ACR CONVERGENCE 2021—A comprehensive reproductive guideline published by the ACR in 2020 addresses making reproductive health and family planning issues in people with rheumatologic diseases an integral part of their care.1 During a session titled Reproductive Health & Psoriatic Arthritis: Enhancing Provider Education, experts described the educational training program developed by the ACR that focuses specifically on educating rheumatologists and other clinicians on reproductive health issues for women with psoriatic arthritis (PsA). Arthur Kavanaugh, MD, professor of medicine at the University of California, San Diego, who has led the Reproductive Health Initiative effort to develop educational materials on PsA and pregnancy, moderated the session.
Called PsA-RESPECT, the program is intended to educate clinicians on, and provide resources for, communicating with women on issues of fertility, pregnancy and lactation within the context of their disease and its management. The program also includes training on how to talk to men with PsA who have concerns about the impact of their disease on family planning.
Interactive cases were used to illustrate different scenarios of a provider-patient conversation around such important issues as contraception and medication safety. Key learning points were presented at the end of each case.
Dr. Murugesan
“The goal of this talk is to enhance education for providers and give them a toolkit so they are better prepared to start these conversations, even if patients themselves are not sure of what they want,” said Vagishwari Murugesan, MBBS, FRCPC, a clinical fellow in psoriatic arthritis at the University of Toronto, who was one of the presenters.
Medication Safety
Dr. Kiwalkar
Sonam Kiwalkar, MD, a rheumatologist at the Vancouver Clinic, Washington, presented a case that illustrated the important conversation providers need to have with their patients around medication safety and family planning. She walked participants through a four-step process—available in a handbook that can be given to female patients—providers can use when talking to patients about ensuring the safest pregnancy possible. The steps include a color-coded description of which drugs are the safest during pregnancy (green list), which drugs can be taken during pregnancy but should be discussed with a rheumatologist (grey list), and which drugs need to be stopped to ensure a safe pregnancy (red list).
Dr. Birru Talabi
Mehret Birru Talabi, MD, PhD, assistant professor of medicine and associate program director of the University of Pittsburgh Medical Center Rheumatology Fellowship Training Program, the third presenter in the session, emphasized during the question-and-answer (Q&A) session the need for clinicians to keep in mind that patients often hear a lot about potential toxicities of medications in general and are therefore concerned about the toxic potential of their medications when considering pregnancy planning. Providers, she said, need to remember to talk to patients about the benefits of these medications as well, both in general and in the context of reproductive health. She underscored the importance for women to understand the need for, and benefits of, adequately and safely treating their disease and the potential positive benefits this has on a future child.
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.
Mary Beth Nierengarten is a freelance medical journalist based in Minneapolis.
Reference
- 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 Apr;72(4):529–556.
