BALTIMORE, Maryland—Clinicians are increasingly prescribing oral contraceptive pills (OCPs) for women with inactive or stable systemic lupus erythematosus (SLE), a dramatic change from former assumptions about OCPs in this population, according to Michelle Petri, MD, a rheumatologist at Johns Hopkins University School of Medicine in Baltimore, Maryland and Jill P. Buyon, MD, a rheumatologist at the New York Hospital for Joint Diseases in New York City.

“Should oral contraceptives be prescribed in SLE? In the last 5 years we have come a long way. The answer today is frequently ‘yes,’ whereas before, the answer was almost always never.”—Michelle Petri, MD
“Should oral contraceptives be prescribed in SLE? In the last 5 years, we have come a long way,” they write in Lupus.1 “The answer today is frequently ‘yes,’ whereas before, the answer was almost always never.”

Why the change of heart?

Drs. Petri and Buyon reviewed biochemical, animal, and human case control data and human cohort studies as well as randomized double-blind, placebo-controlled trials including the Safety of Estrogen in Lupus: National Assessment (SELENA) and the SELENA birth control pills trial, to come to their conclusions about the use of OCPs in women with lupus.

According to results from SELENA, women who have inactive or stable active SLE can be offered OCPs if they are not prescribed for >1 month following diagnosis. Other exclusion criteria highlighted in this trial included
  • Diastolic pressure >95 mm Hg or systolic pressure >145 mm Hg on three readings
  • History of spontaneous deep venous thrombosis
  • Arterial thrombosis or pulmonary embolus
  • Presence of IgG, IgM, or IgA anticardiolipin antibodies and or demonstration of lupus anticoagulant by the dilute Russell viper venom test
  • History of gynecologic or breast cancer
  • History of heart attack
  • Liver dysfunction or liver tumors
  • Uncontrolled diabetes
  • Congenital high cholesterol
  • Migraines with neurological symptoms
  • Unexplained vaginal bleeding
  • Positive pregnancy test

The SELENA trial, however, cannot be generalized to all women with SLE due to the rather extensive exclusion criteria. In the SELENA birth control pills trial, OCP use was similar to placebo in terms of disease flares.

The bottom line? “The risks of OCPs should always be discussed and documented,” they write. “[OCPs] cannot be prescribed to all SLE women, but when appropriate may demonstrably improve quality of life.”

Reference

1. Petri M, Buyon, JP. Oral contraceptives in systemic lupus erythematosis the case for (and against). Lupus. 2008;17:708-710.