Discontinuation of mycophenolate mofetil is indicated for this patient with systemic lupus erythematosus (SLE) who plans to become pregnant. Pregnancy outcomes in patients with SLE are better if their disease has been well controlled for 6 months prior to becoming pregnant. SLE can worsen during pregnancy in up to one third of patients, and hydroxychloroquine can reduce this risk. In addition, most rheumatologists continue stable low-dose prednisone during the pregnancy. Many medications used in SLE are contraindicated in pregnancy; permitted medications include prednisone, hydroxychloroquine, and azathioprine. Mycophenolate mofetil was developed to prevent transplant rejection but in recent years has been used as a treatment for SLE. Mycophenolate works by inhibiting the purine pathway in nucleotide synthesis and may be at least as effective as cyclophosphamide for SLE (including lupus nephritis) but with fewer and milder side effects. This agent is teratogenic and must be stopped for 3 months prior to becoming pregnant. Mycophenolate mofetil use may also be associated with difficulty in conception in some cases. This patient with SLE plans to become pregnant and has stable disease, and her laboratory parameters show no significant activity. Stopping mycophenolate is the only necessary intervention, and both hydroxychloroquine and prednisone should be continued unchanged.

Stopping all three medications would put this patient at unnecessary increased risk of a flare-up during pregnancy.