5 November 2018

Finally, some guidance on rheumatic disease and pregnancy

Rheumatology Women

The first guidelines for reproductive health and rheumatic disease will stress the importance of maintaining good disease control during pregnancy.

In the past, women with rheumatic disease were instructed to stop taking medications during pregnancy to avoid potential harm to the fetus.

But the draft guidelines, presented at the American College of Rheumatology annual meeting in Chicago in October, warned uncontrolled rheumatic disease during pregnancy was probably a greater evil than taking pregnancy-compatible medications.

The draft guidelines were the result of more than a year of work, which included a systematic review of around 12,000 abstracts and more than 300 papers.

“Our patients, fortunately, are pursuing pregnancy more and more and because of that reproductive issues have become of increasing interest over the last years,” Associate Professor Lisa Sammaritano, a rheumatologist at the Hospital for Special Surgery in New York who oversaw the development of the new guidelines, said.

Women had better pregnancy outcomes if their rheumatic disease was quiescent at the time of conception, the guidelines said.

If a patient taking a teratogenic medication wanted to plan a pregnancy, the guidelines suggested switching to a pregnancy-compatible medication and observing disease activity for a period of time.

“We need to be sure that this new medicine will work,” Professor Sammaritano said. “The last thing you want to do is put her on a new medicine, have her get pregnant and have a big flare.”

The guidelines advised continuing hydroxychloroquine, sulphasalazine, azathioprine, colchicine, cyclosporine, tacrolimus and TNFi during pregnancy. “And we conditionally recommend continuing rituximab and other non-TNFi biologics until the time of conception,” Professor Sammaritano said.

Drugs that should be discontinued in women planning pregnancy were thalidomide, mycophenolate, methotrexate and leflunomide.

“We recommend that women consider stopping NSAIDs if they have difficulty conceiving since they are known in some cases to inhibit ovulation,” Professor Sammaritano said.

NSAIDs should be stopped in the third trimester of pregnancy, according to the guidelines. For patients with lupus who were thinking about starting a family, the guidelines advised continuing, and perhaps even initiating, hydroxychloroquine.

Low-dose aspirin should be prescribed towards the end of the first trimester in patients with lupus and antiphospholipid antibodies, regardless of other underlying risk factors for preeclampsia, Professor Sammaritano said.

The guidelines were evidence-based and used a GRADE methodology, but in the many areas where data was lacking the guidelines took a “common sense” approach, she said.

For instance, women with rheumatic disease who preferred to breastfeed should be encouraged to do so, but there was often little data about which medicines were transferred in breast milk and could harm the developing infant, Professor Sammaritano said.

“So it really does involve a discussion with a patient because it really does depend on how risk averse she may be.”

The guidelines recommended that breastfeeding mothers continue taking hydroxychloroquine, TNFi, rituximab and non-fluorinated steroids, and conditionally recommended the use of azathioprine, sulfasalazine, cyclosporine, tacrolimus, colchicine, NSAIDs (preferably ibuprofen) and non-TNFi biologics during breastfeeding.

Medications that should be avoided during breastfeeding included cyclophosphamide, mycophenolate, leflunomide, thalidomide and methotrexate.

The guidelines also aimed to dispel some of the myths surrounding contraception in women with rheumatic disease. Women with rheumatic disease were sometimes incorrectly informed by their gynaecologists they could not get IUDs because their autoimmune disease would cause them to reject the device.

The guidelines clear up this confusion by stating that long-acting reversible contraception should be considered the first-line method of contraception for all women, including those with rheumatic disease.

Also, in the past, some women with systemic lupus were told they could not take birth control pills due to concerns about oestrogen.

The new guidelines overturn this, endorsing the use of the oral contraceptive pill in women with lupus and other rheumatic disease as long as they do not have antiphospholipid antibodies.

“Finally, we encourage all of our patients … to use over-the-counter emergency contraception if needed or desired,” Professor Sammaritano said.

“That is felt to be safe for everyone including aPL-positive patients … when used appropriately, which is infrequently.”