ACR CONVERGENCE 2021—Rheumatologists are often left in a challenging space when managing medications for patients with rheumatic diseases in relation to contraception, pregnancy and breastfeeding, especially with many novel immunosuppressants and often a dearth of pregnancy safety data.
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Explore This IssueDecember 2021
On Nov. 6 during ACR Convergence 2021, leading reproductive health experts came together to speak on this subject in a session titled Reproductive Health Update: ACR 2020 Reproductive Health Guidelines & Medication Management. Mehret Birru Talabi, MD, PhD, assistant professor of medicine in the Division of Rheumatology and Clinical Immunology, University of Pittsburgh, first presented an overview of the ACR’s Guideline for the Management of Reproductive Health in Rheumatic and Musculoskeletal Diseases.1
“Many of the recommendations in the reproductive health guideline are conditional because much of the evidence is limited. Nonetheless, the [guideline] provides a comprehensive framework for reproductive healthcare and management of patients with rheumatic diseases,” she said.
Dr. Birru Talabi noted contraception is safe for women with rheumatic diseases, including hormonal contraception for most patients. Patients with antiphospholipid antibody (aPL) positivity, at moderate or high titer, should avoid estrogen-containing contraception, which can further increase their thrombosis risk. However, these patients can use a copper intrauterine device (IUD), progestin IUD or progestin-only pills.
For patients with systemic lupus erythematosus (SLE) without aPL, estrogen-containing oral contraceptive pills or vaginal rings can be used. However, non-estrogen methods are recommended for patients with SLE with moderate to high disease activity. Additionally, all patients with SLE should avoid the estrogen patch.
An important point was made regarding the potential need for two contraceptive methods in patients on mycophenolate. “Because mycophenolate reduces blood levels of estrogen and progesterone and may reduce the effectiveness of oral contraception pills, the reproductive health guideline recommends patients on mycophenolate also be prescribed a highly effective contraceptive method, such as an IUD, or two other forms of contraception, such as the pill and condoms,” Dr. Birru Talabi said.
Three unique populations are at higher risk for adverse outcomes in pregnancy, Dr. Birru Talabi explained. For patients with SLE, hydroxychloroquine is recommended, as well as low-dose aspirin started in the first trimester to reduce the risk of pre-eclampsia. Ro/SSA or La/SSB antibodies can be transferred across the placenta starting at around 18 weeks of gestation and may cause neonatal lupus, which ranges from transient rash to complete heart block in the neonate.
“For patients with anti-Ro/La positivity, the reproductive health guideline conditionally recommends [administering] hydroxychloroquine to reduce the incidence of heart block in the neonate and obtaining a screening fetal echocardiogram,” she said.