnancy complications,” Clowse says.

Balevic, Clowse, and colleagues published the results in the Journal of Rheumatology in October 2018.

Read more in the series

Helping Women with Rheumatic Disease Have Families

Rheumatic Diseases and Pregnancy: How do Outcomes Correlate to Patient-Reported Measures?

New Lupus Subtyping System Improves Care and Communication

This story was written by Mary-Russell Roberson, a freelance writer for the Department of Medicine.