For clinicians
TNF inhibitors
anti-TNF, adalimumab, etanercept, infliximab, certolizumab, golimumab
Looking for the plain-language version? See the patient version of this page.
Bottom lineBottom line: EULAR 2024 supports use of TNF inhibitors throughout pregnancy on an individualised basis and considers them compatible with breastfeeding. Placental transfer is agent-specific: certolizumab pegol transfers minimally; adalimumab, infliximab, and golimumab transfer more in the second half. Consider infant live-vaccine timing after later-pregnancy exposure to high-transfer agents.
By reproductive phase
| Phase | Position | Detail | Evidence |
|---|---|---|---|
| Pre-conception | Continue | Continue as needed to maintain disease control.[1, 2] | ●●●○moderate evidencestrong |
| 1st trimester | Continue | Continue; large reassuring cohort data, mainly for the first two trimesters.[2, 3] | ●●●○moderate evidencestrong |
| 2nd/3rd trimester | Continue | EULAR 2024 supports continuation throughout; consider timing of third-trimester dosing for high-transfer monoclonals; certolizumab needs no such adjustment.[2, 3, 4] | ●●●○moderate evidenceconditional |
| Breastfeeding | Continue | Compatible with lactation; minimal milk transfer of large antibodies.[2] | ●●●○moderate evidencestrong |
| Paternal | Continue | Compatible with paternal exposure on current evidence.[2] | ●●○○low evidenceconditional |
Guideline comparison
| Guideline | Position | Strength |
|---|---|---|
| ACR 2020 | Conditionally recommend continuing infliximab, etanercept, adalimumab, and golimumab before and during pregnancy: continue through the first and second trimesters and discontinue in the third trimester several half-lives before delivery (Table 3: +/+). Strongly recommend continuing certolizumab before and throughout pregnancy (minimal placental transfer; Table 3: ++). Compatible with breastfeeding (++). Paternal: strongly recommend continuing all TNF inhibitors.[1] | Conditional (infliximab/etanercept/adalimumab/golimumab); strong (certolizumab) |
| EULAR 2024 | All TNF inhibitors can be used throughout pregnancy (2a/B) and are compatible with lactation (2a/B); continuable in men (1b/B).[2] | Oxford LoE/GoR as shown |
| BSR 2022/23 | All compatible at peri-conception and in the first trimester, and with breastfeeding and paternal exposure. In the second/third trimester, infant vaccination depends on the agent: if disease-flare risk is low and the drug is stopped by 20 weeks (infliximab), 28 weeks (adalimumab, golimumab), or 32 weeks (etanercept), a full-term infant can follow the normal vaccination schedule. Certolizumab is compatible throughout with no vaccination caveat.[3] | Verified against BSR Table 1 |
=Guideline divergence. VERIFIED DIVERGENCE (infant vaccination thresholds). EULAR 2024 states rotavirus may be given on schedule after any in utero TNFi exposure, and that BCG should be delayed 6 months after second-half exposure to transferring agents (adalimumab, golimumab, infliximab after GW20; etanercept after GW32). BSR 2023 frames this by stopping thresholds for a normal infant schedule: infliximab by 20 weeks, adalimumab and golimumab by 28 weeks, etanercept by 32 weeks. The adalimumab/golimumab week differs between the two (GW20 vs 28 weeks). Both agree certolizumab requires no change. Both permit TNFi across pregnancy and breastfeeding.
Key points
| Point | Evidence |
|---|---|
| Discontinuation is a recognised flare risk; treat-to-target through pregnancy is favoured over prophylactic withdrawal.[2] | ●●●○moderate evidenceconditional |
Special populations
- CRIB (Mariette 2018, verified primary text): of 14 evaluable infants, 13 had no quantifiable certolizumab at birth (<0.032 ug/mL) and 1 had 0.042 ug/mL (infant/mother plasma ratio 0.0009). The authors conclude there is no to minimal placental transfer, supporting continuation through the third trimester. ●●●○moderate evidenceconditional[4]
- EULAR 2024 (Table 1 footnotes): rotavirus can be given on schedule after in utero TNFi exposure (2b/B). BCG should be delayed 6 months only after second-half exposure to TNFi with transplacental transfer (adalimumab, golimumab, infliximab after GW20; etanercept after GW32) (2b/B). Certolizumab has minimal-to-no transfer and requires no schedule change (2b/B). ●●○○low evidenceconditional[2]
Monitoring
- Note which agent and the timing of the last dose for infant vaccination planning.
- Coordinate infant live-vaccine timing with paediatrics.
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: immunomodulatory drugs and corticosteroids. Rheumatology (Oxford). 2023;62(4):e48-e88. https://academic.oup.com/rheumatology/article/62/4/e48/6783012
- Mariette X, et al. Lack of placental transfer of certolizumab pegol during pregnancy (CRIB). Ann Rheum Dis. 2018;77(2):228-233. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5867410/
- Summary report of the EULAR 2024 update, including infant vaccination guidance after in utero bDMARD exposure and the expanded lactation compatibility list. https://www.rheumatologyadvisor.com/features/2024-eular-update-antirheumatic-drugs-in-reproductive-health/