BERLIN - June 10, 2004 - Physicians who treat patients with autoimmune disease need to consider the risks of the disease to pregnancy and fertility as well as the treatment, according to experts presenting here June 9th at the annual meeting of the European Congress of Rheumatology (EULAR).

"Physicians who treat patients with autoimmune diseases should first ask the patients if they want to have children, so that they can give these patients adequate information," said Monika Oestensen, MD. "This principle applies equally to men and women." Dr. Oestensen is a rheumatologist and professor of medicine at the University of Bern in Bern, Switzerland.

"We also need to remember that, in pregnant patients, it's not a good idea to stop all drugs," she stressed. "A flare of lupus, for example, can cause the pregnancy to fail. Before withdrawing medication, first ask the patient how she does without the treatment."

Caroline Gordon, MD, agreed that the time to discuss medications and their relative safety in pregnancy is before pregnancy. She pointed out that physicians need to be prepared to address the issue of autoimmune disease and pregnancy because the therapeutic advances have caused more of these patients to be encouraged to contemplate pregnancy. Dr. Gordon is a reader in rheumatology at the University of Birmingham in Birmingham, United Kingdom.

She noted that, despite these advances, the risks of maternal and fetal morbidity and mortality are increased in such women, and that different autoimmune diseases have varying effects on pregnancy. For example, rheumatoid arthritis may improve during pregnancy. However, certain conditions may be exacerbated, such as vasculitis, systemic lupus erythematosus, and systemic sclerosis. The risk of exacerbation is increased if the disease is active at the time of conception, she said.

"Patients who are planning to become pregnant must discuss their plans with their physicians in advance, and be careful not to become pregnant until the disease is well controlled on drugs that are appropriate to continue during pregnancy," she stressed. "Any switch in medication should occur before the patient is pregnant."

Examples of drugs that appear to be safe to use during pregnancy include prednisone or prednisolone, azothiaprine, sulfathiazine, aspirin, and rinetadine. She noted that the issue of when to switch patients on warfarin to subcutaneous heparin differs by country. "In the United Kingdom we make the switch when the pregnancy is confirmed," she said. "In the United States, the patient is typically switched before she becomes pregnant." Either practice is safe she said, noting that teratogenic risks are possible during gestational weeks six to nine, "but not earlier."

Patients treated with corticosteroids should receive the lowest possible dose to control their disease, and that doses of prednisone or prednisolone should not exceed 15 mg per day. Higher doses are associated with hypertension, diabetes, infection, and pre-eclampsia.

"However, if the disease cannot be controlled at these dosages, higher doses can be used, as long as the physician watches for and treats these complications," Dr. Gordon said. She stressed that steroids should be avoided in systemic sclerosis unless the lungs or kidneys are involved. Such cases are the only circumstances in which angiotensin-converting enzyme (ACE) inhibitors can be used in pregnancy. Although ACE inhibitors are teratogenic, the risk of maternal death in such cases is high enough to override the teratogenic concerns, she said.