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been found to pose a significant risk to pregnancy. In a registry of pregnancies following solid-organ transplantation, the pregnancy loss rate for those exposed to MMF was 42%, far higher than pregnancies in women without MMF use. Of the surviving pregnancies, 67% delivered preterm and 26% had congenital anomalies (3/4 included abnormalities of the ear) (94). With these high rates of pregnancy loss and anomalies, it is recommended that MMF is to be discontinued prior to conception. For patients maintained on MMF, with stable SLE who desire pregnancy, we recommend transitioning to azathioprine prior to conception. Cyclophosphamide (Category X). Cyclophosphamide is a well-known teratogen, particularly with first-trimester exposure. For women with breast cancer in pregnancy, it has been administered during the latter half of pregnancy without significant pregnancy loss or congenital anomalies (95). The use of cyclophosphamide in lupus pregnancy, however, has been less successful. There are three cases reported in the literature, one resulting in a live birth, and two ending with intrauterine foetal demise soon after the drug was administered (96, 97). Whether it is the medication or the severity of the lupus activity that triggered the use of the drug is unclear. It is important to avoid inadvertent conception during cyclophosphamide therapy by prescribing contraception and administering pregnancy tests throughout therapy. Intravenous immunoglobulin (IVIg). IVIg is an option for the treatment of SLE during pregnancy. It is thought to be relatively safe during pregnancy as the foetus is already exposed to maternal immunoglobulins during the latter half of pregnancy. IVIg can be effective therapy for moderate to severe SLE flares. It has been shown to diminish SLE activity and promote pregnancy success in a small cohort of 12 patients with SLE (98). Further validation of this finding is needed. Kart Koseoglu H, Yucel AE, Kunefeci G, Ozdemir FN, Duran H. Cyclophosphamide therapy in a serious case of lupus nephritis during pregnancy. Lupus 2001;10:818–20. [Google Scholar] Perricone R, De Carolis C, Kroegler B, Greco E, Giacomelli R, Cipriani P, Intravenous immunoglobulin therapy in pregnant patients affected with systemic lupus erythematosus and recurrent spontaneous abortion. Rheumatology (Oxford) 2008;47:646–51. [Crossref], [PubMed], [Web of Science ®], EULAR evidence-based recommendations on the management of systemic glucocorticoid therapy in rheumatic diseases J N Hoes, J W G Jacobs, M Boers, D Boumpas, F Buttgereit, N Caeyers, E H Choy, M This is an abbreviated version of the article; the full version is available online at http://ard.bmj.com/ supplemental See end of article for authors’ affiliations ..... Correspondence to: J N Hoes, Department of Rheumatology & Clinical Immunology (F02.127), University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands; mail@hoesjn. org Accepted 22 July 2007 ........ Ann Rheum Dis 2007;66:1560–1567. doi: 10.1136/ard.2007.072157 Objective: To develop evidence-based recommendations for the management of systemic glucocorticoid (GC) therapy in rheumatic diseases. Methods: The multidisciplinary guideline development group from 11 European countries, Canada and the USA consisted of 15 rheumatologists, 1 internist, 1 rheumatologist–epidemiologist, 1 health professional, 1 patient and 1 research fellow. The Delphi method was used to agree on 10 key propositions related to the safe use of GCs. A systematic literature search of PUBMED, EMBASE, CINAHL, and Cochrane Library was then used to identify the best available research evidence to support each of
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