We thank Dr. Ruiz-Irastorza and colleagues for their thoughtful comments on the ACR guidelines for screening, treatment, and management of lupus nephritis in pregnant women. Dr. Ruiz-Irastorza and colleagues suggested that all pregnant patients with a history of lupus nephritis should be treated with hydroxychloroquine and noted that aspirin is recommended in some patients with nephritis for the prevention of preeclampsia. Although the ACR guidelines recommended hydroxychloroquine as background therapy for all patients with lupus nephritis (see page 802), the Task Force Panel did not recommend introducing new medications for the treatment of lupus in pregnant patients with a history of lupus nephritis but no evidence of disease activity. The majority of the Task Force Panel did vote in favor of adding hydroxychloroquine if there was any indication of active disease. Neither of these scenarios are the same as the scenario given by the authors in their letter, which suggested continuation of hydroxychloroquine in patients who become pregnant. As in all scenarios discussed in the guidelines, there is no intention to suggest that the approach deemed the best choice by a responsible clinician and/or by an evolving literature is contraindicated.
The issue of preventing preeclampsia in lupus patients highlights the need for specific recommendations for the management of lupus in pregnant patients. We agree that this is an important topic; however, we cannot address this topic at this time because this question was not given to the panel. We agree that this question should be considered for discussion in future updates to these guidelines.