Practicing rheumatologists are often ill at ease when it comes to advising patients on issues such as contraception, pregnancy, breast feeding, and menopause. Recognizing the need to improve care for patients with rheumatic diseases during their reproductive years, ACR has developed a new clinical guideline.
The details will be reviewed at a clinical practice session, Reproductive Health in Rheumatology Patients: New ACR Clinical Guideline, from 2:30 – 4:00 pm on Tuesday in Room W375b.
Lisa R. Sammaritano, MD, Clinical Rheumatologist at the Hospital for Special Surgery at Weill-Cornell Medicine, New York, NY, and a researcher who studies reproductive health in rheumatology patients, will provide an overview of the recommendations.
“The new guideline addresses important and common clinical issues for rheumatologists,” she said. “While rheumatologists obviously do not provide direct reproductive health care, our input is critical in helping to manage our complicated medical patients through each stage of the reproductive lifespan. This is an unusual guideline in terms of its broad spectrum. It covers a number of different but related topics.”
For example, the guideline offers recommendations for pre-pregnancy assessments, disease management and monitoring during pregnancy, and appropriate pregnancy-compatible medical therapies.
Under contraception, Dr. Sammaritano said, the guideline addresses the safety and effectiveness of various methods for rheumatic disease patients and offers stratified recommendations for subgroups of patients, including those who are antiphospholipid positive or who have active systemic lupus erythematosus.
The guideline also addresses disease- and medication-related neonatal risks, postpartum management and lactation, fertility issues, menopause therapies, and paternal medication use.
“Women and men with autoimmune and inflammatory disease often face reproductive health issues related to their disease or therapy,” Dr. Sammaritano said. “Since reproductive-aged women are disproportionally affected by rheumatologic disorders, family planning issues including contraception and pre-conception counseling, fertility, pregnancy management, and postpartum management, including breastfeeding, are an important part of disease management. There are, however, many unanswered questions in this area. These recommendations are designed to answer these questions, where possible, as well as to identify new areas for research, where data are lacking.”
The effort to improve reproductive health care for rheumatology patients began more than four years ago, when ACR had a two-day reproductive health summit that included rheumatologists, pediatricians, obstetricians-gynecologists, pharmacologists, and others to explore the many aspects of reproductive health for patients, especially looking at the safety of newer disease-modifying anti-rheumatic drugs (DMARDs) in pregnancy and breastfeeding, she said.
ACR has continued to recognize this aspect of patient care, designating reproductive health as a distinct research category for the Annual Meeting. The ACR released a call for letters of interest for the Reproductive Health Guideline in 2016 and Dr. Sammaritano’s group — composed primarily of researchers working in this area for many years — responded with a proposal.
“I think clinicians should come to this presentation and read the published manuscript for guidance in this area, which often provokes discomfort in rheumatologists because of their lack of familiarity with OB-GYN care,” Dr. Sammaritano said. “Pregnancy management, recommended contraceptives, and data on medication safety in pregnancy and breastfeeding have evolved, and these recommendations will educate and guide clinicians regarding frequently asked questions in these areas. As rheumatologists we cannot and would not expect to learn the intricacies and updates in the field of OB-GYN. We should not expect OB-GYNs to learn the intricacies and updates in rheumatology. As rheumatologists, we should be prepared to offer our expertise to our OB-GYN colleagues in a knowledgeable way and work together with them to provide comprehensive care for our patients.”
Following Dr. Sammaritano’s presentation, investigator Bonnie Bermas, MD, and colleagues will present case examples to demonstrate how to use the reproductive health guideline in practice.
“Things do change during a women’s reproductive life cycle. The course of the rheumatic disease changes and the medications available to us change during pregnancy and breastfeeding and beyond,” Dr. Bermas said.
“For many years, patients with rheumatologic diseases were often told not to get pregnant. But now we understand that we can help our patients if they want to get pregnant,” she said. “We can help them answer questions about when is the best time for them to get pregnant and how to do that if they need assistance. We can answer questions about appropriate contraceptives and hormone replacement and much more.”
For example, one case will highlight medications that are not compatible with pregnancy.
“We want to avoid pregnancy during times when patients are taking medications that are not compatible with pregnancy,” Dr. Bermas said. “And if a patient wants to get pregnant, we need to help them do it at a time when their disease is very well controlled.”
Other case presentations will address the questions of contraception and lactation.
“The guideline will give providers the information necessary to make decisions regarding what medication to use when their patients are nursing. Providers will now have the knowledge they need to successfully navigate the reproductive years with patients,” Dr. Bermas said.
The session will also include a presentation by Eliza Chakravarty, MD, Associate Member of the Arthritis & Clinical Immunology Research Program at the Oklahoma Medical Research Foundation, Oklahoma City, OK, who will discuss the methods and literature review involved in developing the guideline.