Speak Out Rheum: To Prescribe Is Humane (Unless You’re In Texas)

You are a rheumatologist in Texas. You are very well trained. Your mentors included some of the leaders in rheumatology, and you are respected by your colleagues and your patients. You know the devastation of untreated rheumatoid arthritis and lupus.

A young woman with recent onset of systemic lupus erythematosus is your new patient. You discuss the indications and side effects with her, and you both agree that, in her case, methotrexate is the drug of choice. You are well aware of the ACR’s guidelines relating to the use of this drug when there are issues of reproductive health.¹ The risks of pregnancy with methotrexate are discussed as part of the informed consent process. The patient concurs and takes oral contraceptives for several months before initiating treatment with methotrexate.

After starting treatment, and despite using oral contraceptives, your patient becomes pregnant. (Author’s note: Oral contraceptives have a pregnancy prevention failure rate upward of 5%.²) The patient did not realize she was pregnant because her periods have been irregular since she became ill. However, she begins to have pain and severe bleeding, evidence of a spontaneous miscarriage.

A formerly friendly neighbor who is short of cash and is now a bounty hunter becomes aware of her plight and reports her to the authorities.³ The accusation is that she has induced an abortion.

The new pharmacist who refused to renew your methotrexate order for the patient justified that action based on suspicion that you are using it as a abortifacient because you did not indicate on the renewal prescription that it is being used to treat the patient’s lupus.^4-6 You note the drug is used for multiple ailments, and it is not the role of a pharmacist to determine the suitability of a medication for a patient.^7,8

Your happy days as a rheumatologist are over. The joyful days of being a dedicated physician who believed in the sanctity of the doctor–patient relationship is now a myth. The patient’s constitutionally protected rights and the right to privacy that existed prior to the U.S. Supreme Court decision in Dobbs v. Jackson Women’s Health Organization are over in the state of Texas.

The Aftermath

You are accused of inducing an abortion and await your deposition. You ponder the questions: Did you induce the abortion deliberately? Of course not. Then why did you prescribe methotrexate knowing it can induce abortion? Did you conspire with the patient to end the pregnancy because you both feared the toxic effects on the fetus?