Medication use among pregnant women with systemic lupus erythematosus and general population comparators

Background Evidence suggests that continuing hydroxychloroquine (HCQ) during pregnancy in women with systemic lupus erythematosus (SLE) improves outcomes. We sought to describe time trends in the continuation, initiation, and duration of HCQ in a large population-based cohort of pregnant SLE women. Methods A cohort of pregnant women with SLE enrolled continuously in public (Medicaid, 2001-2010) or private (Optum Clinformatics, 2003-2015) health insurance between three months prior to conception and one month after delivery was identified. We assessed the proportion of women initiating or continuing HCQ and the duration of therapy during each calendar year in the study. Results A total of 5300 women with SLE were included. Of these, 852 (16.1%) were on HCQ treatment in the three-month period prior to their pregnancy. During pregnancy, the overall proportion of women with SLE taking HCQ increased from 12.4% in 2001 to 37.7% in 2015. Initiation of HCQ therapy during pregnancy increased from 2.7% in 2001 to 7.5% in 2010 ( p = 0.0002) (Medicaid) and from 4.9% in 2003 to 13.6% in 2015 ( p = 0.0001) (Clinformatics). Continuation of HCQ during pregnancy did not change significantly over time in either data set. The average cumulative day-supply of HCQ prescriptions during pregnancy increased from 37 days in 2001 to 77 days in 2010 ( p = 0.05) among HCQ initiators and from 79 days in 2001 to 125 days in 2010 ( p = 0.0009) among HCQ continuers in Medicaid. Among privately insured women, the average cumulative day-supply of HCQ prescriptions among HCQ continuers increased from 84 in 2004 to 163 in 2015 ( p = 0.0006) but did not change significantly among HCQ initiators. Conclusion The proportion of women initiating HCQ during pregnancy and the average cumulative day-supply of HCQ increased from 2001 to 2015. While these findings are encouraging, overall HCQ use during pregnancy remains low.

Section: Discussionsupporting

confidence: 76%

Section: Introductionmentioning

confidence: 99%

Trends in use of hydroxychloroquine during pregnancy in systemic lupus erythematosus patients from 2001 to 2015

Bermas

Kim

Huybrechts

et al. 2018

“…Using administrative data for 391 women in Sweden, the proportion of use of antimalarials in the three-month period prior to conception was 23.4% and during pregnancy 36.4%. 14 Our study expands on these prior studies in that we assessed medication use over a longer preconception period (up to two years) and additionally assessed the postpartum period, showing that 31.1% took antimalarials after delivery. Furthermore, although these prior studies reported declines in utilization of antimalarials with advancing trimesters of pregnancy, neither explicitly defined and assessed discontinuation, as with our study.…”

Section: Discussionmentioning

confidence: 76%

“…Few prior studies have examined medication use in pregnant women with SLE and showed varying frequencies of use prior to conception, during pregnancy, and postpartum. 11,14 To add more nuanced information on patterns of medication use in SLE pregnancies, our objectives were 1) to characterize the frequency of use of antimalarials, immunosuppressants as well as other medications, before, during, and after pregnancy, and 2) assess discontinuation of antimalarials and immunosuppressants during pregnancy.…”

Section: Introductionmentioning

confidence: 99%

Patterns of medication use before, during and after pregnancy in women with systemic lupus erythematosus: a population-based cohort study

Zusman

Sayre

Aviña‐Zubieta

et al. 2019

Objectives This study aimed to characterize the patterns of medication use before, during and after pregnancy in a population-based cohort of women with systemic lupus erythematosus (SLE). Methods Using population-based administrative data in British Columbia, Canada, with valid information on start date of pregnancy, we identified women with SLE who had singleton pregnancies ending in deliveries between January 1, 2002, and December 31, 2012. We assessed the proportion of SLE pregnancies exposed to SLE medications – namely antimalarials and immunosuppressants – as well as glucocorticosteroids, and nonsteroidal anti-inflammatory drugs (NSAIDs) 24 months before pregnancy, each trimester of pregnancy, and 12 months postpregnancy. We also assessed discontinuation of antimalarials and immunosuppressants, defined as no prescriptions in a given window following a prescription in a preceding window. Results Of 376 pregnancies (284 women) with SLE, 24.2% had one or more dispensing for antimalarials, 8.2% for azathioprine, 19.7% for glucocorticosteroids and 4.8% for NSAIDs during pregnancy. We observed a 16.7% discontinuation of antimalarials in the year prior to pregnancy, 29.8% in the first trimester, 9.7% in the second trimester, and 26.0% in the third trimester. We also observed a 29.2% discontinuation of azathioprine in the first trimester, 8.0% in the second trimester, and 9.1% in the third trimester. Conclusions These population-based data show frequent discontinuation of medications, particularly antimalarials, in SLE pregnancies. These findings suggest the importance of educating women with SLE who are pregnant or planning to become pregnant on the benefits and risks of medications during pregnancy.

“…2 On the other hand, Medicaid datasets, representing the medical care received by low-income Americans, suggest that just under 40% of pregnant women with lupus take HCQ, suggesting a large gap in physician prescribing and/or patient compliance with this medication. 3,4 The goal of this study was to identify the influencing factors that result in the current management of lupus during pregnancy among community and university rheumatologists. We used the structure of the PRECEDE-PROCEED framework 5 to design a mixed-methods approach to reach this goal.…”

Section: Introductionmentioning

confidence: 99%

Provider perceptions on the management of lupus during pregnancy: barriers to improved care

Clowse

Eudy

Revels

et al. 2018

Background More than half of pregnancies in women with systemic lupus erythematosus (lupus) result in adverse outcomes for the mother or the fetus. We sought to identify aspects of current rheumatologic care that could be improved to decrease the frequency of poor outcomes. Methods Focus groups with clinical rheumatologists, based on the PRECEDE/PROCEED framework, identified factors that influenced care. A group of women with lupus on their reproductive journey contributed to our understanding of the dilemmas and care provided. Results Medically ill-timed pregnancies and medication non-adherence during pregnancy were identified by rheumatologists as the two key dilemmas in care. We identified several communication gaps as key modifiable barriers to optimal management. The approach to physician–patient communication was often unsuitable to sensitive discussions about pregnancy planning. The communication of treatment plans was frequently hampered by gaps in knowledge and both physician and patient confidence in the data, encouraging non-adherence among nervous patients. Finally, local rheumatologists and obstetricians/gynecologists providers frequently did not communicate, leading to varying treatment plans and confusion for patients. Conclusions To decrease the frequency of ill-timed pregnancy and medication non-adherence it will be essential to empower rheumatologists, and women with lupus to have open and accurate conversations about pregnancy planning and management.