A further issue with medication safety was presented by Dr. Kiwalkar in a case of a male patient with PsA concerned about whether the medications he was on, including methotrexate, could affect his ability to become a father or if the medications could affect his children.
Dr. Kiwalkar discussed the four-step guide—this one in a handout specifically for men with PsA—that providers can use to talk to men about the safety of the medications they are taking. She pointed out that methotrexate is included in the grey list of drugs, so men on this drug do not necessarily need to stop this drug but would be encouraged to talk to a rheumatologist.
In the Q&A session, Dr. Birru Talabi expanded on this theme by noting that methotrexate is often seen as toxic and dangerous, with the potential to damage the DNA in men’s sperm, but that is when it is given in high doses as in oncology. In rheumatology where the doses are lower, she said such risks have not been consistently shown, leading her to tell her male patients that the drug is safe to use.
Contraception Counseling
Dr. Murugesan emphasized that, unlike with lupus, no types of contraception have contraindications for women with PsA. She stressed the importance of shared decision making between provider and patient to ensure the contraception chosen reflects the best option for that particular woman. Such a decision needs to weigh many issues other than just the effectiveness of birth control method, including side effects, cost, convenience of use, duration of time needed, benefit to such other reproductive health concerns as sexually transmitted diseases, and compatibility with religious and cultural beliefs.
Both Drs. Murugesan and Kiwalkar said that rheumatologists should be responsible for having these conversations with women given their expertise on the drugs used to manage PsA. Dr. Kiwalkar said that a good way to start the conversation is simply with a one liner, such as “Would you like to get pregnant in the next year?,” and then develop communications over this issue over multiple visits.
Talking early and often to women with PsA about their reproductive health is a key takeaway of this session. “We want to have the talk early and have it often, and we want to provide resources to providers so they can effectively communicate with patients,” said Dr. Murugesan.
More information on the ACR Reproductive Health Initiative and Guidelines can be found online: https://www.rheumatology.org/Practice-Quality/Reproductive-Health-Initiative. Resources include links to the PsA toolkit, free continuing medical education/maintenance of certification activities and videos.
