ACR Releases First Ever Guideline on Reproductive Health in Rheumatic Disease
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The American College of Rheumatology has issued a strong recommendation that women with rheumatic disease who do not have lupus or antiphospholipid syndrome use effective contraceptives, along with 130 other recommendations in its first clinical practice guideline for reproductive health.
According to the ACR, the 131 recommendations and 12 good practice statements — which comprise the 2020 Guideline for the Management of Reproductive Health in Rheumatic and Musculoskeletal Diseases — are the first ever evidence-based, clinical practice guidelines related to the management of reproductive health issues for all patients with rheumatic diseases.
“This guideline is paramount, because it is the first official guidance addressing the intersection of rheumatology and obstetrics and gynecology,” Lisa Sammaritano, MD, lead author of the guideline, said in a press release. “Rheumatic diseases affect many younger individuals; however, little education has been provided to rheumatology professionals on current OB-GYN practices.”
“The guideline [and more detailed online appendices] presents vital background knowledge and recommendations for addressing reproductive health issues in the full spectrum of rheumatology patients, with additional focus on specific diagnoses that require more detailed recommendations such as systemic lupus erythematosus and antiphospholipid syndrome,” she added.
The practice statements and guidelines are intended to assist rheumatologists in caring for patients except where indicated as being for those with specific conditions or antibodies present, the organization said. Good practice statements are defined as those in which indirect evidence is compelling enough that a formal vote was considered unnecessary. They are ungraded and presented as suggestions rather than formal recommendations.
However, the recommendations are graded and separated into six categories: contraception, assisted reproductive technology or fertility therapies, fertility preservation with gonadotoxic therapy, menopausal hormone replacement therapy, pregnancy assessment and management, and medication.
Examples of strong recommendations include:
- Women with rheumatic disease who do not have lupus or APS should use effective contraceptives, with a conditional recommendation to preferentially use highly effective IUDs or a subdermal progestin implant;
- Do not use combined estrogen-progestin contraceptives in women who test positive for anti-phospholipid autoantibodies or APS;
- Women with uncomplicated rheumatic disease who are receiving pregnancy-compatible medications, whose disease is stable and who test negative for APL, should receive fertility therapy;
- Men should not use cyclophosphamide or thalidomide prior to attempting conception; and
- NSAIDs should not be used in the third trimester.
Experts involved in the development of the guideline included rheumatologists, obstetrician/gynecologists, reproductive medicine specialists, epidemiologists and patients with rheumatic diseases. A draft of the guideline was presented at the 2018 ACR/ARP Annual Meeting in Chicago. Since then, the original three-part draft has been condensed into a single manuscript with detailed background and discussion information available online.
The paper containing the full guideline is available here.
“This guideline should open avenues of communication between the rheumatologist and the patient, as well as between the rheumatologist and the OB-GYN,” Sammaritano said in the press release. “A better understanding of the risks and benefits of reproductive health options will enhance patient care by providing safe and effective contraception, improving pregnancy outcomes by conceiving during inactive disease periods, and allowing for continued control of rheumatic diseases during and after pregnancy with the use of well-suited medications.” – by Jason Laday
Perspective
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Carolyn Zic, MSN, FNP-BC
This year, the American College of Rheumatology published guidelines addressing reproductive health for patients who have rheumatologic conditions. These clinical guidelines can help providers make recommendations that are evidence-based as well as provide opportunities for collaboration with OB/GYN colleagues.
Rheumatology providers may often think of reproductive health only in the context of contraception, mainly due to the use of known teratogenic medications or due to uncontrolled disease processes. However, these guidelines go beyond the discussion of pregnancy prevention and address topics such as infertility, pregnancy management and hormone replacement. There are also clinical guidelines for fertility preservation and medication use for both women and men, reminding providers that reproductive health includes both men and women.
These guidelines can also be used to promote dialogue between patients and providers about their specific reproductive health needs. Providers who may have found themselves unsure of what to recommend now have guidelines to discuss with patients, enabling them to engage in shared decision making about various aspects of reproductive health. Lastly, these guidelines reiterate the importance of addressing all aspects of our patient’s health needs and how their rheumatologic conditions affect so many aspects of their lives.
Perspective
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David A. McLain, MD, FACP, FACR
It is very helpful in clinical practice to have experts that take frequently asked questions that we have and put them into guidelines that we can reference as we care for patients. For the first time the ACR has issued guidelines addressing reproductive health in patients with rheumatic diseases.
These guidelines were developed by rheumatologists, obstetrician/gynecologists, reproductive medicine specialists, epidemiologists and patients with rheumatic diseases. The online manuscript includes detailed background information and discussion that should prove invaluable in counseling these, often difficult to manage, patients.
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