Use of contraception by women treated with leflunomide due to rheumatic arthritis

Pregnancy Outcumes and Contraceptive Use in Women with Rheumatoid Arthritis: A Comparative Study

Background. Rheumatoid arthritis (RA) is a common chronic autoimmune disorder that has a female predominance and commonly affects women of childbearing age. It is shown to remit during pregnancy in most studies and improve in about half of the patients when assessed with objective disease activity measures.

Objective — to assess the pregnancy outcomes in women with RA prior and after the diagnosis and compare them with those in women with no chronic illness, to evaluate contraceptive practices and contraceptive method efficacy with the use of concomitant rheumatic medications (methotrexate, leflunomide).

Patients and Methods. Female patients diagnosed with RA according to ACR/EULAR 2010 classification criteria were compared with apparently healthy female controls matching in age in this case-control study. Data were collected by questionnaires and interviews. The questionnaires included demographic data and pregnancy outcomes, mode of delivery, contraceptive methods used by patients against the background of methotrexate and leflunomide therapy.

Results and discussion. One hundred patients with RA were included. The mean age of the patients and controls was 38.4±5.1 and 36.7±4.5 years, respectively. The live births significantly decreased in female patients with RA compared to the controls and the period before the diagnosis (p=0.01, p=0.002, respectively). Caesarean section frequency was higher in the control group compared to patients with RA (p=0.001). But in patients with RA, frequency of caesarean section increased after the diagnosis (p=0.021). Frequency of unplanned pregnancy significantly decreased after the diagnosis of RA compared to the period before the diagnosis (p<0.001). About 75.4% of patients had the desired number of children in their family before the diagnosis, and 24.6% feared the effect of RA on themselves and their children. 81% of 100 women with RA used methotrexate, 43.2% of them received rheumatological consultation regarding the contraceptive methods, and 56.8% did not. 30.86% of patients treated with methotrexate used ineffective contraceptive methods, 27.16% — long-acting reversible methods, 14.81% — effective contraceptive methods, and 24.69% did not use any contraceptive methods. 19% of RA patients used leflunomide, and 73.7% of them received rheumatological consultation regarding the type of contraceptive methods, 36.84% used effective methods of contraception, 31.58% — long-acting reversible methods, 15.79% — ineffective contraceptive methods and 15.79% did not use any contraceptive methods.

Conclusion. There is a decrease in live births and an increase in preterm birth frequency as well as caesarean sections in Iraqi female patients with RA. There is lack of knowledge about the importance of contraceptive methods efficacy in relation to teratogenic medications (methotrexate, and leflunomide).

A questionnaire-based study on contraceptive practice in patients with rheumatic disease found no significant difference in age-matched healthy controls

OBJECTIVE

Birth control is crucial in preventing unplanned pregnancy. The study analyzed contraceptive practice in women and men with rheumatic disease.

METHODS

A questionnaire-based study investigated the actual contraceptive practices in patients of reproductive age from three European countries and compared them to age-matched healthy women and men. Associations between patient characteristics and contraception behavior were analyzed by association analysis.

RESULTS

No significant difference in the frequency of contraception use was found in 133 rheumatic patients compared to 122 healthy controls. The main reason for not using contraception was lack of partner or the wish to become pregnant, whereas the current use of contraception was predominantly to limit family size in general or at this stage of life. Both patients and controls preferred barrier methods (48% and 45%, respectively) followed by hormonal contraceptives (31% and 38%, respectively). Characteristics associated with less use of contraception in patients were living single, having no children, and for being religious, whereas gender and education had no influence. Treatment with teratogenic drugs was no major patient concern, and 13 of 30 female patients using methotrexate, mycophenolate mofetil, or leflunomide did not practice birth control.

CONCLUSION

Patients used contraception less frequently than healthy individuals, and the main reason for use was to limit family size. Contraception should be an integral part of counseling patients of fertile age, since the patient-preferred methods in case of active disease or therapy with teratogenic drugs were unreliable for the prevention of pregnancy.

Increasing contraception use among women receiving teratogenic medications in a rheumatology clinic

Teratogenic medications are often prescribed to women of childbearing age with autoimmune diseases. Literature suggests that appropriate use of contraception among these women is low, potentially resulting in high-risk unintended pregnancies. Preliminary review in our clinic showed suboptimal documentation of women's contraceptive use. We therefore designed a quality improvement initiative to target three process measures: documentation of contraception usage and type, contraception counselling and provider action after counselling. We reviewed charts of rheumatology clinic female patients aged 18-45 over the course of 10 months; for those who were on teratogenic medications (methotrexate, leflunomide, mycophenolate and cyclophosphamide), we looked for evidence of documentation of contraception use. We executed multiple plan-do-study-act (PDSA) cycles to develop and evaluate interventions, which centred on interprofessional provider education, modification of electronic medical record (EMR) templates, periodic provider reminders, patient screening questionnaires and frequent feedback to providers on performance. Among eligible patients (n=181), the baseline rate of documentation of contraception type was 46%, the rate of counselling was 30% and interventions after counselling occurred in 33% of cases. Averaged intervention data demonstrated increased provider performance in all three domains: documentation of contraception type increased to 64%, counselling to 45% and provider action to 46%. Of the patients with documented contraceptives, 50% used highly effective, 27% used effective and 23% used ineffective contraception methods. During this project, one unintentional pregnancy occurred in a patient on methotrexate not on contraception. Our interventions improved three measures related to contraception counselling and documentation, but there remains a need for ongoing quality improvement efforts in our clinic. This high-risk population requires increased provider engagement to improve contraception compliance, coupled with system-wide EMR changes to increase sustainability.

