Women on teratogenic DMARDs risking pregnancy

3 minute read

As few as three in 10 women of childbearing age who are using these drugs are also on reliable contraception.

As many as six in 10 women of childbearing age being treated with teratogenic DMARDs are not using reliable contraception, says an Australian rheumatologist and researcher. 

Royal Prince Alfred Hospital consultant rheumatologist Dr Abhishikta Dey said that while she was not “entirely surprised” that only 30 to 40% of patients in this cohort were using reliable contraception, it was a problem that needed attention. 

Dr Dey presented her findings – which are part of her PhD work investigating the use of medicines in women of reproductive age with rheumatic diseases – last weekend at the combined New Zealand Rheumatology Association (NZRA) and Australian Rheumatology Association (ARA) Annual Scientific Meeting. 

“I was not entirely surprised, because I’m seeing women on teratogenic medications who aren’t taking highly effective contraception,” she told The Medical Republic this week.  

“There’s a lot more room to improve.” 

Dr Dey, who has a special interest in the care of patients with osteoporosis, patients considering pregnancy and pain management, said a conversation with a GP colleague at the ASM after her presentation had driven home the need for more awareness at the specialty and primary care levels. 

When neurologists prescribe an antiepileptic or when dermatologists prescribe isotretinoin, it’s made very clear that the patient needs to be on appropriate contraception, the GP told her. But the same was not the case with disease-modifying anti-rheumatic drugs.  

“So I think we need to change that,” Dr Dey said.  

Methotrexate, leflunomide and mycophenolate, in particular, are contraindicated in pregnancy because of the risk of fetal harm. 

“These three have either animal studies or human studies showing fetal harm, and so we would not want patients to be falling pregnant, if possible, on those medications,” Dr Dey said. 

“It doesn’t mean that everyone will definitely come to harm and that people have to have terminations, but it’s not the ideal setting.  

“The other thing to consider is that you want patients to be well controlled from a disease activity point of view before considering pregnancy, so there’s another reason to use contraception.” 

Dr Dey, who is planning to publish the full findings from her research in coming months, said not everyone taking these DMARDs would need to be using reliable contraception (long-acting implants or IUDs), such as those who were not sexually active. But it was a conversation that should be had with all female patients of child-bearing age and followed up in notes to the patient’s GP who could prescribe the appropriate reliable contraception.  

Further follow-up could take place when patients presented for review and prescription renewal. It was also important to discuss pregnancy plans with patients to factor in changing to pregnancy-compatible DMARDs that still provide good disease control. 

Part of Dr Dey’s PhD includes developing a guide for Australian rheumatologists, GPs and patients on prescribing contraception to women being treated for musculoskeletal and inflammatory conditions. 

She hopes it will help bridge the communication gap and increase the number of women using contraception while on teratogenic DMARDs. 

As part of her research, she has developed a contraception survey specifically for GPs, and hopes TMR readers will take part.

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