ACR Develops Guideline for Managing Reproductive Health in Rheumatic, Musculoskeletal Diseases

The American College of Rheumatology (ACR) has published a guideline for the management of reproductive health in patients with rheumatic or musculoskeletal diseases (RMDs). Included in the guideline are 12 ungraded good practice statements and 131 graded recommendations.

The guideline covers an expansive range of topics, including contraception, assisted reproductive technologies, fertility preservation with gonadotoxic therapy, use of menopausal hormone replacement therapy, pregnancy assessment and management, and medication use.

“With the development of this guideline, the ACR recognizes the key role of clinical rheumatologists not only in managing disease activity, but also in understanding the interactions of RMDs and their therapies in the context of reproductive health,” the guideline authors wrote. 

Among the strong recommendations are the following:

• The use of effective contraceptives, such as hormonal contraceptives or intrauterine devices (IUD), is recommended for fertile women with RMD without systemic lupus erythematosus (SLE) or positive antiphospholipid antibody (aPL), as well as for patients with SLE with stable or low disease activity who are not positive for aPL.
• Discuss the use of emergency contraception with all patients, including those with SLE or positive aPL.
• The use of progestin‐only or IUD contraceptives is recommended over combined estrogen‐progestin contraception for patients with SLE with moderate or severe disease activity, including nephritis.
• Among women positive for aPL, the use of IUDs (levonorgestrel or copper) or the progestin‐only pill is recommended.
• The IUD (copper or progestin) is recommended for women with RMD who are receiving immunosuppressive therapy.
• Consider proceeding with assisted reproductive technologies (ART) if needed in women with uncomplicated RMD who are receiving pregnancy‐compatible medications, whose disease is stable/quiescent, and who are negative for aPL.
• ART procdures should be deferred among patients with any RMD while disease is moderately or severely active.
• Switch to a pregnancy‐compatible medication and allow for sufficient time to assess efficacy and tolerability of the new medication in women with RMD who are planning pregnancy and receiving medication that is incompatible with pregnancy.

Except where indicated as being specific for patients with SLE, those positive for aPL, and/or those positive for anti‐Ro/SSA and/or anti‐La/SSB antibodies, the recommendations are intended to guide care for all patients with an RMD.

Among the good practice statements the guideline authors developed are the following:

• Among men receiving treatment with cyclophosphamide, suggest sperm cryopreservation for those who desire it.
• Use hormone replacement therapy in postmenopausal women with RMD without SLE or positive aPL who have severe vasomotor symptoms, have no contraindications, and desire treatment with hormone replacement therapy.
• Encourage women with RMD to breastfeed if they are willing and able to do so. In addition, maintain disease control with lactation‐compatible medications.

“The most important goal of this guideline is to provide substance and direction for discussion between clinicians and patients,” the guideline authors concluded. “A second goal is to encourage development of close working relationships among rheumatologists, specialists in obstetrics‐gynecology, maternal‐fetal medicine, and reproductive endocrinology and infertility, and other involved clinicians.”

—Colleen Murphy

Reference:

Sammaritano LR, Bermas BL, Chakravarty EE, et al. 2020 American College of Rheumatology guideline for the management of reproductive health in rheumatic and musculoskeletal diseases [published online February 23, 2020]. Arthritis Rheumatol. https://doi.org/10.1002/art.41191.