Unintended Consequences of SCOTUS Abortion Decision for Patients With Rheumatic Diseases

Clinical Practice Mexican Guidelines for the Treatment of Systemic Lupus Erythematosus: 2024 Update

Herein we present the update for the Mexican Guidelines for the Treatment of Systemic Lupus Erythematosus. It involves the participation of several experts along the country, following the GRADE system. We included aspects regarding vaccines, pregnancy and cardiovascular risk which were not presented in the previous guidelines in 2017.

Methotrexate: Use in the Post Dobbs v. Jackson Era

ABSTRACT

Methotrexate is one of the most frequently used medications for the treatment of rheumatic diseases. Although initially developed for use as chemotherapy for both solid and hematologic malignancies, it was used as early as the 1960s with success for rheumatoid arthritis (RA) and psoriatic arthritis, ultimately being approved by the US Food and Drug Administration for the treatment of RA in 1988. Beyond RA and psoriatic arthritis, methotrexate is used in the treatment of systemic lupus erythematosus, idiopathic inflammatory myopathies, and other inflammatory conditions. Methotrexate is cytotoxic to the trophoblast and has been used to treat both ectopic pregnancy and gestational trophoblastic neoplasia, leading to studies in the early 1990s that showed it was effective and safe for early abortion in combination with prostaglandin E1 analog misoprostol. Methotrexate is also a teratogen, causing serious birth defects in 6%-10% of patients taking it while pregnant. Additionally, women are more likely to be affected by both RA at SLE, as compared with males, thus worsening the burden of these adverse effects. Both methotrexate's history of use as an abortifacient and its teratogenic properties make its use more complicated in the current era of abortion policy in the United States following the Dobbs v. Jackson Women's Health Organization ruling. Recently published data suggest that this ruling has affected both provider perspectives and patient experiences as it relates to methotrexate use. In the post-Dobbs era, the role of the rheumatologist as it relates to patients' sexual and reproductive health is likely to expand.

Alignment of contraception use with the ACR reproductive health guidelines in women with systemic lupus erythematosus within the RISE registry

OBJECTIVES

Contraception is crucial for safely timing pregnancies in patients with SLE. This study investigated predictors of contraception documentation in patients with SLE, and the alignment of contraception practices with the 2020 American College of Rheumatology (ACR) guidelines, within the Rheumatology Informatics System for Effectiveness (RISE) registry.

MATERIALS AND METHODS

Female patients (aged 18-44 years) with SLE were identified via International Classification of Diseases (ICD)-9/ICD-10 coding within the RISE registry, which includes data from rheumatology clinics across the USA. Eligible patients were required to have ≥1 clinical visit in 2019 (prepandemic) or between 1 April 2020 and 30 March 2021 (mid-pandemic). Adjusted multilevel logistic modelling assessed patient, provider and practice characteristics for associations with contraception documentation. Contraception patterns were identified and compared with the 2020 ACR guidelines.

RESULTS

Contraception documentation rates were similar in the prepandemic and mid-pandemic groups (8.1% and 8.5%, respectively). Higher documentation rates were found in women who were younger, White, and had more visits, as well as those seen within a health system, by a female provider, and within specific regions and electronic health record (EHR) systems. Prescription of a teratogenic medication did not influence contraception documentation or type. Oestrogen-containing contraceptives were prescribed less often to women at high risk for thrombosis (26.2% with thrombotic risk vs 60.6% without, p<0.0001) and history of lupus nephritis (LN) (53.8% with history of LN vs 63.2% without, p=0.024).

CONCLUSIONS

Practices participating in the RISE registry do not currently record contraception in the large majority of women with SLE, although increased documentation in some EHRs suggests that system changes may improve rates of documentation. Women at higher risk for thrombosis were less likely to receive oestrogen, suggesting that warnings against oestrogen use has impacted contraception prescription, although the limited documentation and limited contraception among women taking teratogenic medications suggest a high unmet need.

The impact of US abortion policy on rheumatology clinical practice: a cross-sectional survey of rheumatologists

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Prenatal Care Initiation and Exposure to Teratogenic Medications

Importance

With new legal abortion restrictions, timing of prenatal care initiation is critical to allow for discussion of reproductive options among pregnancies exposed to teratogenic medications.

Objective

To investigate the prevalence of prenatal exposure to teratogenic medications and prenatal care initiation across gestational weeks.

Design, Setting, and Participants

This descriptive, population-based cross-sectional study used health encounter data from a national sample of individuals with employer-sponsored health insurance. A validated algorithm identified pregnancies among persons identifying as female that ended with a live or nonlive outcome between January 2017 and December 2019. Data were analyzed from December 2022 to December 2023.

Exposures

Prenatal exposure to any of 137 teratogenic medications, measured via pharmacy and medical claims. Measurement of prenatal care initiation was adapted from the Children's Health Care Quality Measures.

Main Outcomes and Measures

Prevalence of prenatal exposure to teratogens and prenatal care initiation by gestational week. Timing of prenatal teratogenic exposure was compared with timing of prenatal care initiation and legal abortion cutoffs.

Results

Among 639 994 pregnancies, 472 472 (73.8%; 95% CI, 73.7%-73.9%) had a live delivery (mean [SD] age, 30.9 [5.4] years) and 167 522 (26.2%; 95% CI, 26.1%-26.3%) had a nonlive outcome (mean [SD] age, 31.6 [6.4] years). Of pregnancies with live deliveries, 5.8% (95% CI, 5.7%-5.8%) were exposed to teratogenic medications compared with 3.1% (95% CI, 3.0%-3.2%) with nonlive outcomes. Median time to prenatal care was 56 days (IQR, 44-70 days). By 6 weeks' gestation, 8186 pregnancies had been exposed to teratogenic medications (25.2% [95% CI, 24.7%-25.7%] of pregnancies exposed at any time during gestation; 1.3% [95% CI, 1.3%-1.3%] of all pregnancies); in 6877 (84.0%; 95% CI, 83.2%-84.8%), prenatal care was initiated after 6 weeks or not at all. By 15 weeks, teratogenic exposures had occurred for 48.9% (95% CI, 48.4%-49.5%) of all teratogen-exposed pregnancies (2.5% [2.4-2.5] of all pregnancies); prenatal care initiation occurred after 15 weeks for 1810 (16.8%; 95% CI, 16.1%-17.5%) with live deliveries and 2975 (58.3%; 95% CI, 56.9%-59.6%) with nonlive outcomes. Teratogenic medications most used within the first 15 gestational weeks among live deliveries included antiinfectives (eg, fluconazole), anticonvulsants (eg, valproate), antihypertensives (eg, lisinopril), and immunomodulators (eg, mycophenolate). For nonlive deliveries, most antihypertensives were replaced by vitamin A derivatives.

Conclusions and Relevance

In this cross-sectional study, most exposures to teratogenic medications occurred in early pregnancy and before prenatal care initiation, precluding prenatal risk-benefit assessments. Prenatal care commonly occurred after strict legal abortion cutoffs, prohibiting consideration of pregnancy termination if concerns about teratogenic effects arose.