For clinicians
NSAIDs
ibuprofen, naproxen, non-steroidal anti-inflammatory drugs
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Bottom lineBottom line: usable short-term in the first and second trimesters if needed; avoid from around the third trimester (premature ductus arteriosus constriction, oligohydramnios). EULAR 2024 takes a more restrictive stance than earlier guidance. Heavy pre-conception use can impair ovulation.
By reproductive phase
| Phase | Position | Detail | Evidence |
|---|---|---|---|
| Pre-conception | Use if needed | May be used short-term; heavy/continuous use can cause reversible anovulation (luteinized unruptured follicle); consider limiting when trying to conceive.[1, 2] | ●●○○low evidenceconditional |
| 1st trimester | Use if needed | May be used short-term at the lowest effective dose.[1, 3] | ●●○○low evidenceconditional |
| 2nd/3rd trimester | Avoid | EULAR 2024 (statement I.3a, verified): NSAIDs only intermittently and stopped after 28 weeks of gestation (premature ductus arteriosus constriction, oligohydramnios); nonselective short half-life agents (ibuprofen) preferred over COX-2 inhibitors.[1, 2] | ●●●○moderate evidencestrong |
| Breastfeeding | Continue | EULAR 2024 lists nonselective NSAIDs (e.g. ibuprofen) and celecoxib among agents compatible with breastfeeding.[2, 4] | ●●●○moderate evidenceconditional |
| Paternal | Continue | EULAR 2024 lists NSAIDs among drugs that can be continued in male patients trying to conceive.[2, 4] | ●●○○low evidenceconditional |
Guideline comparison
| Guideline | Position | Strength |
|---|---|---|
| ACR 2020 | Conditionally recommend for the first and second trimesters, preferring nonselective NSAIDs over COX-2 inhibitors (limited COX-2 data); strongly recommend AGAINST in the third trimester (risk of premature closure of the ductus arteriosus). Conditionally recommend discontinuing pre-conception if there is difficulty conceiving (possible NSAID-induced unruptured follicle syndrome). Breastfeeding: ibuprofen preferred. Paternal: conditionally recommend continuing.[1] | Conditional (1st/2nd trimester, nonselective preferred); strong against (3rd trimester) |
| EULAR 2024 | Nonselective NSAIDs may be used if needed to control disease (2a/B), only intermittently and stopped after 28 weeks of gestation; short half-life agents (ibuprofen) preferred; consider stopping if difficulty conceiving. Compatible with lactation (nonselective 2a/B; celecoxib 4/C). Continuable in men (2b/C).[2] | Oxford LoE/GoR as shown |
| BSR 2022/23 | Non-selective NSAIDs compatible peri-conception and, used intermittently, in the first trimester (possible small risk of miscarriage/malformation); wean from the end of the second trimester (26 weeks) and stop by gestational week 30 to avoid premature ductus arteriosus closure (GRADE 1B). Compatible with breastfeeding (ibuprofen preferred) and paternal exposure. COX-2 inhibitors avoided in pregnancy.[5] | Verified against BSR part 2 (Schreiber 2023) |
=Guideline divergence. VERIFIED DIVERGENCE (gestational stop-week). Three sources give three thresholds for stopping non-selective NSAIDs: EULAR 2024 stops after 28 weeks; BSR 2023 weans from 26 weeks and stops by week 30; and the US FDA (2020, cited by BSR) advises avoiding from 20 weeks. All agree on third-trimester avoidance and the mechanism (premature ductus arteriosus constriction, oligohydramnios). Both EULAR and BSR prefer short half-life non-selective agents (ibuprofen) and both avoid COX-2 inhibitors in pregnancy.
Key points
| Point | Evidence |
|---|---|
| Discontinue by around the third trimester; strong agreement across guidelines.[1, 3] | ●●●○moderate evidencestrong |
| Heavy/continuous use can transiently impair ovulation; consider limiting peri-conception.[2] | ●●○○low evidenceconditional |
Monitoring
- Review and stop NSAIDs before the third trimester.
- Consider alternatives for analgesia in later pregnancy.
References
- Sammaritano LR, et al. 2020 ACR Guideline for the Management of Reproductive Health in RMD. Arthritis Rheumatol. 2020;72(3):529-556. https://acrjournals.onlinelibrary.wiley.com/doi/10.1002/art.41191
- Ruegg L, et al. EULAR recommendations for antirheumatic drugs in reproduction, pregnancy, and lactation: 2024 update. Ann Rheum Dis. 2025;84(6):910-926. https://ard.eular.org/article/S0003-4967(25)00818-0/fulltext
- Russell MD, et al. BSR guideline on prescribing drugs in pregnancy and breastfeeding: comorbidity medications used in rheumatology practice. Rheumatology (Oxford). 2023;62(4):1388-1397. https://academic.oup.com/rheumatology/article/62/4/1388/6783016
- EULAR 2024 update, lactation and male-patient sections (nonselective NSAIDs including ibuprofen, and celecoxib, listed as compatible with breastfeeding; NSAIDs continuable in men). https://doi.org/10.1016/j.ard.2025.03.011
- Schreiber K, Frishman M, Russell MD, et al. British Society for Rheumatology guideline on prescribing drugs in pregnancy and breastfeeding: comorbidity medications used in rheumatology practice. Rheumatology (Oxford). 2023;62(4):e89-e104. https://doi.org/10.1093/rheumatology/keac552