Editor’s note: ACR on Air, the official podcast of the ACR, dives into topics important to the rheumatology community, such as the latest research, solutions for practice management issues, legislative policies, patient care and more. Twice a month, host Jonathan Hausmann, MD, a pediatric and adult rheumatologist in Boston, interviews healthcare professionals and clinicians on the rheumatology front lines.
Dr. Hausmann
In a series for The Rheumatologist, we provide highlights from these relevant conversations. Listen to the podcast online at acronair.org, or download and subscribe to ACR on Air wherever you get your podcasts.
Making Medication Decisions
One challenge for patients and their rheumatologists is the decision to use certain medications during pregnancy. Patients may get mixed messages from their doctors in various specialties about drug safety, leading to confusion.
Example: A general practitioner may recommend stopping certain medicines that a rheumatologist may advise the patient to continue, and the OB/GYN’s perspective may be somewhere between those two positions.
“There’s a fine balance between giving medications to control a patient’s disease, [and avoiding] adverse effects on the growing fetus,” says Dr. Hausmann.
Some drugs used to treat patients with rheumatic diseases are generally safe during pregnancy, and others should clearly be avoided.
Dr. Sammaritano
Regarding drugs that fall into the first category, says Lisa Sammaritano, MD, professor of clinical medicine at Weill Cornell Medicine and an attending physician at the Hospital for Special Surgery in New York, “Some patients are so fearful—even if it’s a very, very low risk of an adverse outcome from a medication—that they just will refuse to take [that medication].”
On the other hand, says Dr. Sammaritano, who was the lead author of the 2020 ACR Guideline for the Management of Reproductive Health in Rheumatic and Musculoskeletal Diseases, she has had patients who realize the chance of an adverse side effect is low with some medications and that controlling disease will assist with both patient safety and the success of the pregnancy.1
An article in ACR Open Rheumatology focused on medication decision-making during pregnancy and lactation addressed some of these concerns.2 One of its co-authors, Whitney White, PharmD, BCPS, a clinical pharmacist practitioner with the Birmingham Veterans Affairs Medical Center, Ala., has rheumatoid arthritis (RA). She serves on the core leadership team for the ACR Reproductive Health Initiative and was also a guest on the podcast episode.
The research found a hesitancy to use anti-rheumatic drugs during pregnancy was common among the 66 women who were surveyed. Among the women prescribed medications considered safe during pregnancy, 80% opted not to use them while trying to become pregnant or during pregnancy or lactation.
Dr. White shared her own experience of having the option to change medications during pregnancy or stop medications completely. She chose to stop the medications and evaluate how she felt. She was able to remain off her medications during pregnancy and for a few months after delivering. But she says it’s a personal choice.
This choice is likely easier for patients with RA vs. lupus or other disorders because pregnancy may induce RA remission, Dr. Sammaritano says.
Educating Physicians
Because physicians may give patients mixed messages about which drugs are safe to use, the need exists for education across specialties to make clear which drugs are safe during pre-conception, and during pregnancy and lactation, and which ones are not. This discussion should include general practitioners, OB/GYNs, rheumatologists and pediatricians, if breastfeeding is involved, Dr. Sammaritano says.
Lactation and medications to treat rheumatic conditions were addressed in a 2021 study from Mills et al.3
“Until we reach all of the players who have a role and a voice in terms of a woman’s pregnancy and the health of her newborn, I think we’re going to have continued conflicting opinions,” Dr. Sammaritano says.
The ACR Reproductive Health Guideline addresses issues that become important during pregnancy and lactation.1
What may be helpful going forward is a small reference card that lists which drugs are safe during pregnancy or lactation that patients can share with other providers, the podcast guests say. This approach is also what was used in study by Mills et al., which found rheumatologist knowledge of medications that are safe or unsafe for breastfeeding increased with the simple use of a laminated reference card.3
Dr. White likened it to the new mother packet that patients often receive at an OB/GYN’s office when they are expecting. This packet contains a lot of information about what they will experience during pregnancy and which medications are considered safe or unsafe. Rheumatologists could provide something similar and geared toward rheumatologic medications.
Otherwise, patients are most likely guided by information given by the doctors they see more often, such as general practitioners or pediatricians.
Guiding Health Pre-Pregnancy
Another area discussed during the episode is medication choices made before a woman becomes pregnant. Speakers addressed research from Bortoluzzi et al., which was published in 2021 in Arthritis Care & Research.4 This topic is a key area because of the increased risk of adverse pregnancy outcomes when a patient’s disease is very active. Changing medications if needed to aim for quiet disease is often more useful before pregnancy than trying to do it after a woman is pregnant, Dr. Sammaritano says.
Quiet disease can help lead to better outcomes for both the mother and the baby. This approach applies to both lupus and RA, Dr. Sammaritano says.
This finding increases the importance of rheumatologists discussing family planning with all their patients early because certain medications can be started before the patient gets pregnant.
“Everything we give our patients impacts this area, and we need to be involved from the beginning,” Dr. Sammaritano says. This includes ensuring patients are using contraception if they take medications that are not considered safe during pregnancy.
Dr. White says she has been fortunate to have a rheumatologist who regularly addressed this topic during her pregnancies. It’s also important to address these concerns with male patients of reproductive age, she adds, including reviewing which medications they can use safely if they are trying to father a child.
Vanessa Caceres is a medical writer in Bradenton, Fla.
References
- Sammaritano LR, Bermas BL, Chakravarty EL, Chambers C, Clowse MEB, Lockshin MD, 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.
- Talabi MB, Eudy AM, Jayasundara MJ, et al. Tough choices: Exploring medication decision-making during pregnancy and lactation among women with inflammatory arthritis. ACR Open Rheumatol. 2021 Jul;3(7):475–483.
- Mills BS, Bermas BL. Improving knowledge of lactation compatibility of antirheumatic medications among providers who care for patients with rheumatic disease. ACR Open Rheumatol. 2021 Jan;3(1):50–54.
- Bortoluzzi A, Andreoli L, Carrara G, et al. Improved pregnancy outcomes in patients with rheumatoid arthritis who followed an ideal clinical pathway. Arthritis Care Res (Hoboken). 2021 Feb;73(2):166–172.
