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The ACR Introduces a New Reproductive Health Guideline

  |  Issue: March 2020  |  

third trimester;

  • Continue hydroxychloroquine, sulfasalazine, colchicine and azathioprine during pregnancy. Continue TNF-inhibitors during pregnancy if clinically necessary;
  • Consider cyclophosphamide (in the second or third trimester) or rituximab during pregnancy in women with organ- or life-threatening disease; and
  • In women on non-fluorinated steroid therapy, continue low-dose steroids if needed.

    • Good practice statements on breastfeeding: Rheumatologists should encourage their female patients to breastfeed if they desire, maintain disease control with medications compatible with lactation, and review the risks and benefits particular to each patient. Other recommendations:

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    • While breastfeeding, women should avoid cyclophosphamide, thalidomide, mycophenolate, leflunomide and methotrexate;
    • While breastfeeding, women should continue hydroxychloroquine, TNF inhibitors, rituximab and non-fluorinated steroids; and
    • Women on higher (20 mg or more per day) steroid doses should avoid breastfeeding within four hours of taking their drug—and discard any milk pumped or expressed in that same window.

    Susan Bernstein is a freelance medical journalist based in Atlanta.

    References

    1. Sammaritano LR, Bermas BL, Chakravarty EE, et al. 2020 American College of Rheumatology guideline for the management of reproductive health in rheumatic and musculoskeletal diseases. Arthritis Rheumatol. 2020. [online first].
    2. Committee on Gynecologic Practice Long-Acting Reversible Contraception Working Group. Committee Opinion No. 642. Increasing access to contraceptive implants and intrauterine devices to reduce unintended pregnancy. Obstet Gynecol. 2015 Oct;126:e44–e48.
    3. American College of Obstetricians and Gynecologists—Committee on Practice Bulletins: Gynecology. Practice Bulletin No. 141: Management of menopausal symptoms. Obstet Gynecol. 2014 Jan;123(1):202–216.
    4. Buyon JP, Petri MA, Kim MY, et al. The effect of combined estrogen and progesterone hormone replacement therapy on disease activity in systemic lupus erythematosus: A randomized trial. Ann Intern Med. 2005 Jun 21;142(12 Pt 1):953–962.
    5. Miyakis S, Lockshin MD, Atsumi T, et al. International consensus statement on an update on the classification criteria for definite antiphospholipid syndrome (APS). J Thromb Haemost. 2006 Feb;4(2):295–306.

    Editor’s note: Updated from an article in the January 2019 issue of The Rheumatologist.

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