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Abstract
BACKGROUND More than half of pregnancies in women with systemic lupus erythematosus (lupus) result in adverse outcomes for the mother or the fetus. We sought to identify aspects of current rheumatologic care that could be improved to decrease the frequency of poor outcomes. METHODS Focus groups with clinical rheumatologists, based on the PRECEDE/PROCEED framework, identified factors that influenced care. A group of women with lupus on their reproductive journey contributed to our understanding of the dilemmas and care provided. RESULTS Medically ill-timed pregnancies and medication non-adherence during pregnancy were identified by rheumatologists as the two key dilemmas in care. We identified several communication gaps as key modifiable barriers to optimal management. The approach to physician-patient communication was often unsuitable to sensitive discussions about pregnancy planning. The communication of treatment plans was frequently hampered by gaps in knowledge and both physician and patient confidence in the data, encouraging non-adherence among nervous patients. Finally, local rheumatologists and obstetricians/gynecologists providers frequently did not communicate, leading to varying treatment plans and confusion for patients. CONCLUSIONS To decrease the frequency of ill-timed pregnancy and medication non-adherence it will be essential to empower rheumatologists, and women with lupus to have open and accurate conversations about pregnancy planning and management.
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Affiliation(s)
- M E B Clowse
- 1 Division of Rheumatology & Immunology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - A M Eudy
- 1 Division of Rheumatology & Immunology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - J Revels
- 2 Duke Office of Clinical Research, Duke University School of Medicine, Durham, North Carolina, USA
| | - L Neil
- 1 Division of Rheumatology & Immunology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - G D Sanders
- 3 Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA; Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA; Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA
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Eudy AM, Jayasundara M, Haroun T, Neil L, James AH, Clowse MEB. Reasons for cesarean and medically indicated deliveries in pregnancies in women with systemic lupus erythematosus. Lupus 2017; 27:351-356. [DOI: 10.1177/0961203317720525] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective To determine reasons for cesarean and medically indicated deliveries in a registry of pregnant women with SLE compared to RA. Methods Pregnant women with SLE or RA were prospectively followed, and pregnancy outcomes were collected, including whether labor was spontaneous or medically indicated and delivery was vaginal or cesarean. Preterm birth was defined as a birth <37 weeks gestation. Differences in reasons for cesarean delivery and indication of delivery between term and preterm births were determined by Fisher’s exact test. Results Compared to RA pregnancies, SLE pregnancies had modestly higher rates of preterm birth (24% SLE vs 14% RA), pre-eclampsia (15% SLE vs 7% RA), and cesarean delivery (48% SLE vs 30% RA). The majority of preterm births among women with SLE were indicated (70%), most commonly for pre-eclampsia or the health of the infant or mother. The majority of preterm births among women with RA, however, were spontaneous, primarily due to premature rupture of membranes. Conclusion Pre-eclampsia and maternal SLE activity appear to be the key drivers for the high rate of preterm birth and medically indicated delivery in SLE. This contrasts with RA, where preterm labor is most often due to spontaneous onset of labor.
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Affiliation(s)
- A M Eudy
- Duke University Medical Center, Durham, NC, USA
| | | | - T Haroun
- Duke University Medical Center, Durham, NC, USA
| | - L Neil
- Duke University Medical Center, Durham, NC, USA
| | - A H James
- Duke University Medical Center, Durham, NC, USA
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Abstract
Objective The objective of this study was to estimate the proportion of pregnant women with systemic lupus erythematosus meeting Institute of Medicine guidelines for gestational weight gain and determine correlates of adherence to guidelines. Methods Singleton, live births in the Hopkins Lupus Pregnancy Cohort 1987-2015 were included. Pre-pregnancy weight was the weight recorded 12 months prior to pregnancy/first trimester. Final weight was the last weight recorded in the third trimester. Adherence to Institute of Medicine guidelines (inadequate, adequate, or excessive) was based on pre-pregnancy body mass index. Fisher's exact test and analysis of variance determined factors associated with not meeting guidelines. Stepwise selection estimated predictors of gestational weight gain. Results Of the 211 pregnancies, 34%, 24% and 42% had inadequate, adequate and excessive gestational weight gain, respectively. In exploratory analyses, differences in Institute of Medicine adherence were observed by pre-pregnancy body mass index, race, elevated creatinine during pregnancy and pre-pregnancy blood pressure. Odds of inadequate and excessive gestational weight gain increased 12% with each 1 kg/m2 increase in pre-pregnancy body mass index. Lower maternal education was associated with increased odds of inadequate and excessive gestational weight gain. Conclusions As in the general population, most women with systemic lupus erythematosus did not meet Institute of Medicine guidelines. Our results identified predictors of gestational weight gain to aid in targeted interventions to improve guideline adherence in this population.
