Lana Dykes

Holistic, collaborative, multidisciplinary, and integrated communication between physicians and women of childbearing age is lacking, according to a study published in 

 Medical treatment and family planning, particularly among women of childbearing age with rheumatoid arthritis (RA) and psoriatic arthritis (PsA), should be considered within this patient population. Patient-centered care including reproductive choices should be integrated as a part of routine clinical practice.

“The proportion of women being treated with biologics is growing,” investigators explained. “However, data on treatment recommendation awareness among treating physicians and women who are considering pregnancy and family planning are limited.”

An English-language, 55-question survey was developed to identify the current practices of physicians regarding the reproductive health needs of women with RA, PsA, and psoriasis in the Czech Republic, Slovakia, and Hungary. The questionnaire was designed to simultaneously elicit spontaneity of physicians while allowing for the processing of responses, mutual comparison, and overall assessment. The survey obtained information from 120 physicians, including 82 rheumatologists and 38 dermatologists.

Female patients of reproductive age (aged 18 to 45 years) with moderate-to-severe disease encompassed 10-30% of all respondents. Roughly two-thirds of physicians discussed family planning with their patients when making the diagnosis. Rheumatologists collaborated with other specialists more frequently when compared with dermatologists and gynecologist/obstetricians. Pregnancy effects were the top concern for female patients.

Approximately half of the rheumatologists revised treatment 6 months prior to when the patient planned on becoming pregnant (44% [n = 36/81]). However, dermatologists acted much sooner (26% [n = 10/38]), acting 2 to 3 years prior planned parenthood. While rheumatologists selected systemic glucocorticoids as firs-line treatment to counteract pregnancy flares, dermatologists preferred topical corticosteroids.

Although gender alone did not influence treatment choice in 11% of dermatologists and 39% of rheumatologists, all dermatologists and 96% of rheumatologists were influenced by the patient’s fertility and pregnancy. Disease severity and uncontrolled disease were the main risk factors linked to conception in this patient population. In fact, 53% of dermatologists and 79% of rheumatologists believed that poor disease control was associated with poor pregnancy outcomes. Of the most valuable sources of information as determined by physicians, congresses and interdisciplinary forums were the most highly rated. Patient education and collaboration were noted as key factors in reducing unplanned pregnancies.

A cross-border investigation, from the perspective of both rheumatologist and dermatologist, strengthened the study. However, investigators did not evaluate or categorize the individual physicians’ level of experience with biologics or reproductive health and instead based data on actual clinic experience. Investigators theorize that those who have had more exposure to this approach would be more willing to utilize it. The lack of formal survey validation, and the fact that the survey was provided in English, further limits the study.

“To improve the reproductive health of sexually active women of childbearing age in Central Europe who have chronic inflammatory diseases (CID), rheumatologists and dermatologists must improve their education and work with other specialists,” investigators concluded. “More timely discussions with women of reproductive age and family planning are needed to educate them about the disease's effects on their childbearing potential and the selection of treatment options based on their reproductive goals. Best practices in patient-centered care must consider each patient's reproductive decisions in their treatment planning to give the best patient-centered care.”

This article originally appeared on Rheumatology Network®. 

Olejárová M, Macejová Ž, Gkalpakiotis S, Procházková L, Tóth Z, Prágr P. Reproductive Healthcare in Women with Rheumatoid Arthritis and Psoriatic Diseases in Routine Clinical Practice: Survey Results of Rheumatologists and Dermatologists [published online ahead of print, 2022 Sep 24]. Rheumatol Ther. 2022;10.1007/s40744-022-00488-z. doi:10.1007/s40744-022-00488-z

Articles

Although the proportion of women treated with biologics continues to grow, data on treatment recommendations among both physicians and female patients of childbearing age remain limited.

Survey addresses concerns regarding reproductive health care communication in women with RA, PsA

Our sister publication, Rheumatology Network,

 interviewed Bonnie L Bermas, MD, to discuss the ways in which the Supreme Court decision to overturn Roe v Wade, a ruling that had guaranteed the right to abortion in the United States since 1973, will change the way rheumatologists are able to care for their patients. She emphasizes the negative effects this legislation will have on marginalized populations, explains how the ruling will impact pregnancy in patients with rheumatic disease, and what rheumatologists need to know moving forward. Bermas, Professor in the Department of Internal Medicine at UTSouthwestern Medical Center, co-authored the article “Overturning Roe v. Wade: Toppling the Practice of Rheumatology,” published in 

 What was the motivation for you and your team to want to address the recent decision to overturn Roe v Wade?

 We as rheumatologists, and in particular this collection of rheumatologists, amongst many other rheumatologists, have an interest in reproductive issues in our rheumatic disease patients. We think about this a lot because we care for a lot of patients who are in their reproductive health years. This ruling has tremendous impact on our patients. Our motivation was the impact it has in our patients.

 Overturning Roe v Wade will obviously affect patients with a constellation of rheumatic diseases. However, it might disproportionately affect women with lupus, who are often diagnosed in their reproductive years. What are your thoughts on how this decision might impact this particular patient population and pregnancy in general?

 We know that lupus pregnancies are high risk pregnancies, and they have a higher incidence of adverse pregnancy outcomes both amongst the mothers and the developing fetus and infant. One of the crucial things in controlling those or preventing adverse pregnancy outcomes, which can be progression of disease or an adverse pregnancy outcome in the fetus, is that the disease really needs to be under good control. And, as you know, no contraception is perfect. Inadvertent pregnancies do occur, or people will get pregnant when their disease is active. And that can be really detrimental and dangerous. The maternal mortality rate for lupus patients is during pregnancy is significantly higher than in general population.

