Pregnancy and Lactation The use of many immunosuppressive drugs may present risks to an unborn baby. If you are beginning these drugs, talk to your doctor about your long-term plans for pregnancy. Your doctor will be able to suggest contraceptive measures during treatment. If you have uncontrolled lupus, pregnancy should be avoided until the lupus is controlled, as outcomes will be better for the baby and for you. Your doctor may also suggest delaying pregnancy for several months after stopping certain drugs to allow them to be cleared from your system and avoid affecting your unborn baby. Some drugs may pass into breast milk. Expectant mothers who plan to breastfeed and who take any medications should consult their lupus specialists to ensure that breastfeeding is safe for the baby. Cyclophosphamide (Cytoxan®): This agent inhibits cell division and growth, and it is a strong immunosuppressive drug. Cyclophosphamide in lupus treatment is reserved for very serious kidney disease or other internal organ involvement. It has the potential for severe side effects, including the risk of serious infection. Although well tolerated by most people, cyclophosphamide may cause nausea and vomiting, and its use may decrease blood cell counts. Hair loss may also be a problem. Additional side effects can include temporary or permanent sterility in both women and men. There may be options for limiting this risk, so discuss with your specialist. This drug can also damage a developing fetus if a woman becomes pregnant while being treated with the drug, so using contraception is very important. Because this medication is cleared by the kidneys and excreted in the urine, it can cause inflammation and bleeding in the bladder. One way to try to prevent this is to drink extra fluids, as directed by your doctor. The drug is usually given by injection in lupus, often with another intravenous medication (Mesna™ or Uromitexan®) to limit adverse effects on the bladder. Methotrexate (Rheumatrex®): Methotrexate may be useful for certain types of lupus activity (e.g. arthritis) when other drugs (e.g.,nonsteroidal anti-inflammatory drugs (NSAIDs) or anti-malarials) do not adequately control the symptoms. In fact, methotrexate is often used in combination with these drugs. Some people like this drug because it is only taken once a week. Methotrexate is generally not chosen for very severe lupus. Side effects of methotrexate may include liver and lung reactions, as well as lowered cell counts. Stomach upset, sores in your mouth, or hair loss may also be a problem. If you are receiving this drug, you should have blood tests to monitor your cell counts and liver regularly; your doctor will modify the dosage if you experience side effects. To re- duce toxicity, a supplement (folic acid) is prescribed. Avoid drinking any alcohol while on methotrexate. This drug should not be taken during pregnancy as it can cause miscarriages and birth defects. Mycophenolate mofetil (CellCept®): Developed to prevent the rejection of transplant- ed organs, mycophenolate is increasingly used as an alternative to cyclophosphamide for lupus with kidney involvement. It may be useful for other forms of lupus activity also. Mycophenolate works by curbing excessive activity of lymphocytes (a type of white blood cell). It is often well tolerated, although it can cause nausea and diarrhea. When you take this drug, regular lab tests including cell counts, are required. 57