EXECUTIVE SUMMARY

A recent webinar hosted by the Washington, DC-based Association of Reproductive Health Professionals offers providers the information they need to review contraception and pre-conception counseling options for a patient presenting with rheumatoid arthritis.

  • Rheumatoid arthritis is a systemic inflammatory disease that manifests itself in multiple joints in the body. This inflammation usually affects the synovial membrane, but also can affect other organs. This inflamed joint lining leads to erosions of the cartilage and bone, sometimes causing joint deformity.
  • Women diagnosed with rheumatoid arthritis must consider their drug treatment when choosing a contraceptive. Current treatment practice is to prescribe non-biologic, disease-modifying antirheumatic drugs, which reduce disease activity and prevent joint deformity, within three months of diagnosis.

How can clinicians best address sexual and reproductive health issues for women presenting with rheumatoid arthritis (RA)? A recent webinar hosted by the Washington, DC-based Association of Reproductive Health Professionals offers providers the information they need to review contraception and pre-conception counseling options for a patient suffering from rheumatoid arthritis. (Editor’s Note: The webinar is available at: http://bit.ly/2fWy0K4.)

According to information from the CDC, RA is a systemic inflammatory disease that manifests itself in multiple joints in the body. This inflammation usually affects the synovial membrane (lining of the joints), but also can affect other organs. This inflamed joint lining leads to erosions of the cartilage and bone, sometimes causing joint deformity. Pain, swelling, and redness are common joint symptoms.

The Rochester Epidemiology Project in Minnesota, which provides the most recent U.S. data on the incidence of the disease, reports that from 1995 to 2007, 41 per 100,000 people were diagnosed with RA annually.1 Incidence of the disease increased with age (8.7 per 100,000 people among those 18-34 years of age, compared with 54 per 100,000 among those 85 years of age or older) and peaked between age 65-74 (89 per 100,000); all estimates age-adjusted to 2000 U.S. population. From 1995-2007, rates increased by 2.5% each year among women, but there was a small decrease (0.5%) among men. In 2005, the age-standardized prevalence of RA among women in the Rochester Epidemiology Project had increased to 1% (9.8 per 1,000) from 0.8% (7.7 per 1,000) in 1995. The prevalence among men was the same (0.4%) in 1995 and 2005 (4.1 per 1,000 in 1995 and 4.4 per 1,000 in 2005).1

Women diagnosed with RA must consider their drug treatment when choosing a contraceptive. Current treatment practice is to prescribe non-biologic disease-modifying antirheumatic drugs, which reduce disease activity and prevent joint deformity, within three months of diagnosis.

According to the U.S. Medical Eligibility Criteria for Contraceptive Use (US MEC), women with RA who are on immunosuppressive therapy can initiate the progestin-only pill and the contraceptive implant with no restrictions. Both forms of intrauterine contraception (the levonorgestrel IUD and the copper-T IUD) may be continued with no restrictions; initiation of either is classified as Category 2, where the method generally can be used, but careful follow-up may be required. The combined pill, contraceptive patch, contraceptive vaginal ring, and contraceptive injection also are classified as Category 2 methods; the injection is classified as Category 3 (use usually is not recommended unless other more appropriate methods are not available or acceptable) if the patient is at risk for non-traumatic fracture.2

For women presenting with RA who are not on immunosuppressive therapy, the progestin-only pill, the contraceptive implant, the levonorgestrel IUD, and the copper-T IUD all may be used with no restrictions. Combined pills, patch, and ring, as well as the contraceptive injection, are classified as Category 2 methods.

In counseling women suffering from RA on their options, use active listening and clarify women’s goals. Talk with patients about typical use rates for each method and use a tier-based visual aid to demonstrate levels of effectiveness. (Use the CDC chart at: http://bit.ly/29K8XXD.) Provide hands-on models for women to see the methods, and avoid directive statements.

Women of reproductive age presenting with RA must understand that some of the mainstay medications for RA treatment are teratogenic. Methotrexate, now considered the first-line disease-modifying antirheumatic drugs for most patients with RA, is teratogenic, states Mary Hébert, PharmD, FCCP, professor in the School of Pharmacy at the University of Washington, Seattle.

A European League Against Rheumatism task force recently was established to define points to consider on use of antirheumatic drugs before pregnancy and during pregnancy and lactation. Based on a systematic literature review and pregnancy exposure data from several registries, statements on the compatibility of antirheumatic drugs during pregnancy and lactation were developed. The benefits of hydroxychloroquine, sulfasalazine, azathioprine, cyclosporine, tacrolimus, colchicine, TNF-alpha inhibitors, and glucocorticoids often are found to outweigh the risks in pregnancy and lactation. Methotrexate, mycophenolate mofetil, and cyclophosphamide require discontinuation before conception due to proven teratogenicity, the task force found. Insufficient research in regard to fetal safety leads to the discontinuation of leflunomide, tofacitinib, abatacept, rituximab, belimumab, tocilizumab, ustekinumab, and anakinra before a planned pregnancy, the task force notes. Among biologics, tumor necrosis factor inhibitors are the best-studied, and safety data are promising with first and second trimester use. Restrictions in use apply for the few proven teratogenic drugs and the large proportion of medications for which insufficient safety data for the fetus/child are available, the task force concludes.3

For women suffering from RA who wish to become pregnant, preconception care is a critical period, Hébert says. Clinicians must balance the removal of teratogens with need for disease control. The importance of a planned pregnancy must be stressed, and drug selection should be based on an agreement between patient, rheumatologist, and obstetric team. Pharmacists are in a unique position to counsel patients on the risks and benefits of drugs used to treat RA during pregnancy and lactation and refer patients receiving teratogenic drugs who are considering pregnancy to their rheumatologist for medication adjustments prior to pregnancy, she notes.

REFERENCES

  1. Myasoedova E, Crowson CS, Kremers HM, et al. Is the incidence of rheumatoid arthritis rising? Results from Olmsted County, Minnesota, 1955-2007. Arthritis Rheum 2010;62:1576-1582.
  2. Curtis KM, Tepper NK, Jatlaoui TC, et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. MMWR Recomm Rep 2016;65:1-103.
  3. Götestam Skorpen C, Hoeltzenbein M, Tincani A, et al. The EULAR points to consider for use of antirheumatic drugs before pregnancy, and during pregnancy and lactation. Ann Rheum Dis 2016;75:795-810.