The ACR Has Introduced a New Reproductive Health Guideline Draft

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CHICAGO—Reproductive health can be a concern for patients with rheumatic diseases, and practitioners in both disciplines often work closely together. The Reproductive Health in Rheumatic and Musculoskeletal Diseases Guideline, a draft of new clinical recommendations developed by an ACR-convened group for pregnant women, post-menopausal women, lactating women, and women and men trying to conceive or delay conception, was presented at the 2018 ACR/ARHP Annual Meeting. The evidence-based guideline includes contraceptive recommendations and suggestions for rheuma­tologists co-managing patients with obstetrician-gynecologists and other specialists.

Literature Review

The guideline’s literature review team accepted 319 out of 11,760 published manuscripts for systematic review, said Eliza Chakravarty, MD, MS, associate member, Arthritis and Clinical Immunology Research Program at the Oklahoma Medical Research Foundation, Oklahoma City. Other fields have many well-structured, randomized, controlled trials, but “we wound up working with relatively lower-quality evidence based on the available studies,” she said. Thus, most of the recommendations are conditional, not strong.

The Voting Panel included rheumatologists, OB/GYNs, reproductive medicine specialists and patients. The panel required 70% agreement to reach consensus on whether to include or discard recommendations, said Dr. Chakravarty. The guideline also includes good practice statements, which are clinical suggestions, such as to counsel rheumatic disease patients on the use of potentially teratogenic medications.

Principal Investigator Lisa R. Sammaritano, MD, associate professor of clinical medicine at Weill Cornell Medical College and associate attending physician at the Hospital for Special Surgery, New York, presented many of the recommendations from three draft manuscripts that will be submitted in early 2019 to the ACR for approval and to Arthritis & Rheumatology and Arthritis Care & Research for 2019 publication. Patients on the panel had a consistent message, she said: “My rheumatologist knows me much better than my gynecologist.” Even if you are pressed for time, “patients really do want to talk to their rheumatologists about these topics,” she said.

Contraception

Condoms and the estrogen-progestin combination pill have lower efficacy in preventing pregnancy, so the guideline suggests the more effective long-acting reversible contraception (LARC) methods, such as IUDs or implants, when possible.¹

Good practice statements on contraception include: Discuss contraception and pregnancy plans at an initial or early office visit or when initiating treatment with potentially teratogenic medications, and counsel patients on contraceptive methods based on efficacy, safety and personal values.

Recommendations include:

• Encourage the use of effective LARC for all patients;
• Avoid estrogen in antiphospholipid antibody (aPL) positive patients or those with active systemic lupus erythematosus (SLE), using an intra-uterine device or the less-effective progestin-
  only pill in these patients;
• Avoid depot medroxyprogesterone acetate injections in patients at high risk for osteoporosis; and
• Encourage all patients to use over-the-counter morning-after emergency contraception, if desired.

Fertility/Assisted Reproductive Technology (ART)

Fertility is becoming more of a concern for patients, because women may delay pregnancy until their disease is inactive, said Dr. Sammaritano. “As a result, they may end up needing fertility therapy. Oocyte or embryo cryopreservation is now standard care, rather than experimental, and if you haven’t yet had patients ask you about this, I guarantee that you will.”

Elevated estrogen levels during ovarian stimulation and retrieval mean flare and/or thrombosis are major concerns for women with SLE. Coordinate care with a patient’s reproductive endocrinologist in these cases, the Voting Panel suggested.

Recommendations include: