Men who want families, said Dr. Kavanaugh, should avoid medications that mutate sperm or interfere with its production. These treatments tend to be chemotherapeutic agents, of which cyclophosphamide is the most commonly used to treat rheumatic disease. Men should consider preserving their sperm if they need to go on the drug.
“Hydroxychloroquine, sulfasalazine, azathioprine, cyclosporine, tacrolimus, colchicine, all of the TNF [tumor necrosis factor] inhibitors and prednisone are all considered pregnancy compatible. There are data for all of those showing they are safe in pregnancy,” said Dr. Clowse, also a co-author of the 2020 ACR guideline.
Of the more than 600 pregnancies Dr. Clowse has managed in patients with rheumatic diseases, 90–95% are prescribed medication on the list above.
“All of our data really suggest that taking one of these medications, if it controls your disease, gives you a better chance of having a live birth, as well as having a baby delivered at term—all the way to their due date, or close to their due date,” she said.
For other medications, patients should consult with their doctors, given that safety data may not yet be available.
Some patients may also seek medical procedures or interventions to help them become pregnant, including in vitro fertilization, egg or sperm freezing and fertility medication. In most patients with quiet disease, according to the 2020 ACR guideline, assisted reproductive technologies can be strongly recommended. However, for patients with SLE or who are aPL positive, certain procedures carry additional risks because they may lead to potentially life-threatening lupus flares or blood clots. Patients and their providers should consult the guideline and discuss safety before proceeding.
According to a recent cross-sectional analysis from the Netherlands, men with inflammatory arthritis tend to have fewer children than the general population, especially when diagnosed at age 30 or younger.2
“This speaks to the importance of reproductive health, certainly from a male perspective,” said Dr. Kavanaugh, who also co-authored the 2020 ACR guideline. He recommended men have their disease under control before trying to conceive and that they discuss their circumstances with their doctors.
Among the limitations when it comes to guidance for patients with rheumatic diseases is a lack of comprehensive clinical data pertaining to many aspects of reproductive health. The guideline relied on Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology to rate the quality of evidence when making recommendations. The guideline authors also used group consensus to grade the strength of the recommendations. From this process, 12 good practice statements and 131 graded recommendations emerged for reproductive healthcare in patients with rheumatic diseases. The intent of the guideline is to inform a shared decision-making process between patients and their providers.
