Alice Goodman

June 01, 2011

June 1, 2011 (London, United Kingdom) — In the absence of clear guidelines about the safety of drugs for rheumatic disease during conception, pregnancy, and lactation, it is not surprising that a new survey reported here at the European League Against Rheumatism (EULAR) Congress 2011 showed a lack of uniformity among rheumatologists and obstetricians in the United Kingdom. The situation is the same in the United States, according to experts who spoke with Medscape Medical News.

"This survey is the first of its kind among rheumatologists and obstetricians in the UK. This is a grey area for doctors who treat patients with rheumatic diseases, and we need to develop local and national guidelines in collaboration with obstetricians," said lead author Sonia Panchal, MD, from the University Hospitals of Leicester National Health Service Trust, Leicester, United Kingdom. She surmised that the low response rate to the survey reflects indecision regarding current practices and strengthens the call for guidelines.

The survey was mailed to 500 rheumatologists and 500 obstetricians. Response rates were 20% (n = 102) and 7% (n = 33), respectively. The list of medications considered safe during pregnancy, according to the most recent evidence, includes steroids, hydroxychloroquine, sulphasalazine, and azathioprine. Unsafe drugs are methotrexate, leflunomide, and biologics (anti–tumor necrosis factor [TNF] agents and rituximab).

Thirty-two percent of rheumatologists and 18% of obstetricians opted to continue treatment of nonsteroidal anti-inflammatory drugs during prepregnancy, whereas 67% and 39%, respectively, would discontinue treatment, even though steroids are considered safe.

For hydroxychloroquine, another safe drug, 80% of rheumatologists and 61% of obstetricians would continue treatment during prepregnancy, whereas 19% and 15%, respectively, opted to discontinue. For azathioprine, 62% of rheumatologists and 58% of obstetricians chose to continue treatment, whereas 36% and 21%, respectively, opted for discontinuation.

Reassuringly, no survey respondent for either specialty would continue leflunomide or methotrexate. The majority of rheumatologists (92%), but only 54% of oncologists, would discontinue anti-TNF treatment during prepregnancy, whereas 95% of rheumatologists and 52% of obstetricians would discontinue rituximab.

Although the survey is limited by small numbers, especially of obstetricians, audience members agreed that guidelines are sorely needed.

Providing a US perspective, Jane E. Salmon, MD, professor of medicine at the Hospital for Special Surgery, Weill-Cornell College of Medicine, New York City, called this a critical area for patients and their physicians.

"Reproductive counseling is essential for lupus and [rheumatoid arthritis] patients who take potentially teratogenic drugs. The onus for counseling is on the rheumatologist who prescribes these drugs, to either provide education or make an appropriate referral and determine whether the patient followed his or her suggestions," Dr. Salmon asserted.

"Many drugs are strongly contraindicated in women of reproductive age. The challenge is for the drugs where the data are less clear, such as anti-TNF agents and azathioprine," Dr. Salmon continued.

She agreed that there is a need for guidelines, but said that good evidence is needed to drive guidelines, and until there is such evidence, counseling patients using currently available information is of the utmost importance. "The challenge is that we do not know the true risk with some of our drugs. Rheumatologists should initiate discussions, not just about preconception, but about contraception. Patients need to understand the risks of medications, and that might direct their contraceptive choices," Dr. Salmon stated.

Dr. Panchal and Dr. Salmon have disclosed no relevant financial relationships.

European League Against Rheumatism (EULAR) Congress 2011: Abstract OP0135. Presented May 26, 2011.

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