title: Safety of pain therapy during pregnancy and lactation in patients with inflammatory arthritis: a systematic literature review.
abstract: OBJECTIVE
  To systematically review the safety of various pain therapies used during pregnancy and lactation in patients with inflammatory arthritis.
  
  
  METHODS
  A systematic literature review was performed in Medline, Embase, the Cochrane Library, and the American College of Rheumatology/European League Against Rheumatism 2008-2009 meeting abstracts, as part of the multinational 3e (Evidence, Expertise, Exchange) Initiative for generating practical recommendations about Pain Management by Pharmacotherapy in Inflammatory Arthritis. Articles fulfilling predefined inclusion criteria were reviewed, and quality appraisal was performed.
  
  
  RESULTS
  The search yielded a total of 3974 articles and 7 abstracts. The only study that fulfilled the criteria for pain therapies in pregnancy was a systematic review published in 2008, evaluating the effects of nonsteroidal antiinflammatory drug (NSAID) use during pregnancy in patients with rheumatic conditions. Two of the 3 studies reviewed in the 2008 publication could be included in our current review. No studies were included in the review in relation to lactation. A total of 204 malformations were identified among infants exposed to NSAID, with an OR of 1.04. The number of identified cardiac defects was higher than expected, with an OR of 1.86. There seemed to be no specificity for the type of NSAID used. Among the 6 infants with orofacial clefts, 5 occurred with naproxen use and 1 with ibuprofen.
  
  
  CONCLUSIONS
  Only 2 studies evaluating the risk of NSAID use in patients with inflammatory arthritis were identified, with results suggesting a higher rate of cardiac malformations in infants exposed to NSAID during the first trimester. No studies evaluating the effects of other treatments, such as paracetamol, corticosteroids, muscle relaxants, neuromodulators, antidepressants, opioids, or opioid-like therapy in the specific context of rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, or spondyloarthritis, and no studies with respect to lactation were identified. Research is needed to improve the risk-benefit ratio of the use of pain therapies for inflammatory arthritis during pregnancy.
authors.affiliation: Department of Internal Medicine, Rheumatology Service, Centre Hospitalier Universitaire de l'Université Laval, Québec, Quebec, Canada. karen.adams@utoronto.ca
authors.forename: Karen
authors.initials: K
authors.lastname: Adams
authors.forename: Claire
authors.initials: C
authors.lastname: Bombardier
authors.forename: Désirée M
authors.initials: DM
authors.lastname: van der Heijde
mesh_terms: D000014:Abnormalities, Drug-Induced / Q000209:etiology; D000328:Adult; D000700:Analgesics / Q000009:adverse effects*; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000009:adverse effects; D001168:Arthritis / Q000150:complications / Q000188:drug therapy* / Q000503:physiopathology; D047108:Embryonic Development / Q000187:drug effects; D005260:Female; D047109:Fetal Development / Q000187:drug effects; D006330:Heart Defects, Congenital / Q000209:etiology; D006801:Humans; D007774:Lactation / Q000187:drug effects* / Q000502:physiology; D018811:Maternal Exposure / Q000009:adverse effects*; D010146:Pain / Q000188:drug therapy* / Q000209:etiology / Q000503:physiopathology; D059408:Pain Management / Q000379:methods*; D011247:Pregnancy; D011248:Pregnancy Complications / Q000188:drug therapy / Q000209:etiology; D011256:Pregnancy Outcome
chemical_list: D000700:Analgesics; D000894:Anti-Inflammatory Agents, Non-Steroidal