021
Question
I was diagnosed with Rheumatoid Arthritis recently. I am taking Methotrexate, Sulfasalazine, Hydroxychloroquine and Prednisolone. I was advised to postpone pregnancy for one year. The doctor told me to take pills or use a condom. I am newly married and looking forward to having a child when my arthritis gets better. What is the best family planning method for me?
Answer
Rheumatoid arthritis (RA) is a chronic (long-standing) condition that frequently affects the hand joints. They can involve many other joints throughout the body. This is an autoimmune disease, which means our own immune cells attack our normal bodily cells. In the case of RA, the joint cells (cartilages and bones) are damaged by the immune cells. The patient would find it difficult to use the affected joints after a period of rest or sleep. This is due to the accumulation of excess fluid in the joints and this slightly improves with activity. Apart from joint involvement, RA can affect many other organs such as lungs, heart, nerves and blood.
The exact cause of this condition is unknown. If left untreated RA can result in destruction of the joint and functional disability. RA is treated with an array of medications most of which alter our immune system.
Unintended pregnancies in women with RA or any medical condition can lead to many problems. Pregnancy can increase the severity of some of those illnesses or the drugs that are used to treat them can harm the growing foetus. This can result in multiple complications during pregnancy and childbirth. Thus it can pose a risk to the mother’s life. Therefore, women with significant medical conditions should always seek doctors’ advice before becoming pregnant.
Methotrexate is commonly used to treat RA and many other medical disorders. If a growing fetus is exposed to methotrexate in early pregnancy it can result in some serious birth defects. Therefore, women in the child bearing age should use proper contraceptive methods while using this medication and even after few weeks of stopping this.
Sulfasalazine can be taken during pregnancy. There is a slight risk of blood disorders (haemolysis) in the fetus during the latter part of pregnancy. This can be avoided by supplementing with an adequate amount of folic acid. Likewise, hydroxychloroquine can be continued during pregnancy since the benefit overweighs the risks. Prednisolone should be used cautiously during pregnancy since it can interfere with adrenal hormone production in the baby.
Some contraceptive methods have failures and drug interactions. Certain hormonal methods can interact with RA drugs. This can decrease the efficiency of the drug or increase the severity of the illness. Some of the RA drugs can reduce the efficiency of the contraceptive medications.
When doctors prescribe a contraceptive method, they consider many factors including effectiveness, patient’s medical conditions, drug interactions, side effect profile and patient’s preferences as well. In the situation given above, the patient should use a method which has the lowest failure rate.
Oral contraceptive pills (OCP) can be used. But there were few cases of contraceptive failures reported in patients taking methotrexate. Condom is not an effective contraceptive method because it has a failure rate of 3 to 14 percent in the first year of use. Nevertheless, it can be practiced along with another method to increase the collective efficiency.
For the situation described in the question, copper IUCD (intra-uterine contraceptive device / commonly known as ‘loop’), LNG IUS (levonorgestrel-releasing intrauterine system / a hormone releasing ‘loop’) and hormonal injections (e.g. Depo-Provera) can be recommended as safe and effective methods. These methods have no known interaction with the above drugs. Further it does not influence the RA disease process as well.
References
- BMJ Group. 2017. British National Formulary. 74. London: BMJ Group and the Royal Pharmaceutical Society of Great Britain.
- Dawson, AL, T Riehle‐Colarusso, J Reefhuis, JF Arena, and the National Birth Defects Prevention Study. 2014. “Maternal exposure to methotrexate and birth defects: A population‐based study.” Am J Med Genet Part A 164A: 2212-2216. doi:10.1002/ajmg.a.36625.
- Faculty of Sexual and Reproductive Healthcare. 2019. “FSRH CEU Guidance: Drug Interactions with Hormonal Contraception.” Faculty of Sexual and Reproductive Healthcare of the Royal College of the Obstetricians and Gynaecologists. January. Accessed August 28, 2020. https://www.fsrh.org/standards-and-guidance/documents/ceu-clinical-guidance-drug-interactions-with-hormonal/.
- Samra, OM, and BD Cowan. 2018. How Often Do Condoms Fail? September 17. Accessed August 28, 2020. https://www.emedicinehealth.com/ask_how_often_do_condoms_fail/article_em.htm#ask_a_doctor.
- Shah, Ankoor, and St. Clair EW. 2018. “Rheumatoid Arthritis.” In Harrison’s Principles of Internal Medicine, by Jameson L, Fauci A, Kasper D, Hauser S, Longo D and Loscalzo J, 2527-2540. McGraw-Hill Education.
