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How long should I come off methotrexate before trying to conceive?

Q) I am 32 and have rheumatoid arthritis. I take methotrexate and have eight weekly infusions of infliximab. My husband and I would like a family, however I have been told I have to come off all treatment for six months before trying to conceive. Last year my eight-weekly treatment was delayed by one week and I deteriorated badly and quickly. The thought of not having treatment for six months is not good, but I would like a family. Is there anything that can be done?
Mrs Anne Shenton, Weeping Cross, Stafford (Winter 2012)

A) This is a common problem. Methotrexate can cause birth defects and should be stopped before trying to conceive. Just how long the drug should be stopped for is under debate – some say six months, some three months. It is also recommended by the manufacturers that TNF inhibitors are also discontinued prior to conception but the evidence that these drugs cause birth defects is not anywhere near as strong. My practice is to recommend discontinuation of methotrexate for three months before trying for a baby and to advise the prospective parents of the recommendations and risks of continuing with TNF inhibitors. If the prospective parents are not prepared to risk continuing with TNF inhibitors then other drugs, known to be relatively safe, must be given. These may include hydroxychloroquine, sulfasalazine and steroids. The good news is that for most people the arthritis will improve during the pregnancy.


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