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Affiliation(s)
- A M Eudy
- 1 Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina Chapel Hill, Chapel Hill, USA
| | - A M Siega-Riz
- 1 Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina Chapel Hill, Chapel Hill, USA
| | - S M Engel
- 1 Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina Chapel Hill, Chapel Hill, USA
| | - N Franceschini
- 1 Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina Chapel Hill, Chapel Hill, USA
| | - A G Howard
- 2 Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina Chapel Hill, Chapel Hill, USA
| | - M E B Clowse
- 3 Division of Rheumatology & Immunology, Duke University Medical Center, Durham, USA
| | - M Petri
- 4 Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, USA
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Wallace DJ, Hobbs K, Clowse MEB, Petri M, Strand V, Pike M, Merrill JT, Leszczyński P, Neuwelt CM, Jeka S, Houssiau F, Keiserman M, Ordi-Ros J, Bongardt S, Kilgallen B, Galateanu C, Kalunian K, Furie R, Gordon C. Long-Term Safety and Efficacy of Epratuzumab in the Treatment of Moderate-to- Severe Systemic Lupus Erythematosus: Results From an Open-Label Extension Study. Arthritis Care Res (Hoboken) 2016; 68:534-43. [PMID: 26316325 DOI: 10.1002/acr.22694] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 07/17/2015] [Accepted: 08/11/2015] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The primary objective was to assess the long-term safety of repeated courses of epratuzumab therapy in patients with moderate-to-severe systemic lupus erythematosus. Secondary objectives were to assess long-term efficacy and health-related quality of life (HRQOL). METHODS Eligible patients from the 12-week, phase IIb, randomized, placebo-controlled EMBLEM study enrolled into the open-label extension (OLE) study, SL0008. In the SL0008 study, patients received 1,200 mg epratuzumab infusions at weeks 0 and 2 of repeating 12-week cycles, plus standard of care. Safety measures included treatment-emergent adverse events (TEAEs) and serious TEAEs. Efficacy measures included combined treatment response, the British Isles Lupus Assessment Group score, the Systemic Lupus Erythematosus Disease Activity Index score, and the physician's and patient's global assessment of disease activity. Total daily corticosteroid dose and HRQOL (by the Short Form 36 health survey) were also assessed. RESULTS A total of 113 of the 203 patients (55.7%) who entered the SL0008 study continued epratuzumab therapy until study closure (total cumulative exposure: 381.3 patient-years, median exposure: 845 days, and maximum exposure: 1,185 days/approximately 3.2 years). TEAEs were reported in 192 patients (94.6%); most common were infections and infestations (68.0%, 138 patients). Serious TEAEs were reported in 51 patients (25.1%), and 14 patients (6.9%) had serious infections. In patients treated for 108 weeks (n = 116), the median corticosteroid dose was reduced from 10.0 mg/day at OLE screening to 5.0 mg/day at week 108. Improvements in efficacy and HRQOL measures in EMBLEM were maintained in the OLE, while placebo patients exhibited similar improvements in disease activity upon a switch to epratuzumab. CONCLUSION Open-label epratuzumab treatment was well tolerated for up to 3.2 years, and associated with sustained improvements in disease activity and HRQOL, while steroids were reduced.
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Affiliation(s)
- D J Wallace
- Cedars-Sinai Medical Center, Los Angeles, California
| | - K Hobbs
- Denver Arthritis Clinic, Denver, Colorado
| | - M E B Clowse
- Duke University Medical Center, Durham, North Carolina
| | - M Petri
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - V Strand
- Biopharmaceutical Consultant, Portola Valley, California
| | - M Pike
- MedPharm Consulting, Inc., Cambridge, Massachusetts
| | - J T Merrill
- Oklahoma Medical Research Foundation, University of Oklahoma Health Sciences Center, Oklahoma City
| | - P Leszczyński
- Poznan University of Medical Sciences, Poznan, Poland
| | - C M Neuwelt
- Alameda County Health System, Oakland, California
| | - S Jeka
- Clinic of Rheumatology and Connective Tissue Diseases, 2nd University Hospital, CM UMK, Bydgoszcz, Poland
| | - F Houssiau
- Clinique Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - M Keiserman
- Pontifical Catholic University, School of Medicine, Porto Alegre, Brazil
| | - J Ordi-Ros
- Universitari Vall d'Hebron, Barcelona, Spain
| | | | | | | | - K Kalunian
- University of California San Diego School of Medicine, La Jolla
| | - R Furie
- North Shore-Long Island Jewish Health System, New York, New York
| | - C Gordon
- School of Immunity and Infection, College of Medical and Dental Sciences, University of Birmingham, and NIHR/Wellcome Trust Clinical Research Facility, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
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Abstract
Introduction Breastfeeding is known to improve the well-being of a mother and her infant, and about half of all new mothers breastfeed, but it is unknown how breastfeeding is pursued in systemic lupus erythematosus (SLE; lupus) patients. We sought to determine the rate of breastfeeding and the factors influencing this among women with lupus. In addition, we reassessed the current safety data in lactation of lupus medications. Methods Data were collected from lupus patients enrolled in a prospective registry who fulfilled the 2012 SLICC criteria, had a live birth, and for whom postpartum breastfeeding status was known. Data included physician assessments of lupus activity and medications, breastfeeding intentions during pregnancy and practice following pregnancy. The safety of medications in breastfed infants was assessed through a comprehensive review of LactMed, a national database about medications in lactation. Results A total of 51 pregnancies in 84 women with lupus were included in the study. Half of the lupus patients ( n = 25, 49%) chose to breastfeed. The rate of breastfeeding was not significantly affected by socioeconomic factors. In contrast, low postpartum lupus activity, term delivery, and a plan to breastfeed early in pregnancy were significantly associated with breastfeeding in lupus patients. In reviewing the most up-to-date data, the majority of lupus medications appear to have very minimal transfer into breast milk and are likely compatible with breastfeeding. Conclusion Half of women with lupus breastfed and most desire to breastfeed. Hydroxychloroquine, azathioprine, methotrexate, and prednisone have very limited transfer into breast milk and may be continued while breastfeeding.