Low prevalence of contraceptive use among Brazilian women of reproductive age with systemic lupus erythematosus

This was a cross-sectional study of women of reproductive age with systemic lupus erythematosus (SLE) being treated at Bahiana School Rheumatology Service in Brazil. The study aimed to assess the prevalence of contraceptive counselling and use. An interview was performed, and the results were analysed before and after the SLE diagnosis. Eighty-five women were included; the mean age of the group was 32.98 ± 8.39 years. Before SLE diagnosis, most of the patients had used some contraceptive method; mainly oral contraceptives (54%) or hormone injections (21%). After SLE diagnosis, 53% of patients did not use any contraceptive method. Among the remaining patients who continued using contraceptives, 22% used condoms, 11% used combined oral contraceptives and 7% used hormone injections. Although 62% of the patients regularly visited the gynaecologist, 56% were unaware of which contraceptive method could be used safely. Thus, a better contraceptive counselling of women of a reproductive age should be performed after SLE diagnosis. Impact Statement What is already known on this subject? Women diagnosed with SLE have inadequate counselling about family planning. What the results of this study add? Brazilian women with SLE have a low prevalence of contraceptive use after their diagnosis and are exposed to having high-risk pregnancies. What the implications are of these findings for clinical practice and/or further research? The results we found highlight the importance of continued medical educational programmes and establish questions for further studies in order to investigate the interventions used to improve the contraceptive use for women diagnosed with SLE.

Age at natural menopause in women on long-term methotrexate therapy for rheumatoid arthritis

OBJECTIVE

The aim of the study was to compare the natural menopause ages of healthy women with those of women with methotrexate (MTX)-treated rheumatoid arthritis (RA), and to specifically assess the effect of disease onset and activity and the use of MTX on the age of the last menstruation.

METHODS

We performed a retrospective review of medical records to identify the ages at which menopause occurred in women with premenopausal RA treated with MTX and in women with postmenopausal onset, irrespective of therapy. Natural menopause ages were also compared between participants with and without RA.

RESULTS

Women with premenopausal onset of RA underwent menopause at a significantly younger age than did healthy women (P < 0.001) or those with postmenopausal disease onset (P = 0.001). Menopause also occurred at younger ages in participants with postmenopausal disease onset than in healthy controls (P = 0.012). The study suggested that menopause age was positively correlated with the age at which RA was diagnosed (R = 0.51; P < 0.001) in women with premenopausal RA onset, but was independent of the participant's age at menarche, number of pregnancies, or MTX therapy. Participants with RA onset at ≤ 35 years of age had a ninefold higher risk of premature menopause (P = 0.008).

CONCLUSIONS

The age at which menopause occurs in a patient with RA depends on the patient's age at the time of disease onset and its duration, but is not influenced by MTX treatment.

Effects of leukotriene B4 on interleukin-32, interferon-γ and chemokines in rats with rheumatoid arthritis

The objective of this study was to investigate the effects of leukotriene B4 (LTB4) on the expression of interleukin-32 (IL-32) interferon-γ (IFN-γ) and chemokine monocyte chemoattractant protein (MCP-1) and macrophage inhibitory protein (MIP-1α) in rheumatoid arthritis (RA). The rat model of RA collagen induced-arthritis (CIA) was established. The levels of LTB4, interleukin-32, IFN-γ and chemokines MCP-1 and MIP-1α in CIA rats were detected by ELISA. After the rat synovial cells were isolated and treated with different concentrations of LTB4, the effect of LTB4 the expression of IL-32, IFN-γ and chemokines MCP-1 and MIP-1α mRNA in synovial cells was detected by real-time quantitative PCR, the effect of LTB4 on protein expression was detected by immunoblotting. The effects of different concentrations of LTB4 on the viability and apoptosis of synovial cells were detected by LDH and cell proliferation reagent WST-1. Compared with the control group, the levels of LTB4, IL-32, IFN-γ and chemokines MCP-1 and MIP-1α were significantly increased in the serum of the CIA group. After treatment of CIA rat synovial cells with different concentrations of LTB4, the expression of IL-32, IFN-γ and chemokines MCP-1 and MIP-1α mRNA and protein were increased with significant differences among groups. WST-1 and flow cytometry showed that LTB4 had significant toxic effects on synovial cells and promoted apoptosis. In conclusion, LTB4 promotes the expression of interleukin-32, IFN-γ and chemokines MCP-1 and MIP-1α in synovial cells and facilitates apoptosis of synovial cells.