What is your approach to transitioning an SLE patient from a pregnancy incompatible regimen to pregnancy compatible regimen?

There are no clear data on how to do this. One study (Fischer-Betz et al., PMID 23382355) transitioned patients by reducing the MMF by 500mg/d dosing every four weeks and then stopping MMFo once the patient is down to MMF 500mg/d and adding azathioprine 2mg/kg. In my clinical practice, I taper faster since I am going to observe the patients for four-six months once I have them transitioned, and this means that patients may be waiting nine months before trying to conceive. Moreover, since I try t...

I agree with Dr. @Dr. First Last and Dr. @Dr. First Last that there are not clear data, and it is more of an art than a science.

My rationale:

If I have someone preparing for pregnancy: that person has been in remission or close to remission for at least 3-6 months minimum (for the 3 months, it is because I would then do a 3 mo trial of azathioprine on top of that before trial of conception) before adjusting meds.

If the patient has severe enough SLE to require mycophenolate mofetil (MMF), I wou...

This is definitely more of the art than the science of lupus management.

I tend to overlap, but work fairly quickly, with alternating lab work and dose escalations to titrate up the azathioprine (after TPMT is obtained) in this MMF->aza swap. I do try to have them wait for 3 months after stopping MMF to try and conceive to look for disease stabilization. I really emphasize the TRY part because some patients think once the med is swapped they are ok to start trying.

For methotrexate or leflunomi...