Our patients are frequently treated with medications that can cause birth defects. And so that is another issue in terms of this rule. Also, lupus disproportionately impacts minoritized patient populations. Those patient populations, unfortunately, often live in the states that have the most restrictive abortion laws, and some of these patients may not have the resources to travel out of state if they need to have a pregnancy termination.

 What are some of the potential outcomes of this legislation on the practice of rheumatology in terms of prescribing medications and treating patients?

 That's a really important point. The first thing is that we try to encourage rheumatologists to tell their patients up front about the risks of unplanned pregnancies and emphasize the importance of contraception in women who are sexually active. We need to make sure that we're discussing this a lot with our patients.

The second thing is there are going to be providers who are possibly reticent to prescribe teratogenic medications to their patients. The 2 most common medicines that would fall under that category would be methotrexate and Mycophenolate Mofetil. Methotrexate is the first drug of choice for the treatment of inflammatory arthritis issues such as juvenile idiopathic arthritis and rheumatoid arthritis. Mycophenolate Mofetil is one of our key medications in treating lupus and lupus kidney disease. You can imagine that there will be some hesitancy in prescribing these medications. Potentially, we're talking about rheumatologists not prescribing the best medication for their patients.

 What do rheumatologists need to know moving forward?

 They need to know that pregnancy across all rheumatic diseases does best when pregnancies are planned. So that means really ramping up our understanding of what the most effective contraceptive methods are. And it is also about asking if patients are sexually active, if they're planning to get pregnant, and referring them appropriately for contraception if they're not already on contraception. Providers also need to understand which medications are teratogenic.

 Is there anything else that you would like to add before we wrap up?

 What really motivated us to write this is that this ruling is not good for patient care and it's not good for our patients. Like the vast majority of providers, we care about our patients and their wellbeing. So, it's pretty devastating to feel that there's been a politicized ruling that is going to negatively impact our ability to provide our patients with the best care.

Bonnie L Bermas, MD, emphasizes the negative effects this legislation will have on marginalized populations and explains how the ruling will impact pregnancy in patients with rheumatic disease.

How will overturning Roe v Wade affect rheumatology?

Children who were exposed to low dose prednisone in utero had no increased risk for insulin resistance in early childhood (from infancy through approximately 7 years). Although the results are reassuring, further research should analyze if insulin resistance remains as children age, according to a study published in 

The use of long-term corticosteroids during pregnancy has been growing over the past decades,” investigators stated. “Corticosteroids can be given when an auto-inflammatory disease like rheumatoid arthritis (RA) is too active. Several studies have shown that long-term corticosteroids use in pregnancy is associated with maternal and fetal adverse outcomes, like preeclampsia, shorter gestational age, lower birth weight, and rapid catch-up growth. These last two outcomes could influence the insulin resistance later in life.”

In total, 103 children were initially included in the study after their mother participated in a prospective cohort study (PARA) evaluating RA and pregnancy. Of these children, 42 (41%) were exposed to prednisone in utero and 61 were non-exposed. Insulin resistance was measured by homeostasis model of assessment insulin resistance (HOMA-IR) and lipid and serum adiponectin levels, which were corrected for body fat distribution. Children, aged 5 years or older, were seen at the Sophia Children’s Hospital in Rotterdam, located in the Netherlands. Participants gave fasting blood samples, anthropometric measurements were performed, and a dual-energy x-ray absorptiometry (DXA-scan) analyzed fat distribution.

Pregnant women in the original study received an average of 6 mg of prednisone (IQR: 1–15 mg) daily during pregnancy. Mean fasting glucose level was 4.87 (0.37) mmol/L in the children exposed to prednisone and 4.94 (0.42) those who were not exposed. Insulin was 4.95 (3.57) µU/mL and 4.92 (2.03) µU/mL, respectively. Dosage made no difference in mean HOMA-IR (SD) between children in the prednisone-exposed cohort (1.10 [0.84]) and those in the non-exposed group (1.09 [0.49]). There were no differences in the mean adiponectin level and lipid levels, such as total cholesterol, high-density lipoprotein, or fasting triglyceride, and body fat distribution.

Prospectively following all pregnancies of patients was a main strength of the study, as well as following medication intake and disease activity throughout pregnancy, which was assessed by the same research assistants. Further, the data were both measured and collected by 1 doctor, thus preserving continuity. Although roughly half of children (54%) participated, there were no statistical differences between those who participated and those who did not. While investigators conducted a nationwide study, all children needed to be evaluated at Sophia’s Children’s Hospital in Rotterdam, which caused 38% of parents to opt out due to the distance of the hospital. The second most prevalent reason parents opted out of the study was due to too much burden for the child (30%). Lastly, investigators did not use a hyperinsulinemic euglycemic clamp (HEC), intravenous, or oral glucose tolerance test (OGTT) to quantify insulin resistance.

“Long-term corticosteroids use in pregnancy is associated with fetal adverse outcomes, like lower birth weight and rapid catch-up growth which can influence the insulin resistance later in life,” investigators concluded. “Findings are reassuring because prednisone use during pregnancy is increasing worldwide. Further research should evaluate if the insulin resistance remains absent in the future.”

de Steenwinkel FDO, Dolhain RJEM, Hazes JMW, Hokken-Koelega ACS. Does prednisone use in pregnant women with rheumatoid arthritis induce insulin resistance in the offspring? [published online ahead of print, 2022 Aug 30]. 

. 2022;10.1007/s10067-022-06347-0. doi:10.1007/s10067-022-06347-0

Long-term corticosteroids during pregnancy is associated with maternal and fetal adverse outcomes which may influence the insulin resistance later in life.

Lana Dykes

Articles

Survey addresses concerns regarding reproductive health care communication in women with RA, PsA

How will overturning Roe v Wade affect rheumatology?

No increased risk of insulin resistance in prednisone-exposed fetuses