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Affiliation(s)
- M Noviani
- Department of Rheumatology, Duke University Medical Center, Durham, NC, USA
- Duke-National University of Singapore Graduate Medical School, Singapore
| | - S Wasserman
- Department of Rheumatology, Duke University Medical Center, Durham, NC, USA
| | - M E B Clowse
- Department of Rheumatology, Duke University Medical Center, Durham, NC, USA
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Harward LE, Mitchell K, Pieper C, Copland S, Criscione-Schreiber LG, Clowse MEB. The impact of cyclophosphamide on menstruation and pregnancy in women with rheumatologic disease. Lupus 2012; 22:81-6. [DOI: 10.1177/0961203312468624] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background While cyclophosphamide (CYC) can save the life of a young woman with severe rheumatologic disease, it may lead to the long-term side-effects of infertility and premature menopause. We compared the reproductive health histories of young women with rheumatologic disease with and without prior CYC exposure to identify the impact of this medication on this important component of health. Methods This research includes a case-series study of women diagnosed with SLE, vasculitis, and scleroderma prior to age 35. Each patient completed a questionnaire about desired childbearing, menstrual regularity, infertility, and pregnancy history. Women with prior CYC therapy were queried about the use of gonadotropin-releasing hormone agonists (GnRH-a) for fertility preservation. The responses to this questionnaire were compared for women with and without CYC exposure. Results Of the 43 participants, 23 had prior CYC exposure and 20 were CYC naïve. The current age of these groups was similar (average age 32), but women with prior CYC were four years younger at diagnosis than women without CYC. More women with prior CYC had cessation of menses in the year prior to the study (30.4% vs 0%, p < 0.05). Of the women with prior CYC exposure, those with loss of menses were older at study enrollment, older at CYC treatment, and had a higher cumulative CYC dose than those with preserved menstruation. While more women with GnRH-a co-therapy during CYC had maintained menses, this difference did not reach statistical significance. Women with prior CYC without GnRH-a co-therapy had a higher frequency of nulliparity and had greater trouble conceiving than women with GnRH-a co-therapy. Few pregnancies were conceived following CYC exposure and all resulted in elective termination, miscarriage, or preterm birth. Conclusion In this cohort of young women with rheumatologic disease, more women with prior CYC than without had amenorrhea, nulliparity, and infertility. GnRH-a co-therapy may prevent these adverse effects of CYC.
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Affiliation(s)
- LE Harward
- Department of Medicine, Medical University of South Carolina, USA
| | - K Mitchell
- Department of Medicine, Duke University Medical Center, USA
| | - C Pieper
- Department of Biostatistics & Bioinformatics, Duke University Medical Center, USA
| | - S Copland
- Department of Obstetrics & Gynecology, Duke University Medical Center, USA
| | | | - MEB Clowse
- Department of Medicine, Duke University Medical Center, USA
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Abstract
Severe systemic lupus erythematosus often requires the use of cyclophosphamide in women of reproductive age. As cyclophosphamide is generally avoided during pregnancy because of its teratogenic risk, its impact on fetal survival is poorly understood. This is a case series of lupus patients exposed to cyclophosphamide during pregnancy. We reviewed pregnancies in patients with lupus seen at a large university hospital between October 1986 and September 2003. The pregnancies were evaluated prospectively for cyclophosphamide exposure, lupus activity, and fetal outcome. Comparison was made between pregnancies with severe lupus requiring cyclophosphamide and those that did not. We identified four pregnancies with cyclophosphamide exposure. Two pregnancies were inadvertently exposed to cyclophosphamide early in the first trimester; both resulted in first trimester miscarriages. Two patients were administered cyclophosphamide for severe lupus nephritis and thrombocytopenia during the second trimester. Soon after the administration of cyclophosphamide, both pregnancies ended with fetal demise. Pregnancies exposed to cyclophosphamide for severe lupus flare resulted in a higher rate of fetal losses than pregnancies with severe lupus but not requiring the drug (100% versus 31.25%). In conclusion we present four pregnancies exposed to cyclphosphamide, each ending with pregnancy loss. Based on our experience, the survival of the fetus is strongly in doubt when cyclophosphamide is required to treat lupus in the mother.
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Affiliation(s)
- M E B Clowse
- Department of Medicine, Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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