Call for more focus on reproductive health in rheumatology appointments

Wednesday, 19 May 2021

More work is needed on implementing national guidance on family planning in rheumatology departments, especially around medicines that are dangerous in pregnancy, a leading doctor has urged.

It has been almost two years since a drug safety update from the Medicines and Healthcare Regulatory Agency on pregnancy prevention for women treated with drugs with potential teratogenic was issued, yet not much has changed said Dr Iona Thorne, consultant rheumatologist and acute/obstetric physician at Chelsea and Westminster NHS Foundation Trust.

Several medicines used in routine rheumatology fall would fall under the MHRA guidance such as leflunomide, methotrexate and cyclophosphamide, she said but the evidence suggests that family planning is often not talked about in rheumatology consultations.

The guidelines recommend steps including discussing the safest methods of contraception and the need for pregnancy testing.

In some specialities such as dermatology and epilepsy, formal pregnancy prevention programmes have been put in place because of the proven dangers of medicines such as sodium valproate and retinoids, says Dr Thorne.

While the risks associated with medicines in rheumatology are lower, the MHRA does recommend that pregnancy prevention is specifically discussed by the prescriber, she added.

Writing in Rheumatology, Dr Thorne who has set up the British Society of Rheumatology Special Interest Group on Pregnancy and Rheumatic Disease said the MHRA guidance might be challenging to implement but should be seen as an opportunity to better support patients.

She also points to guidance from the Faculty of Sexual and Reproductive Health stating that all women taking medicines with potential teratogenic effects should always be advised to use ‘highly effective’ contraception such as a coil or implant.

Speaking with the limbic, Dr Thorne said that in addition, recommendations from the 2016-18 confidential inquiry into maternal deaths and morbidity in the UK and Ireland state that it is the responsibility of all professionals involved in the care of women of reproductive age with co-existing medical problems, whatever their professional background and medical specialty, to provide pre- or post-pregnancy advice and contraception.

“When the MHRA guidance came out I thought it would be the stick we needed in rheumatology but when it comes to implementation that is quite hard to do.

“Unless the patient brings it up, it is really hard to find the time to discuss this on top of everything else that needs to happen in a consultation,” she said.

“You think to yourself, do I need to do a pregnancy test every time I prescribe this medication because the risk is lower than with other drugs.

“Part of this is about having much more tailored recommendations and it being up to rheumatology to think about how best to implement the guidance.”

But she said it does have to be an approach that is achievable and can include steps such as making reproductive health part of an annual review and understanding how to have discussions around ‘highly effective contraception’.

“There does need to be a protocol but we should be wary of being too serious about the risks because if you put too many barriers in place you may end up with worse consequences of women not having access to medicines they need.”

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