Marla Dubinsky, MD: So the question is, when should we even start having these discussions with patients? How early on should you talk to the patient about this? Since I treat both children and adults, I sort of have different discussions. For my patients who are children, mothers often ask me, “Is this a medication that she’ll be on for the rest of her life?” That’s often the question. That’s actually a common question for both males and females. “Does this therapy impact my child’s ability to get pregnant, or would she have to stop using the drug during pregnancy?” I often say to them…what I say to a woman who is asking me that same question. Fast-forward 12 years or 20 years from that discussion, and I’ll say the same thing: “Whatever therapy I’m going to prescribe for you today is something that you’ll be able to continue to use even if you get pregnant tomorrow.” For a patient who is on methotrexate plus an anti-TNF [tumor necrosis factor], I will stop the methotrexate 6 months before conception and continue the anti-TNF inhibitor.
If they’re on thiopurines plus an anti-TNF and are durably well, I’m actually going to have a discussion with the patient and may say, “You don’t need to be on 2 drugs. You can probably just be on 1.” Even if I’m not concerned about the risk of malformation, I still like the mother to feel confident and comfortable that we’re minimizing exposure to anything. A more recent study showed that the mom is at risk of getting flares if they stop, particularly with TNF. There is also an increased risk of maternal infection in women who are exposed to TNF. This is not controlled for a lot of things, like steroids and how the active their disease is, which I think is more relevant, but I do want to put it out there. There is data out there that talks about how to counsel patients and whether to stop a medication. At every stage, when you see a patient and are starting a new therapy, I think you should assure them that these drugs are safe during pregnancy. Or you should address the fact that even 5 years from now, if the patient is on a different drug, if something changes and they want to have children—it’s an ongoing dialogue—I explain to them that we’ll adjust their treatment accordingly. But I say, “Whatever I’m starting you on today is something you’re going to be able to get pregnant on, unless I’m starting you on methotrexate.” I think that’s the only one that I would counsel on differently.