Lupus Family Planning Recommendations Issued by EULAR

The European League Against Rheumatism (EULAR) issued recommendations for women’s health and family planning for patients with systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS). The recommendations were published in the Annals of the Rheumatic Diseases.¹

SLE and APS, which commonly affect women of childbearing age, raise the risk for pregnancy loss due to the effects of autoantibodies on fertilization, implantation, embryonic development, and placental function.² Family planning is gaining increasing importance as advances in medicine allow earlier diagnosis of SLE and APS.¹ Limited data are available, however, to guide family planning in patients with SLE and APS.³

The EULAR writing committee, led by Angela Tincani, MD, and Laura Andreoli, MD, from the University of Brescia in Italy, conducted a systematic literature review to develop recommendations for family planning and women’s health issues in women with SLE and APS.¹

Because most women with SLE or APS can have successful pregnancies, family planning is best addressed as soon as possible after diagnosis. Risk stratification and risk factor management can help mitigate the possibility of adverse maternal or fetal outcomes. The committee also made recommendations for fetal monitoring during pregnancy, particularly in the third trimester.¹

Assisted reproduction techniques are considered safe in patients with stable or inactive disease, although patients with APS should be treated with antithrombotic agents such as aspirin or anticoagulants.¹

Gonadotropin-releasing hormone analogues may be used to preserve fertility in women requiring treatment with alkylating agents. Patients with stable or inactive disease may use hormonal contraception or hormonal replacement therapy with little concern for thrombosis.¹

The committee also outlined recommendations regarding human papillomavirus (HPV) immunization and screening for gynecological malignancies, particularly in patients who have received immunosuppressive drugs.¹

Although the writing committee provides evidence-based recommendations for managing women’s health issues in SLE and APS, unmet needs still exist. “Not much is known about the long-term outcome of children born to these women,” Dr Tincani told Rheumatology Advisor. “Patients often think that children will inherit their disease or will have problems related to their treatments. Patients are also afraid that they will not be able to raise their children for health-related reasons. We need to clarify these issues.”

Summary and Clinical Applicability

Fertility and pregnancy are important issues for women with SLE and APS, which often affect women of childbearing age. However, guidelines to steer the management of family planning and women’s health in these patients are lacking. The EULAR writing committee issued recommendations for family planning in women with SLE and APS based on a systemic review.

“We hope that the EULAR recommendations will be of practical use for counseling young patients about family planning, contraception, and pregnancy,” Dr Tincani said. “We also considered other common problems such as menopause, screening for malignancy, and HPV vaccination.”

“The aim of our work is to allow patients with SLE and APS to live as normal a life as possible,” she concluded.

Study Limitations

• Data are limited on methods for assessing fertility in women with SLE/APS and fertility preservation strategies in women with SLE undergoing treatment
• Several recommendations are based on data from observational or nonrandomized studies

References

1.  Andreoli L, Bertsias GK, Agmon-Levin N, et al. EULAR recommendations for women’s health and the management of family planning, assisted reproduction, pregnancy and menopause in patients with systemic lupus erythematosus and/or antiphospholipid syndrome. Ann Rheum Dis. 2017;76(3):476-485. doi:10.1136/annrheumdis-2016-209770
2. Østensen M. New insights into sexual functioning and fertility in rheumatic diseases. Best Pract Res Clin Rheumatol. 2004;18(2):219-232. doi:10.1016/j.berh.2004.01.002
3. Kavanaugh A, Cush JJ, Ahmed MS, et al. Proceedings from the American College of Rheumatology Reproductive Health Summit: the management of fertility, pregnancy, and lactation in women with autoimmune and systemic inflammatory diseases. Arthritis Care Res. 2015;67(3):313-325. doi:10.1002/acr.22516

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