Reproductive Health Considerations in Psoriatic Arthritis Care

Key Takeaways:

• If possible, time conception to disease control. PsA activity tends to ease during pregnancy and rebound within 6 months postpartum, so aim for remission or low disease activity on a pregnancy-compatible regimen before conception.
• Sort the drugs early. Methotrexate, leflunomide, mycophenolate, and thalidomide must be stopped before conception with effective contraception in place, whereas tumor necrosis factor inhibitors can generally continue.
• Plan for lactation and the other parent. All biologic disease-modifying antirheumatic drugs are considered compatible with breastfeeding, and methotrexate and sulfasalazine are now regarded as compatible with male reproduction.

Psoriatic arthritis (PsA) frequently shows up during the third and fourth decades of life, the same years in which many patients are building families. Yet reproductive health is often the part of the visit that goes unspoken, displaced by joint counts, skin scores, and treatment changes.

For a disease managed with agents that range from clearly teratogenic to reassuringly compatible with pregnancy, that silence carries real risk. Folding family planning into routine PsA care is not an add-on; it is part of prescribing responsibly.

Timing conception to disease control

The strongest lever a clinician holds is timing. In a prospective multicenter cohort of 108 pregnancies in women with PsA, roughly three-quarters were in remission or low disease activity during and after pregnancy, with activity tending to fall during gestation and rising again within the first 6 months postpartum.¹

That pattern argues for conceiving during quiescent disease and anticipating a postpartum flare rather than being caught off guard by it. Both the American College of Rheumatology (ACR) and the European Alliance of Associations for Rheumatology (EULAR) frame remission or low disease activity on pregnancy-compatible therapy as the preconception goal.^2,3

Medications that must stop before conception

Several drugs used in PsA are incompatible with pregnancy and should be discontinued in advance. Methotrexate and leflunomide are established teratogens. The ACR guideline advises stopping methotrexate before conception and performing a cholestyramine washout for leflunomide given its long half-life, while mycophenolate, cyclophosphamide, and thalidomide are likewise contraindicated.²

Because these agents are common in PsA and adjacent disease, effective contraception – long-acting reversible methods are preferred – belongs in the same conversation as the prescription, ideally at the visit when a potentially teratogenic drug is first started.²

Therapies that can continue

Reassurance matters just as much. Tumor necrosis factor (TNF) inhibitors may be continued through pregnancy when needed to maintain control, a position shared by the ACR and reaffirmed in the 2024 EULAR update.^2,3

Certolizumab pegol is a useful option near term. In the CRIB study, 13 of 14 infants had no detectable drug at birth, consistent with minimal placental transfer.⁴

Other monoclonal TNF inhibitors cross the placenta increasingly in the second and third trimesters, which does not preclude their use but should inform the timing of certain vaccines, such as the BCG vaccine for tuberculosis, in the exposed infant.^2,3

Low-dose glucocorticoids and several pregnancy-compatible conventional synthetic agents round out the toolkit. Nonsteroidal anti-inflammatory drugs may be used selectively earlier in pregnancy but should limit prescribing between 20 and 30 weeks and avoid after 30 weeks, where the US Food and Drug Administration (FDA) warns of oligohydramnios from fetal renal effects. The low-dose 81 mg Aspirin is the exception, for preeclampsia prophylaxis.^3,5

Where the evidence is still thin

The newer targeted therapies occupy less certain ground. Human pregnancy data for interleukin-17 and interleukin-23 inhibitors are accumulating but remain limited. And the oral targeted synthetic agents – Janus kinase inhibitors and the tyrosine kinase 2 inhibitor – lack sufficient human safety data and are generally discontinued before conception, with effective contraception advised during use.^2,3

When a patient on one of these agents plans a pregnancy, transitioning to a better-characterized option, most often a TNF inhibitor, is the pragmatic path.³

Lactation and the other parent

The postpartum plan matters as much as the prenatal one. The 2024 EULAR update concludes that all biologic disease-modifying antirheumatic drugs may be used during breastfeeding; certolizumab again has direct evidence, with minimal to no transfer into breast milk in the CRADLE study.^3,6

Paternal exposure warrants its own counseling. Current EULAR guidance regards methotrexate and sulfasalazine as compatible with male reproduction, correcting an older reflex to stop them, though sulfasalazine can cause reversible oligospermia relevant to a couple struggling to conceive.³

Making the conversation routine

None of this works as a one-time disclaimer. The practical move is to raise contraception and pregnancy intentions early – at diagnosis and whenever therapy changes – document the plan, and coordinate with obstetric colleagues around a shared timeline. Handled proactively, reproductive health becomes another domain of PsA control rather than a reason to abandon it.