The subject of pregnancy and inflammatory bowel disease has been writtenabout extensively. Treatments are changing, and one worries about the effecton the unborn child. One reader wrote the following:
Thanks for an informative web page. I also subscribe to the IBD list and appreciate your comments. I have looked through some old IBD posts and saw where you said taking Imuran when conceiving a child gave you the willies. I was diagnosed with Crohn’s in 1993. I am now 27 years old and my husband and I want a child. I have been taking Imuran (50 mg a day)since November 1994. My GI has reluctantly agreed to let me try to taperoff Imuran. He feels Imuran is the reason that I was finally able to taper off prednisone after 3 years. I have been on Pentasa since March 1994.My GI feels that I will have a flare up when I discontinue the Imuran andthat would be a greater risk to the baby than the risk of birth defectscaused by continuing to take Imuran. My OB says the Imuran is unsafe duringpregnancy. I also would like to breast feed and Imuran would make thatimpossible. I’ve been told by my GI and OB that Pentasa is safe during pregnancy.
The above situation is a real example of the problems that face onewho is contemplating pregnancy with Crohn’s. The physicians seem to begiving contradictory advice. Actually, each is concerned about the outcomefor the patient, and different factors come into play.
While no one advocates the use of Azathioprine in pregnancy, the reportsof the outcomes for patients on azathioprine who get pregnant seem to beno worse than the results of patients with untreated Crohn’s. That is tosay, fetal loss is common in active Crohn’s and also when on azathioprine.The incidence of birth defects is not higher when on azathioprine. My interpretationof this is that if azathioprine causes birth defects in a given pregnancy,they are so severe that the fetus will not survive. There was some controversya while back on what the effect of pregnancy on Crohn’s is. I think theliterature pretty much now shows that people respond variably, but thatif Crohn’s is active at the time of conception that things will probablynot go well.
All that said, most drugs used in treatment of IBD have been found tobe safe during pregnancy. Steroids are known to be safe, as is sulfasalazine.Mesalamine is probably safe during pregnancy. Flagyl is not to be used(though the data I recall are just scattered case reports, and the warningto not use it may not stand up in the future).
Remember that many people were successfully treated with medicationsbefore azathioprine came into common use for Crohn’s disease. While azathioprinemay be used to get a patient off steroids, the situation generally is notthat steroids were ineffective, but that steroids were needed chronicallyand side effects were a concern.
My feeling about this is that since pregnancy is self limited in duration,getting off azathioprine at worst will mean 12 to 16 months of steroids.If the Crohn’s can be controlled with other medications, then all the better.In general, I would advise patients on azathioprine to get off the azathioprineand start steroids, a form of mesalamine, or both depending on circumstances.Also, I generally advise Crohn’s patients to avoid anything with sucrosein it, since some studies in the past showed a 50% reduction in complicationsof Crohn’s when that was done.
The above notwithstanding, there is the possibility that a particularcase of Crohn’s was so bad that even the thought of recurrence is painful.I could imagine someone who had multiple fistulas, obstructions, operationsand wound failure, was starting to get cataracts, and who only got outof a cycle of repeated hospitalizations when put on azathioprine. A casesuch as that might warrant the risk of azathioprine.
I cannot tell what is the right choice, however. This will depend onhow the risks sound to you and many aspects of your views on life, death,having children, and dealing with birth defects. It is not your responsibilityto make the medical decisions, but the input to your physicians on howyou value the various outcomes will let your doctors, who have a sensefor the relative rates of occurrence of the above outcomes, give betteradvice on how to proceed.
Best of luck in your efforts!
Stephen Holland, M.D.
Section of Clinical Pharmacology
University of Illinois College of Medicine at Peoria