Communication, controlled disease key to avoid ‘severe pregnancy outcomes’ in lupus
Click Here to Manage Email Alerts
Having well controlled disease is the first and most important step to a safe pregnancy in patients with lupus, according to a presenter at the 2021 Congress of Clinical Rheumatology-West.
Megan Clowse, MD, MPH, associate professor of medicine in the Division of Rheumatology and Immunology at Duke University, urged rheumatologists to address reproductive issues at every visit with patients of reproductive age. When these issues are poorly addressed, it can lead to ambivalence. “A lot of women want to get pregnant, but maybe think that they should not get pregnant,” she said. “This means that a lot of women are not really getting prepared for pregnancy.”
The most serious consequence of this is clear: unplanned pregnancies. “We know that unplanned pregnancies lead to much higher risks of complications,” she said. “You know that, you feel that, but the data also support that.”
These complications range from early termination to preterm birth. “In our patients with lupus, we see more severe pregnancy outcomes,” she said. “In our unplanned pregnancies, 70% have severe neonatal outcomes in terms of being in the hospital for more than a week at a time.”
Communication issues aside, Clowse discussed ways to avoid these pitfalls. “The safest way to have a good pregnancy is to have your disease under control with pregnancy compatible medicines,” she said.
With that, Clowse ran through the “Go list” and the “Stop list” of drugs approved or not approved in pregnancy. “Azathioprine is safe in pregnancy,” she said, and added that cyclosporine, tacrolimus and colchicine are all safe to use, as well.
“Prednisone, I hate as much as Michelle Petri, but you can use it if you need to,” Clowse said.
As for the “Stop” list, Clowse highlighted the mycophenolate mofetil as a significant driver of birth defects. “It is a major teratogen and it is just as bad as cyclophosphamide,” she said. “They both have basically the same rate of birth defects — different birth defects — as thalidomide.”
Methotrexate is also “problematic,” according to Clowse, but not particularly teratogenic. The same is true for leflunomide (Arava, Sanofi).
On the caution list are belimumab (Benlysta, GlaxoSmithKline) and rituximab (Rituxan, Genentech). “I am not a big fan of rituximab in pregnancy in general, but I prefer it, at this point, to belimumab, based on the data which I have seen,” Clowse said. “Which is limited.”
Beyond therapeutic interventions, Clowse also addressed ways clinicians can identify and mitigate other pregnancy risks in their lupus patients. Inflammatory markers in the last 6 months should be target number one.
“Controlling hypertension is really important,” she said.
Antiphospholipid antibodies also should be checked. If they are positive with no clinical symptoms, the patient should receive aspirin. If they are positive with some symptoms, aspirin plus low molecular weight heparin is recommended, according to Clowse.
“I always check Ro and La antibodies at this point, as well,” she said. “The reason we check them is neonatal lupus.”
Clowse acknowledged that the particulars of dealing with pregnancy in lupus can be overwhelming for clinicians not accustomed to managing them. It is for this reason that she recommended www.LupusPregnancy.org as a comprehensive resource that can offer guidance on all the relevant topics.
Collapse
Clowse MEB. Optimizing Management of Rheumatic Disease in the Pregnant Patient. Presented at: Congress of Clinical Rheumatology-West annual symposium; September 18-21, 2021 (hybrid meeting).
Read more about
Click Here to Manage Email Alerts